Every finding on record at Friendship Health and Rehab Center - South

Based on staff interview, clinical record review and facility document review the facility staff failed to accurately label medications for 1 of 2 residents, Resident #1. The findings included: For Resident #1 the facility staff failed to ensure the medication Morphine Sulfate was labeled with the correct dosage, resulting in the resident receiving multiple incorrect doses. Resident #1's face sheet listed diagnoses which included but not limited to multiple sclerosis, epilepsy, long term use of opiate analgesic, and personal history of traumatic brain injury. Resident #1's most recent minimum data set with an assessment reference date of 11/18/24 assigned the resident a brief interview for mental status score of 3 out of 15. This indicates that the resident is severely cognitively impaired. Resident #1's comprehensive care plan was reviewed and contained a plan for . has dx (diagnosis) of MS (multiple sclerosis) with chronic pain . Interventions for this care plan included Administer medications as per orders. See MAR (medication administration record) for details. Resident #1's clinical record was reviewed and contained a physician's order summary which read in part, Morphine Sulfate Oral Solution 10 mg/5 ml (Morphine Sulfate). Give 2.5 ml via G-Tube every hour as needed for Pain/SOB (shortness of breath)-start date 01/27/25, Morphine Sulfate Oral Solution 10 mg/ 5 ml (Morphine Sulfate). Give 2.5 ml via G-Tube every 4 hours for pain/SOB-start date 01/27/25, Morphine Sulfate Oral Solution 10 mg/5ml (Morphine Sulfate). Place and dissolve 2.5 ml buccally every 4 hours for pain/SOB-start date 01/28/25, Morphine Sulfate Oral Solution 10 mg/5ml. Place and dissolve 2.5 ml buccally every 2 hours for pain/SOB-start date 01/29/25, and Morphine Sulfate Oral Solution 10 mg/5 ml. Place and dissolve 2 ml buccally every 6 hours for pain/SOB-start date 01/29/25 Resident #1's electronic medication administration record for the month of January 2025 was reviewed and contained entries as above. The entry for Morphine via G-Tube every 4 hours had been initialed as being administered ordered at 10 pm on 01/27/25, 2 am, 6 am and 10 am on 01/28/25. The entry for Morphine buccally every 4 hours had been initialed as being administered at 2 pm and 6 pm on 01/28/25. The entry for Morphine every 6 hours buccally was initialed as being administered at 12 am and 6 am on 01/29/25. The entry for Morphine every hour as needed via G-Tube was initialed as being administered on 01/29/25 at 8:07 am. The entry for Morphine every 2 hours buccally was initialed as being administered on 01/29/25 at 12 pm. Resident #1's Individual Resident's Controlled Substance Record for morphine was reviewed and contained a pharmacy label which read in part, Morphine 100 mg/5ml Conc-3 30 ml. Give 2.5 ml VGT (via G-Tube) every hour as needed for pain/SOB. Surveyor spoke with the facility administrator on 06/16/25 regarding Resident #1's morphine order and subsequent medication errors. Administrator stated that pharmacy sent a different concentration of the morphine, labeled the dosage incorrectly, and the nurses that administered the morphine failed to compare the label to the physician's order. Surveyor requested and was provided with a facility policy entitled Administering Medications which read in part, Medications shall be administered in a safe and timely manner, and as prescribed .7. The individual administering the medication must check the label to verify the right medication, right dosage, right time, and right method (route) of administration before giving the medication. Administrator provided surveyor with a copy of the facility's investigation which read in part, . (Resident #1) readmitted to . (facility omitted) on 01/27/2025 .Resident was readmitted .for hospice, end of life care with a prognosis of days to weeks. Discharge orders from . (name omitted) included: Morphine 10 mg/5 ml, give 2.5 ml every 1 hour as needed. Orders were entered correctly into . (electronic record) and prescriptions sent to . (omitted) pharmacy. On January 27, 2025, at 2043 . received the Morphine Sulfate from pharmacy. The bottle and narcotic control sheet were both labeled Morphine 100 mg/5 ml concentrate give 2.5 ml every 1 hours as needed for pain/sob. Pharmacy failed to notify . (facility omitted) of a concentration change from original order sent to pharmacy. Additionally, with change in concentration, pharmacy made an error instructing to give 2.5 ml (50 mg) every hour as needed for pain/sob. The facility administrator provided the surveyor with a copy of the facility's Plan of Correction which read as follows: On January 31, 2025, RCA (root cause analysis) completed for . (facility omitted) nursing department. Findings from the RCA identified 2 root causes for the error. First, the MAR (medication administration record) dosing did not match the concentration or instructions on the narcotic control sheet nor on the actual medication bottle that was provided by pharmacy. Second, nurses failed to administer the medication based on the facility policy and procedure. Based on the findings, the facility's plan of correction is as follows: 1. Upon discovery of the error on January 29, 2025, an immediate audit was completed on all remaining residents receiving liquid narcotics to ensure no system wide failure occurred. There were no findings from this audit. 2. Review of our current policy and procedure for medication administration was completed. No changes indicated during this review. 3. Created a 2-step verification on all liquid controlled narcotics received from pharmacy to ensure that concentration and instructions match concentration and instructions on the MAR. 4. (name omitted), Administrator and . (name omitted), DON (director of nursing) met with all 4 nurses and provided education in regards to medication error. All 4 nurses were placed on disciplinary action to include a Performance Improvement Plan and all 4 nurses were reported to the Board of Nursing. 5. All nursing staff at . (facility omitted) were assigned education in . (name omitted) with a mandatory completion date of February 28, 2025. Additional training to be provided on drug calculations by February 28, 2025. 6. A review with attestation to be completed with all nursing staff on medication administration policy and procedure. 7. Medication administration observation to be completed on all nursing staff by February 28, 2025. 8. To assist with compliance, . (name omitted), DON will present findings of the above to our quarterly QAPI (quality assurance and performance improvement) meeting and a determination will be made on future audits/actions. All credible evidence was reviewed and verified on 06/16/25. Nursing staff were interviewed on policy and procedure for medication administration. A review of new hire nurses was completed to ensure that all new hires have received training in medication administration and dosage calculations. Medication storage rooms and medication carts were observed for correct labeling of medications with no discrepancies found. The administrator also provided the surveyor with an RCA and Plan of Correction from the pharmacy which read as follows: On January 31, 2025 a Root Cause Analysis (RCA) was completed with . (pharmacy name omitted). Members of the RCA included . (name omitted) VP (vice-president) of Operations, . (name omitted), Administrator, . (name omitted), DON (director of nursing), . (name omitted) Pharmacist, and . (name omitted), Director of Pharmacy. (pharmacy name omitted) to submit to . (facility omitted) an action plan to include notifying nursing staff of any variations to the original orders that involve concentration changes and supplying a warning label on all medications to check concentration of any liquid narcotics. Medication Administration Error Correction Process Report Purpose: To ensure residents remain free from medication errors. Incident Overview: Resident . (name omitted) at . (facility name omitted) was prescribed Morphine 10 mg/5 ml with the following instructions: 2.5ml every 4 hours via PEG (percutaneous endoscopic gastrostomy tube) for 14 days 2.5ml every hour as needed for pain via PEG tube The prescription was issued by the hospitalist upon the resident's discharge from the hospital to the nursing home. However, due to a pharmacy dispensing error, the pharmacist provided a 30ml bottle of Morphine 100mg/5ml instead of the prescribed 10mg/5ml. This resulted in a different concentration that what was prescribed and recorded on the Medication Administration Record (MAR). At . (facility omitted), 2.5ml (50mg) of the incorrect concentration was administered to . (Resident #1) by the nursing staff. Upon discovering the error, . (pharmacy name omitted) was immediately notified. The pharmacy staff corrected the issue and promptly re-educated the pharmacy staff. A Quality Assurance (QA) report was completed as required, and the physician was informed. The correct medication was then delivered to the facility. Corrective Actions Taken: 1. Staff Education and Re-Education The pharmacist and certified pharmacy technician responsible for the error were re-educated on proper dispensing procedures. Both employees received verbal notices regarding the importance of following correct processes. The Pharmacist-in-Charge met with the employees to reinforce adherence to dispensing protocols. 2. Process Improvements to Prevent Future Errors: Highlighting Concentrations in the Docu-Trak System: The morphine concentration to be dispensed will now be highlighted in the system to ensure visibility and accuracy. Enhanced Prescription Entry in QS1 Pharmacy System When entering liquid morphine prescriptions, the quantity to be administered will now include the dose in milligrams (mg) in parentheses. Example: 0.25 ml (5 mg) instead of pulling directions directly from . (electronic record system). Improved Storage and Labeling of Morphine Concentrations: Different morphine concentrations will be stored in separate areas of the narcotic cabinet to prevent mix-ups. Warning stickers will be placed on bottles to emphasize concentration differences. The 10mg/5ml bottles come in 100ml calibrated bottles, whereas the 100mg/5ml bottles come in 30ml calibrated bottles. Staff will be required to verify concentration during final checks before dispensing. These measures aim to enhance patient safety and eliminate the risk of similar medication errors in the future. The concern of not ensuring the medication Morphine sulfate was labeled with the correct dosage information was discussed with the administrator, director of nursing, assistant director of nursing, and vice-president of operations on 06/16/25 at 4:00 pm. No further information was provided prior to exit. This is a past non-compliance deficiency.

Based on staff interview, clinical record review, and facility policy review the facility staff failed to follow professional standards of practice for the administration of medications for 1 of 2 residents, Resident #1. The finding included: For Resident #1 the facility staff failed compare the medication label to the physician's order, resulting in the resident receiving multiple incorrect doses of the medication morphine sulfate. Resident #1's face sheet listed diagnoses which included but not limited to multiple sclerosis, epilepsy, long term use of opiate analgesic, and personal history of traumatic brain injury. Resident #1's most recent minimum data set with an assessment reference date of 11/18/24 assigned the resident a brief interview for mental status score of 3 out of 15. This indicates that the resident is severely cognitively impaired. Resident #1's comprehensive care plan was reviewed and contained a plan for . has dx (diagnosis) of MS (multiple sclerosis) with chronic pain . Interventions for this care plan included Administer medications as per orders. See MAR (medication administration record) for details. Resident #1's clinical record was reviewed and contained a physician's order summary which read in part, Morphine Sulfate Oral Solution 10 mg/5 ml (Morphine Sulfate). Give 2.5 ml via G-Tube every hour as needed for Pain/SOB (shortness of breath)-start date 01/27/25, Morphine Sulfate Oral Solution 10 mg/ 5 ml (Morphine Sulfate). Give 2.5 ml via G-Tube every 4 hours for pain/SOB-start date 01/27/25, Morphine Sulfate Oral Solution 10 mg/5ml (Morphine Sulfate). Place and dissolve 2.5 ml buccally every 4 hours for pain/SOB-start date 01/28/25, Morphine Sulfate Oral Solution 10 mg/5ml. Place and dissolve 2.5 ml buccally every 2 hours for pain/SOB-start date 01/29/25, and Morphine Sulfate Oral Solution 10 mg/5 ml. Place and dissolve 2 ml buccally every 6 hours for pain/SOB-start date 01/29/25 Resident #1's electronic medication administration record for the month of January 2025 was reviewed and contained entries as above. The entry for Morphine via G-Tube every 4 hours had been initialed as being administered ordered at 10 pm on 01/27/25, 2 am, 6 am and 10 am on 01/28/25. The entry for Morphine buccally every 4 hours had been initialed as being administered at 2 pm and 6 pm on 01/28/25. The entry for Morphine every 6 hours buccally was initialed as being administered at 12 am and 6 am on 01/29/25. The entry for Morphine every hour as needed via G-Tube was initialed as being administered on 01/29/25 at 8:07 am. The entry for Morphine every 2 hours buccally was initialed as being administered on 01/29/25 at 12 pm. Resident #1's Individual Resident's Controlled Substance Record for morphine was reviewed and contained a pharmacy label which read in part, Morphine 100 mg/5ml Conc-3 30 ml. Give 2.5 ml VGT (via G-Tube) every hour as needed for pain/SOB Surveyor spoke with the facility administrator on 06/16/25 regarding Resident #1's morphine order and subsequent medication errors. Administrator stated that pharmacy sent a different concentration of the morphine, labeled the dosage incorrectly, and the nurses that administered the morphine failed to compare the label to the physician's order. Surveyor requested and was provided with a facility policy entitled Administering Medications which read in part, Medications shall be administered in a safe and timely manner, and as prescribed .7. The individual administering the medication must check the label to verify the right medication, right dosage, right time, and right method (route) of administration before giving the medication. Administrator provided surveyor with a copy of the facility's investigation which read in part, . (Resident #1) readmitted to . (facility omitted) on 01/27/2025 .Resident was readmitted .for hospice, end of life care with a prognosis of days to weeks. Discharge orders from . (name omitted) included: Morphine 10 mg/5 ml, give 2.5 ml every 1 hour as needed. Orders were entered correctly into . (electronic record) and prescriptions sent to . (omitted) pharmacy. On January 27, 2025, at 2043 . received the Morphine Sulfate from pharmacy. The bottle and narcotic control sheet were both labeled Morphine 100 mg/5 ml concentrate give 2.5 ml every 1 hours as needed for pain/sob. Pharmacy failed to notify . (facility omitted) of a concentration change from original order sent to pharmacy. Additionally, with change in concentration, pharmacy made an error instructing to give 2.5 ml (50 mg) every hour as needed for pain/sob. The facility administrator provided the surveyor with a copy of the facility's Plan of Correction which read as follows: On January 31, 2025, RCA (root cause analysis) completed for . (facility omitted) nursing department. Findings from the RCA identified 2 root causes for the error. First, the MAR (medication administration record) dosing did not match the concentration or instructions on the narcotic control sheet nor on the actual medication bottle that was provided by pharmacy. Second, nurses failed to administer the medication based on the facility policy and procedure. Based on the findings, the facility's plan of correction is as follows: 1. Upon discovery of the error on January 29, 2025, an immediate audit was completed on all remaining residents receiving liquid narcotics to ensure no system wide failure occurred. There were no findings from this audit. 2. Review of our current policy and procedure for medication administration was completed. No changes indicated during this review. 3. Created a 2-step verification on all liquid controlled narcotics received from pharmacy to ensure that concentration and instructions match concentration and instructions on the MAR. 4. (name omitted), Administrator and . (name omitted), DON (director of nursing) met with all 4 nurses and provided education in regards to medication error. All 4 nurses were placed on disciplinary action to include a Performance Improvement Plan and all 4 nurses were reported to the Board of Nursing. 5. All nursing staff at . (facility omitted) were assigned education in . (name omitted) with a mandatory completion date of February 28, 2025. Additional training to be provided on drug calculations by February 28, 2025. 6. A review with attestation to be completed with all nursing staff on medication administration policy and procedure. 7. Medication administration observation to be completed on all nursing staff by February 28, 2025. 8. To assist with compliance, . (name omitted), DON will present findings of the above to our quarterly QAPI (quality assurance and performance improvement) meeting and a determination will be made on future audits/actions. All credible evidence was reviewed and verified on 06/16/25. Nursing staff were interviewed on policy and procedure for medication administration. A review of new hire nurses was completed to ensure that all new hires have received training in medication administration and dosage calculations. Medication storage rooms and medication carts were observed for correct labeling of medications with no discrepancies found. The concern of nursing staff failing to follow professional standards of practice for the administration of medications was discussed with the administrator, DON, assistant director of nursing and vice-president of operations on 06/16/25 at 4:00 pm. No further information was provided prior to exit. This is a past non-compliance deficiency.

Based on staff interview, clinical record review, facility document review and during a medication pass and pour observation the facility staff failed to ensure medications were available for administration for 4 of 26 residents, #57, #76, #18, and #44. The findings included: 1. For Resident #57 the facility staff failed to ensure the medication Tylenol 500 mg was available for administration. Resident #57's face sheet listed diagnoses which included but not limited to rheumatoid arthritis, anxiety disorder, osteoarthritis, and scoliosis. Resident #57's most recent minimum data set with an assessment reference date of 02/19/24 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #57's comprehensive care plan was reviewed and contained a care plan for . reports frequent pain that she attributes to RA (rheumatoid arthritis) to hands that does not interfere with sleep and occasionally limits day-to-day activities . Interventions for this care plan include administer analgesia as per orders. Surveyor observed licensed practical nurse (LPN) #5 during a medication pass and pour on 04/24/24 at 8:30 am. LPN #5 prepared Resident #57's medications, then stated to surveyor that the resident's Tylenol 500 mg was not on the cart, and they had ordered it over the weekend. LPN #5 stated they would have to pull it from the iStat (emergency medication supply). LPN #5 went to the medication room the remove the Tylenol from the iStat, then stated to surveyor that the iStat only contained 325 mg Tylenol. LPN #5 then contacted the nurse practitioner to obtain a one-time order to administer Tylenol 325 mg ii tabs. Surveyor reconciled Resident #57's medications with the clinical record on 04/24/24. Resident #57's clinical record contained a physician's order summary which read in part, Tylenol Extra Strength Oral Tablet 500 mg (Acetaminophen). Give 2 tablet by mouth two times a day for pain max 3 grams/24 hours. Surveyor requested and was provided with a list of medications available in the iStat system. Tylenol 500 mg was not listed. The concern of not ensuring Resident #57's Tylenol was available for administration was discussed with the administrator, director of nursing, assistant director of nursing and regional vice president of operations on 04/25/24 at 4:35 pm. No further information was provided prior to exit. 2. For Resident #76 the facility staff to ensure the medication Thiamine was available for administration. Resident #76's face sheet listed diagnoses which included but not limited to acute and chronic respiratory failure, iron deficiency anemia, immunodeficiency, unspecified, and other malaise. Resident #76's most recent minimum data set with an assessment reference date of 03/03/24 assigned the resident brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #76's comprehensive care plan was reviewed and contained a care plan for . has had desired weight gain . Interventions for this care plan include, Administer medications as ordered. Surveyor observed licensed practical nurse (LPN) #1 on 04/24/24 at 8:10 am during a medication pass and pour. LPN #1 prepared Resident #76's medications but stated to surveyor that resident's Thiamine was not on the cart, and they would have to order it from the pharmacy. Surveyor reconciled Resident #76's medications on 04/24/24. Resident #76's clinical record contained a physician's order summary which read in part, Thiamine HCl Oral Tablet 100 mg (Thiamine HCl). Give 1 tablet by mouth one time a day for supplement. Surveyor asked LPN #1 on 04/24/25 at 12:30 pm if resident's Thiamine had arrived from pharmacy, and LPN #1 stated that it had not. Surveyor asked LPN #1 on 04/25/24 at 8:50 am if they had received Resident #76's Thiamine and LPN #1 stated they still did not have it, that they had faxed the order to the pharmacy yesterday, that pharmacy would not deliver until after lunch today, and that the nurse practitioner is aware. Surveyor requested and was provided with a list of medications available in the iStat (emergency medication supply) system. Thiamine 100 mg was not listed. The concern of not ensuring Resident #76s Thiamine was available for administration was discussed with the administrator, director of nursing, assistant director of nursing and regional vice president of operations on 04/25/24 at 4:35 pm. No further information was provided prior to exit. 3. For Resident #18 the facility staff failed to ensure the medications Valium (diazepam) and Fibercon were available for administration Resident #18's face sheet listed diagnoses which included but not limited to multiple sclerosis, paraplegia, constipation, and muscle spasm. Resident #18's most recent minimum data set with an assessment reference date of 03/21/24 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. Resident #18's comprehensive care plan was reviewed and contained care plans for . receives anti-anxiety medication related to muscle relaxation and . has the potential for constipation r/t (related to) medications side effects and decreased mobility. Interventions for these care plans include administer medications as ordered and give anti-anxiety medications as ordered by physician. Resident #18's electronic medication administration record (eMAR) for the month of March 2024 was reviewed and contained entries which read in part, Valium Tablet 2 mg (diazepam). Give 1 tablet by mouth three times a day for muscle relaxation . and FiberCon (Calcium Polycarbophil). Give 2 tablets by mouth one time a day for constipation. The entry for Valium was marked [NAME] on 03/05/24 at 1500 (3 pm), and the entry for FiberCon was marked [NAME] on 03/11/24 at 1700 (5 pm). Surveyor spoke with licensed practical nurse (LPN) #1 on 04/25/24 at 8:50 am. Surveyor asked LPN #1 what [NAME] on the eMAR indicated, and LPN #1 stated, [NAME] means the medication was unavailable. Surveyor requested and was provided with a list of medications available in the iStat (emergency medication supply) system. Neither Valium 2 mg nor Fibercon were listed. The concern of not ensuring Resident #18's medications were available for administration was discussed with the administrator, director of nursing, assistant director of nursing and regional vice president of operations on 04/25/24 at 4:35 pm. No further information was provided prior to exit. 4. For Resident #44 the facility staff failed to ensure the medications Valproic acid and Atorvastatin were available for administration. Resident #44's face sheet listed diagnoses which included but not limited to diastolic (congestive) heart failure, bipolar disorder, hypothyroidism, and hyperlipidemia. Resident #44's most recent minimum data set with an assessment reference date of 03/22/24 assigned the resident a brief interview for mental status score of 7 out of 15 is section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #44's comprehensive care plan was reviewed and contained a care plan for . receives psychotropic medication including an antidepressant and antipsychotic r/t (related to) BIPOLAR DISORDER, DEPRESSION, AND INSOMNIA. Interventions for this care plan include Administer medications as ordered. Resident #44's clinical record was reviewed and contained a physician's order summary which read in part, Atorvastatin Calcium Oral Tablet 10 mg (Atorvastatin Calcium). Give 1 tablet by mouth one time a day for HDL (hyperlipidemia) and Valproic Acid Oral Solution 250 mg/5 ml (Valproate Sodium). Give 5 ml by mouth three times a day related to BIPOLAR DISORDER . Resident #44's electronic medication administration record for the months of February, March, and April 2024 were reviewed and contained entries as above. The entry for Atorvastatin was marked [NAME] on 02/09/24. The entry for Valproic acid was coded 5 on 03/29/24 and coded 9 on 04/22/24. Chart coded 5 is the equivalent of hold/see nurse's notes and the chart code 9 is the equivalent of other/see nurse's notes. Resident #44's nurse's notes were reviewed and contained notes which read in part, 03/29/2024 12:40. Note Text: Valproic Acid Solution 250 mg/5ml. Give 5 ml by mouth three times a day for hypomania pharmacy to send and Valproic Acid Oral Solution 250 mg/5 ml. Give 5 ml by mouth three times a day related to BIPOLAR DISORDER not on med cart. Surveyor spoke with licensed practical nurse (LPN) #1 on 04/25/24 at 8:50 am. Surveyor asked LPN #1 what [NAME] on the eMAR indicated, and LPN #1 stated, [NAME] means the medication was unavailable. Surveyor requested and was provided with a list of medications available in the iStat (emergency medication supply) system. Neither Valproic Acid Oral Solution nor Atorvastatin were listed. The concern of not ensuring Resident #44s medications were available for administration was discussed with the administrator, director of nursing, assistant director of nursing and regional vice president of operations on 04/25/24 at 4:35 pm. No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review and facility document review the facility staff failed to ensure 1 of 26 residents was clinically appropriate for self-administration of medications. The findings included: For Resident #56 the facility staff failed to complete a self-administration of medications assessment. Resident #56's face sheet listed diagnoses which included but not limited to traumatic subdural hematoma without loss of consciousness, quadriplegia, moderate persistent asthma, and personal history of other diseases of the respiratory system. Resident #56's most recent minimum data set with an assessment reference date of 01/21/24 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. Resident #56's comprehensive care plan was reviewed, and surveyor could not locate a care plan for self-administration of medications. Resident #56's physician's order summary was reviewed and contained orders which read in part, Advair HFA Inhalation Aerosol 45-21 MCG-ACT (Fluticasone-Salmeterol). 2 inhalation inhale orally one time a day for Asthma unsupervised self-administration-start date 02/18/24 and Xopenex Inhalation Aerosol (Levalbuterol tartrate). 1 puff inhale orally every 4 hours as needed for SOB (shortness of breath) unsupervised self-administration. Resident #56's electronic medication administration record (eMAR) for the month of April 2024 was reviewed and contained entries as above. The entry for Advair was initialed U-SA, which is equivalent to unsupervised self-administered. Resident #56's clinical record was reviewed, and surveyor could not locate a self-administration of medications assessment. Surveyor spoke with unit manager (UM) on 04/25/24 at 10:05 am regarding Resident #56. Surveyor asked UM who does the self-administration of medications assessments for residents, and UM stated they do. Surveyor asked if they had completed one for Resident #56, and UM stated that Resident #56 does not self-administer any medications. Surveyor spoke with Resident #56 on 04/25/24 at 10:10 am. Surveyor asked Resident #56 if they keep their inhaler to use when they need it, and Resident #56 stated, I don't have it right now, but sometimes I do. Surveyor asked Resident #56 if the nurse leaves the inhaler in their room for them the use, and Resident #56 stated, Yes, they leave it in here for me. Surveyor spoke with licensed practical nurse (LPN) #1 on 04/25/24 at 10:35 am regarding Resident #56. Surveyor asked LPN #1 if Resident #56 self-administered any medications, and LPN #1 stated, She keeps her Advair and Xopenex inhalers in her room, the FNP (family nurse practitioner said she can, and wrote an order. Surveyor spoke with FNP on 04/25/24 at 2:15 pm regarding Resident #56. FNP stated that resident can administer the inhalers herself, and that she understands how to use them. Surveyor asked FNP if facility should have completed a medication self-administration assessment for Resident #56, and FNP stated the facility should be aware if resident has any issues. Surveyor requested and was provided with a facility policy entitled Administering Medications which read in part, 17. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. A self-administration assessment will be completed prior to allowing a resident to self-administer medication and repeated quarterly or as needed due to change in status. The assistant director of nursing provided the surveyor with a copy of Assessment For Self-Administration Of Medications forms on 04/25/24 at 2:25 pm. One form was dated 12/06/21 and the second form was dated 04/25/24. The concern of not completing quarterly self-administration of medication assessments was discussed with the administrator, director of nursing, assistant director of nursing, and regional vice president of operations on 04/25/24 at 4:35 pm. No further information provided prior to exit.

Based on interviews and clinical record review, the facility staff failed to provide the necessary activities of daily living (ADL) care to maintain appropriate grooming, personal and oral care for one (1) of 26 sampled residents, Resident #62. The findings were: The facility staff failed to provide appropriate activities of daily living (ADLs), specifically combing hair, washing hands, washing face, shaving, and brushing teeth, for Resident #62. Resident #62's admission record listed diagnoses which included but were not limited to hemiplegia (total or partial paralysis of one side) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant side, aphasia (language disorder), dysphagia (difficulty swallowing), and apraxia (speech disorder) following cerebral infarction, lack of coordination, and repeated falls. The minimum data set assessment with an assessment reference date of 09/12/22 indicated Resident #62 should not have a brief interview for mental status conducted due to the resident being rarely/never understood. In Section C (cognitive patterns) the resident was coded as having a problem with long-term memory. The resident's short-term memory was coded as ok. Resident #62's cognitive skills for daily decision making was coded as Severely impaired - never/rarely made decisions. Section G (functional status) coded the resident required extensive assistance and one-person physical assist for ADL Self-Performance of personal hygiene (how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face, and hands). For Functional Limitation in Range of Motion, Resident #62 was coded as having impairment on one side for both upper and lower extremities. Resident #62's care plan documented a focus area which included but was not limited to the resident having a self-care deficit in ADL performance. This focus area, with a revision date of 9/26/22, listed interventions which included but were not limited to staff assisting with oral/personal care extensive assist with 2 persons. Resident #62's ADL documentation forms (titled Documentation Survey Report v2) for August, September, and October 2022 were reviewed. On 04/25/24 at 1:15 p.m. the Assistant Director of Nursing (ADON) explained the code/legend for the ADL documentation. The ADL titled personal hygiene (defined on the form as how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face, and hands) provided space for documentation for every day and every shift (day, evening, and night shift). For the month of September 2022, there were seven (7) shifts left blank; no documentation noted. For the month of October 2022, there were 11 shifts left blank; no documentation noted. At 1:40 p.m. on the same day, the director of nursing (DON) and ADON were shown the ADL documentation the surveyor was reviewing and asked what the blank spaces indicated. Both the DON and ADON acknowledged blank spaces provided no way to know whether the care was provided. The ADON stated, there was education needed. On 04/25/24 at 2:47 p.m. licensed practical nurse (LPN #4) and certified nursing assistant (CNA #3) were interviewed and shown Resident #62's ADL documentation from August, September, and October 2022. Both staff were familiar with Resident #62. When asked how the blank spaces were interpreted, LPN #4 stated blank spaces means someone did not chart. The nurse acknowledged there was no evidence the care was provided on those shifts. During an end of day meeting on 04/25/24 at 4:30 p.m., the administrator, vice president of operations, DON, and ADON were informed of the blank spaces within Resident #62's ADL documentation. No further information was provided prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer an updated 2023-2024 formula COVID-19 vaccine for 3 of 5 sampled residents, Resident #3, #24, and #75. The findings included: 1. For Resident #3, the facility staff failed to offer the resident an updated 2023-2024 formula COVID-19 vaccine. Resident #3's diagnosis list indicated diagnoses, which included, but not limited to Hypertensive Chronic Kidney Disease, Chronic Embolism and Thrombosis of Left Femoral Vein, and Osteoarthritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/12/24 assigned the resident a brief interview for mental status (BIMS) summary score of 13 out of 15 indicating the resident was cognitively intact. According to Resident #3's immunization history documented in the clinical record, the resident had previously received COVID-19 vaccines on 1/30/21, 2/20/21, and 12/15/21. Surveyor reviewed Resident #3's clinical record and was unable to locate evidence of the resident being offered an updated 2023-2024 formula COVID-19 vaccine. Surveyor met with the Director of Nursing (DON) and Infection Preventionist (IP) on 4/25/24 at 12:55 PM and discussed Resident #3's COVID-19 vaccination status. The DON and IP were unable to provide evidence of the facility offering the resident an updated 2023-2024 formula COVID-19 vaccine. Surveyor requested and received the facility policy titled Influenza/Pneumococcal/COVID-19 Immunization and Education with a reviewed/revised date of 1/16/24 which read in part .8. COVID-19 vaccines are provided by the facility weekly. A resident's vaccination status will be determined at time of admission. Consent will be obtained for resident requesting a vaccine. Pharmacy will verify vaccination status prior to administration through VIIS [Virginia Immunization Information System] portal. The vaccines will be administered per the CDC [Centers for Disease Control and Prevention] guidelines. 9. A master list of residents .receiving the .COVID immunizations will be maintained by the organization's occupational nurse as a means to track all residents .receiving the vaccination annually . On 4/25/24 at 4:35 PM, the survey team met with the [NAME] President of Operations, Administrator, DON, and IP and discussed the concern of facility staff failing to offer Resident #3 an updated 2023-2024 formula COVID-19 vaccine. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/25/24. 2. For Resident #24, the facility staff failed to offer the resident an updated 2023-2024 formula COVID-19 vaccine. Resident #24's diagnosis list indicated diagnoses, which included, but not limited to Osteomyelitis of Vertebra, Sacral, and Sacrococcygeal Region, Atherosclerotic Heart Disease of Native Coronary Artery, Paroxysmal Atrial Fibrillation, Thoracic Aortic Aneurysm, and Polyneuropathy. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/08/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. According to Resident #24's immunization history documented in the clinical record, the resident had previously received COVID-19 vaccines on 3/05/21 and 4/02/21. Surveyor reviewed Resident #24's clinical record and was unable to locate evidence of the resident being offered an updated 2023-2024 formula COVID-19 vaccine. Surveyor met with the Director of Nursing (DON) and Infection Preventionist (IP) on 4/25/24 at 12:34 PM and discussed Resident #24's COVID-19 vaccination status. The DON stated the resident's physician did not want the COVID-19 vaccine given while Resident #24 was receiving IV (intravenous) antibiotics, and the resident did not meet the requirements at the time the vaccine was being administered. The DON and IP were unable to provide evidence of the facility offering the resident an updated 2023-2024 formula COVID-19 vaccine or documentation of contraindications to receiving the vaccine. Surveyor requested and received the facility policy titled Influenza/Pneumococcal/COVID-19 Immunization and Education with a reviewed/revised date of 1/16/24 which read in part 1. Upon admission the resident or their responsible party will be provided the option for the resident to receive the .COVID-19 immunization .4. Documentation of the resident acceptance or refusal of the immunization or the medical contraindications of the immunization will be made in each resident's medical record .8. COVID-19 vaccines are provided by the facility weekly. A resident's vaccination status will be determined at time of admission. Consent will be obtained for resident requesting a vaccine. Pharmacy will verify vaccination status prior to administration through VIIS [Virginia Immunization Information System] portal. The vaccines will be administered per the CDC [Centers for Disease Control and Prevention] guidelines. 9. A master list of residents .receiving the .COVID immunizations will be maintained by the organization's occupational nurse as a means to track all residents .receiving the vaccination annually . On 4/25/24 at 4:35 PM, the survey team met with the [NAME] President of Operations, Administrator, DON, and IP and discussed the concern of facility staff failing to offer Resident #24 an updated 2023-2024 formula COVID-19 vaccine. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/25/24. 3. For Resident #75, the facility staff failed to offer the resident an updated 2023-2024 formula COVID-19 vaccine. Resident #75's diagnosis list indicated diagnoses, which included, but not limited to Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, Congestive Heart Failure, and Type 2 Diabetes Mellitus. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/05/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. According to Resident #75's immunization history documented in the clinical record, the resident had previously received COVID-19 vaccines on 6/25/21 and 7/15/21. Surveyor reviewed Resident #75's clinical record and was unable to locate evidence of the resident being offered an updated 2023-2024 formula COVID-19 vaccine. Surveyor met with the Director of Nursing (DON) and Infection Preventionist (IP) on 4/25/24 at 12:55 PM and discussed Resident #75's COVID-19 vaccination status. The DON and IP were unable to provide evidence of the facility offering the resident an updated 2023-2024 formula COVID-19 vaccine. Surveyor requested and received the facility policy titled Influenza/Pneumococcal/COVID-19 Immunization and Education with a reviewed/revised date of 1/16/24 which read in part .8. COVID-19 vaccines are provided by the facility weekly. A resident's vaccination status will be determined at time of admission. Consent will be obtained for resident requesting a vaccine. Pharmacy will verify vaccination status prior to administration through VIIS [Virginia Immunization Information System] portal. The vaccines will be administered per the CDC [Centers for Disease Control and Prevention] guidelines. 9. A master list of residents .receiving the .COVID immunizations will be maintained by the organization's occupational nurse as a means to track all residents .receiving the vaccination annually . On 4/25/24 at 4:35 PM, the survey team met with the [NAME] President of Operations, Administrator, DON, and IP and discussed the concern of facility staff failing to offer Resident #75 an updated 2023-2024 formula COVID-19 vaccine. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/25/24.

Based on observation, staff interview, clinical record review and facility document review the facility staff failed to ensure an accurate minimum data set (MDS) assessment for 1 of 26 residents, Resident #50. The findings included: For Resident #50 the facility staff failed to code the MDS assessment for use of a CPAP (continuous positive airway pressure) machine. Resident #50's face sheet listed diagnoses which included but not limited to encephalopathy, Parkinson's disease, and obstructive sleep apnea. Resident #50's most recent MDS with an assessment reference date of 03/22/24 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Section O, Special Treatments, Procedures and Programs, subsection G3, CPAP, was not coded at being used. Resident #50's comprehensive care plan was reviewed, and surveyor could not locate a care plan for use of CPAP. Resident #50's clinical record was reviewed and contained a physician's order summary for the month of April. This summary did not include an order for CPAP. Surveyor observed Resident #50 on 04/23/24 at 1:45 pm. Resident #50 was observed resting on bed with CPAP mask in place. Surveyor observed Resident #50 again on 04/24/24 at 9:30 am, Resident was resting in bed with CPAP mask in place. Surveyor spoke with licensed practical nurse (LPN) #9 on 04/24/24 at 10:30 am regarding Resident #50. LPN #9 stated that uses CPAP all the time when he's lying down, and he puts it on himself. Surveyor spoke with MDS coordinator on 04/25/24 at 9:40 am regarding Resident #50. Surveyor asked MDS coordinator if use of the CPAP should be included on the MDS, if resident was using CPAP during the look back period. Surveyor requested and was provided with a facility policy entitled Resident Assessment and Care Planning which read in part, A. The nursing facility shall conduct an initial and periodic assessment of each resident's needs. The assessment shall accurately describe the resident's capability to perform daily life functions and significant impairments in functional capacity. This comprehensive assessment shall include, but is not limited to: 6. Special treatment or procedures; The MDS coordinator provided the surveyor with a modified MDS on 04/25/24 at 11:05 am and stated that use of the CPAP was included on the MDS and added to the care plan. The concern of not ensuring an accurate MDS assessment was discussed with the administrator, director of nursing, assistant director of nursing, and regional vice president of operations on 04/25/24 at 4:35 pm. No further information was provided prior to exit.

Based on observation, staff interview, resident interview, clinical record review, and facility document review the facility staff failed to develop a comprehensive care plan for 2 of 26. residents, #50 and #56. The findings included: 1. For Resident #50 the facility staff failed to develop a care plan for use of a CPAP (continuous positive airway pressure) machine. Resident #50's face sheet listed diagnoses which included but not limited to encephalopathy, Parkinson's disease, and obstructive sleep apnea. Resident #50's most recent MDS with an assessment reference date of 03/22/24 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Section O, Special Treatments, Procedures and Programs, subsection G3, CPAP was not coded at being used. Resident #50's comprehensive care plan was reviewed, and surveyor could not locate a care plan for use of CPAP. Resident #50's clinical record was reviewed and contained a physician's order summary for the month of April. This summary did not include an order for CPAP. Surveyor observed Resident #50 on 04/23/24 at 1:45 pm. Resident #50 was observed resting on bed with CPAP mask in place. Surveyor observed Resident #50 again on 04/24/24 at 9:30 am, Resident was resting in bed with CPAP mask in place. Surveyor spoke with licensed practical nurse (LPN) #9 on 04/24/24 at 10:30 am regarding Resident #50. LPN #9 stated that uses CPAP all the time when he's lying down, and he puts it on himself. Surveyor spoke with MDS coordinator on 04/25/24 at 9:40 am regarding Resident #50. Surveyor asked MDS coordinator if use of the CPAP should be included in the care plan. MDS stated that it should be. Surveyor requested and was provided with a facility policy entitled Resident Assessment and Care Planning which read in part, Policy: The facility will develop a comprehensive care plan within 7 days of completion of the Comprehensive Assessment, which will include measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs identified in the comprehensive assessment. In addition to the admission care plan, a comprehensive plan of care will be done annually or with any significant change in the resident's status. The MDS coordinator provided the surveyor with a modified MDS on 04/25/24 at 11:05 am and stated that use of the CPAP was included on the MDS and added to the care plan. The concern of not developing a care plan for use of a CPAP was discussed with the administrator, director of nursing, assistant director of nursing, and regional vice president of operations on 04/25/24 at 4:35 pm. No further information was provided prior to exit. 2. For Resident #56 the facility staff failed to develop a care plan for self-administration of medications. Resident #56's face sheet listed diagnoses which included but not limited to traumatic subdural hematoma without loss of consciousness, quadriplegia, moderate persistent asthma, and personal history of other diseases of the respiratory system. Resident #56's most recent minimum data set (MDS) with an assessment reference date of 01/21/24 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. Resident #56's comprehensive care plan was reviewed, and surveyor could not locate a care plan for self-administration of medications. Resident #56's physician's order summary was reviewed and contained orders which read in part, Advair HFA Inhalation Aerosol 45-21 MCG-ACT (Fluticasone-Salmeterol). 2 inhalation inhale orally one time a day for Asthma unsupervised self-administration-start date 02/18/24 and Xopenex Inhalation Aerosol (Levalbuterol tartrate). 1 puff inhale orally every 4 hours as needed for SOB (shortness of breath) unsupervised self-administration. Resident #56's electronic medication administration record (eMAR) for the month of April 2024 was reviewed and contained entries as above. The entry for Advair was initialed U-SA, which is equivalent to unsupervised self-administered. Surveyor spoke with unit manager (UM) on 04/25/24 at 10:05 am regarding Resident #56. Surveyor asked UM who does the self-administration of medications assessments for residents, and UM stated they do. Surveyor asked if they had completed one for Resident #56, and UM stated that Resident #56 does not self-administer any medications. Surveyor spoke with Resident #56 on 04/25/24 at 10:10 am. Surveyor asked Resident #56 if they keep their inhaler to use when they need it, and Resident #56 stated, I don't have it right now, but sometimes I do. Surveyor asked Resident #56 if the nurse leaves the inhaler in their room for them the use, and Resident #56 stated, Yes, they leave it in here for me. Surveyor spoke with licensed practical nurse (LPN) #1 on 04/25/24 at 10:35 am regarding Resident #56. Surveyor asked LPN #1 if Resident #56 self-administered any medications, and LPN #1 stated, She keeps her Advair and Xopenex inhalers in her room, the FNP (family nurse practitioner) said she can and wrote an order. Surveyor spoke with FNP on 04/25/24 at 2:15 pm regarding Resident #56. FNP stated that resident can administer the inhalers herself, and that she understands how to use them. Surveyor spoke with the MDS coordinator on 04/25/24 at 2:20 pm regarding Resident #56. MDS coordinator stated if Resident #56 has been assessed as appropriate for self-administration of medications, then it should be care planned. MDS coordinator also stated they would expect to see a physician's order as well. Surveyor requested and was provided with a facility policy entitled Resident Assessment and Care Planning which read in part, Policy: The facility will develop a comprehensive care plan within 7 days of completion of the Comprehensive Assessment, which will include measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs identified in the comprehensive assessment. In addition to the admission care plan, a comprehensive plan of care will be done annually or with any significant change in the resident's status. The concern of not developing a care plan for self-administration of medications was discussed with the administrator, director of nursing, assistant director of nursing, and regional vice president of operations on 04/25/24 at 4:35 pm. No further information provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer a pneumococcal vaccine to 2 of 5 sampled residents (Resident #24 and #76) in accordance with nationally recognized standards. 1. For Resident #24, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 20 (PCV20) or a pneumococcal polysaccharide vaccine 23 (PPSV23) following admission to the facility. Resident #24's diagnosis list indicated diagnoses, which included, but not limited to Osteomyelitis of Vertebra, Sacral, and Sacrococcygeal Region, Paroxysmal Atrial Fibrillation, Atherosclerotic Heart Disease of Native Coronary Artery, and Thoracic Aortic Aneurysm. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/08/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. According to Resident #24's immunization history documented in the clinical record, the resident had previously received a Prevnar13 vaccine on 2/01/16 with no other documented pneumococcal vaccines. Resident #24's clinical record included a Influenza and Pneumococcal Vaccines Consent signed by the resident on 11/07/23 with a checkmark by the statement Yes, I have received the pneumococcal vaccine in the recent past (date), on the line for the date, unsure was written. The Centers for Disease Control and Prevention (CDC) guideline titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate last reviewed 9/22/23, read in part, for adults [AGE] years or older who have only received PCV13, CDC recommends one dose of PCV20 or PPSV23 at least one year after PCV13. Surveyor reviewed Resident #24's clinical record and was unable to locate evidence of the resident being offered a PCV20 or a PPSV23 vaccine. Surveyor met with the Director of Nursing (DON) and Infection Preventionist (IP) on 4/25/24 at 12:34 PM and discussed Resident #24's pneumococcal vaccination status. The DON stated the resident was unsure if their pneumococcal vaccine was up to date and he had been sick. The DON and IP were unable to provide evidence of the facility offering the resident a PCV20 or PPSV23 vaccine according to CDC guidelines. Surveyor requested and received the facility policy titled, Influenza/Pneumococcal/COVID-19 Immunization and Education with a reviewed/revised date of 1/16/24 which read in part, .Purpose: To provide a means for the facility to track .pneumococcal immunization administration and education ensuring all eligible residents receive immunization as recommended by the Center for Disease Control .3. The facility will determine if the resident is eligible to receive the immunizations and will administer per the facility's protocol .4. Documentation of the resident acceptance or refusal of the immunization or the medical contraindications of the immunization will be made in each resident's medical record .10. Persons sixty-five (65) years of age and older who have not received the pneumococcal vaccine is [sic] the past five (5) years should receive another dose of vaccine . On 4/25/24 at 4:35 PM, the survey team met with the [NAME] President of Operations, Administrator, DON, and IP and discussed the concern of Resident #24 not being offered a PCV20 or PPSV23 vaccine following admission to the facility. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/25/24. 2. For Resident #76, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 20 (PCV20) or a pneumococcal polysaccharide vaccine 23 (PPSV23) following admission to the facility. Resident #76's diagnosis list indicated diagnoses, which included, but not limited to Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Emphysema, Congestive Heart Failure, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Myelodysplastic Syndrome, Immunodeficiency, and Atherosclerotic Heart Disease of Native Coronary Artery. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/03/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. According to Resident #76's immunization history documented in the clinical record, the resident had previously received a Prevnar13 vaccine on 12/09/16 with no other documented pneumococcal vaccines. Resident #76's clinical record included an Influenza and Pneumococcal Vaccines Consent signed by the resident on 7/03/23 with a checkmark by the statement Yes, I have received the pneumococcal vaccine in the recent past (date), on the line for the date, unsure was written. The Centers for Disease Control and Prevention (CDC) guideline titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate last reviewed 9/22/23, read in part adults between 19 through [AGE] years old with conditions or risk factors such as Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and Emphysema who have only received PCV13, CDC recommends one dose of PCV20 or PPSV23 at least one year after PCV13. On 4/25/24 at 12:20 PM, surveyor met with the Infection Preventionist (IP) who stated the resident should have received a PCV20 or PPSV23. IP stated the facility offers PCV20 vaccines and to their recollection, Resident #76 consented to receiving it. On 4/25/24 at 12:27 PM, surveyor spoke with the Director of Nursing (DON) who stated at one point, the facility was having issues with insurance not paying for pneumococcal vaccines but currently the facility has ten doses on hand. Surveyor requested and received the facility policy titled, Influenza/Pneumococcal/COVID-19 Immunization and Education which read in part, .Purpose: To provide a means for the facility to track .pneumococcal immunization administration and education ensuring all eligible residents receive immunization as recommended by the Center for Disease Control .3. The facility will determine if the resident is eligible to receive the immunizations and will administer per the facility's protocol .4. Documentation of the resident acceptance or refusal of the immunization or the medical contraindications of the immunization will be made in each resident's medical record .10. Persons sixty-five (65) years of age and older who have not received the pneumococcal vaccine is [sic] the past five (5) years should receive another dose of vaccine . On 4/25/24 at 4:35 PM, the survey team met with the [NAME] President of Operations, Administrator, DON, and IP and discussed the concern of Resident #76 not being offered a PCV20 or PPSV23 vaccine following admission to the facility. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/25/24.

Based on observations, staff interviews, and facility document review, the facility staff failed to ensure individuals providing resident care correctly performed hand hygiene. The findings include: A contract staff member (SM #20) failed to perform hand hygiene between facility residents when providing toenail care. The following information was found in a facility policy and procedure titled Handwashing (with a revised date of 3/18/23): - It is the policy of this facility that hand washing be regarded as the single most important means of preventing the spread of infections. - The use of gloves does not replace the need for hand hygiene by either alcohol based waterless hand rubs or hand washing with soap and water. - Handwashing to be performed for at least twenty (20) seconds under the following conditions: . Before and after having contact with a resident (i.e., bed bath, changing linen, etc.) . After contact with inanimate objects to include medical equipment in the vicinity of the patient . On 4/25/24 at 1:10 p.m., a contract staff member (SM #20) was observed to finish providing toenail care to Resident #38 and to start providing toenail care to Resident #68; SM #20 was observed to change their gloves but did not perform hand hygiene. On 4/25/24 at 1:16 p.m., SM #20 was observed to finish providing toenail care to Resident #68 and to start providing toenail care to Resident #61; SM #20 was observed to change their gloves but did not perform hand hygiene. On 4/25/24 at 1:24 p.m., SM #20 stated they had changed their gloves, between residents, while providing toenail care to the aforementioned residents. SM #20 stated they had not performed hand hygiene between the aforementioned residents. On 4/25/24 at 4:33 p.m., the survey team met with the facility's Administrator, Director of Nursing, Assistant Director of Nursing, and Vice-President of Operations. During this meeting, the surveyor discussed observations of SM #20 not performing hand hygiene when changing gloves between residents.

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to ensure complete and/or accurate clinical records for three (3) of 33 residents (Resident #50, Resident #60, and Resident #106). The findings include: 1. The facility staff failed to ensure Resident #106's medication allergy section of the electronic health record was complete and/or accurate. The facility staff failed to ensure Resident #106 initial skin assessment documented the presence of areas that were receiving medication and/or treatment. Resident #106's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/29/23, was signed as completed on 12/6/23. Resident #106 was assessed as being able to make self understood and as being able to understand others. Resident #106's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. Resident #106 was assessed as requiring assistance with or being dependent on another for toileting hygiene, dressing, and bathing. The following information was found in a facility policy and procedure titled Nursing Documentation (with a revised date of 2/20/24): - Documentation in the medical record facilitates communication among professionals from different disciplines and on different shifts. It provides information so that health care providers can deliver care in a coordinated manner. - PROCEDURE: . The admission assessment and all aspects of the admission process to include height, facility obtained weight and vital signs [sic]. - This policy indicated, Normal and abnormal staff observations should be documented. Resident #106's allergy section of the facility's electronic health record did not include the medication ampicillin/sulbactam. Resident #106's discharge summary, from their hospital stay prior to coming to the facility, included documentation that indicated the resident experienced a possible anaphylactic reaction after receiving a dose of ampicillin/sulbactam; Resident #106's symptoms were documented as flushing, hives, and low blood pressure. (Anaphylaxis is a severe allergic reaction that is potentially life-threatening without medical intervention.) This discharge summary advised Resident #106 to consider having formal allergy /desensitization testing on elective basis if penicillin therapy again [sic] needed in the future . On 4/24/24 at 3:55 p.m., Licensed Practical Nurse (LPN) #2 reported part of their job responsibilities was to admit new residents to the facility. LPN #2 reported to determine a resident's allergies on admission they would review the electronic health information provided by the sending facility; LPN #2 stated this information would include any provided discharge summary. Resident #106's admission skin assessment failed to capture areas where the resident had a rash and had treatment ordered by the provider at the time of admission. (At the time of admission Resident #106 had an order for Triamcinolone Acetonide External Cream to be applied twice a day to the areas of skin affected by a rash.) Resident #106 had a skin assessment completed five days after admission that indicated the resident had multiple red areas in skin folds. On 4/25/24 at 4:05 p.m., the surveyor discussed Resident #106's second skin assessment, which included documentation of the resident having red areas noted to multiple skin folds, with the facility's Assistant Director of Nursing (ADON). The ADON acknowledged that Resident #106's red areas in skin folds were not captured on the initial skin assessment but felt that the medical provider order for cream to be applied to rashes indicated the rash was present on admission and the rash was being treated by facility staff. 34307 2. For Resident #50 the facility staff failed to ensure the Virginia Department of Health Durable Do Not Resuscitate (DDNR) for was complete. Resident #50's face sheet listed diagnoses which included but not limited to encephalopathy, Parkinson's disease, and obstructive sleep apnea. Resident #50's face sheet also indicated that the resident has a do not resuscitate order. Resident #50's most recent MDS with an assessment reference date of 03/22/24 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. Resident #50's comprehensive care plan was reviewed and contained a care plan for . has Advance Directives-Code Status: DDNR Interventions for this care plan were, Advance Directives will be maintained in medical record with review/revision as indicated. Resident #50's clinical record was reviewed and contained a physician's order summary which read in part, Do Not Resuscitate (DNR). Resident #50's clinical record contained a Virginia Department of Health DDNR form which read in part, I, the undersigned, state that I have a [NAME] fide physician/patient relationship with the patient named above .I further certify (must check 1 or 2): .If you checked 2 above, you must check A, B, or C below: . None of the specified boxes were checked. The concern of Resident #50 incomplete DDNR form was discussed with the administrator, director of nursing, assistant director of nursing, and regional vice-president of operations of 04/25/24 at 4:35 pm. No further information was provided prior to exit. 42353 3. For Resident #60, the facility staff failed to document in the clinical record the responsible party's decision to decline the influenza, pneumococcal, and updated 2023-2024 formula COVID-19 vaccines. Resident #60's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Panic Disorder, and Psychotic Disorder with Delusions. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/17/24 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. According to Resident #60's immunization history documented in the clinical record, the resident had previously received COVID-19 vaccines on 1/25/21, 2/15/21, 6/14/22, 10/20/22 and the most recent influenza vaccine was received on 10/12/22. The resident's immunization documentation did not include a history of any previous pneumococcal vaccines. Surveyor reviewed Resident #60's clinical record and was unable to locate evidence of the resident being offered a 2023 influenza vaccine, pneumococcal vaccine, or an updated 2023-2024 formula COVID-19 vaccine. On 4/25/24 at 12:30 PM, surveyor met with the Infection Preventionist (IP) who stated the Unit Manager (UM) offered the vaccines to the resident's responsible party (RP) however, the RP declined the vaccines due to the resident's condition and the UM failed to document this in the clinical record. On 4/25/24 at 12:43 PM, surveyor spoke with the UM (licensed practical nurse #4) who stated they offered the vaccines to Resident #60's RP and they declined but failed to document it in the clinical record. Surveyor requested and received the facility policy titled Influenza/Pneumococcal/COVID-19 Immunization and Education with a reviewed/revised date of 1/16/24 which read in part .4. Documentation of the resident acceptance or refusal of the immunization or the medical contraindications of the immunization will be made in each resident's medical record . On 4/25/24 at 4:35 PM, the survey team met with the [NAME] President of Operations, Administrator, Director of Nursing, and the IP and discussed the concern of facility staff failing to document Resident #60's RP's decision to decline offered vaccinations. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/25/24.

Based on staff interview,clinical record review, and facility document review the facility staff failed to ensure 1 of 26 residents was free of significant medication errors, Resident #6. The findings included: For Resident #6 the facility staff failed to administer the medication Levothyroxine per the physcian's order. Resident #6's face sheet listed diagnoses which included but not limited to post procedural hypothyroidism. Resident #6's most recent minimum data set with an assessment reference date of 02/04/24 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. Resident #6's comprehensive care plan was reviewed and contained a care plan for .has a health history of type II diabetes mellitus with neuropathic/ophthalmic complication, anemia, . and other co-morbidities. Interventions for this care plan include Provide medications/treatments as ordered. Resident #6's clinical record was reviewed and contained a physician's order summary which read in part, Levothyroxine Sodium Oral Tablet 50 mcg (Levothyroxine Sodium). Give 50 mcg by mouth one time a day for hypothyroidism-start date 04/06/2024 and Levothyroxine Sodium Oral Tablet 75 mcg (Levothyroxine Sodium). Give 75 mcg by mouth one time a day for hypothyroidism-end date 04/05/2024. Resident #6's electronic medication administration record for the months of March and April 2024 were reviewed and contained entries as above. The entry for 03/12/24 was coded 9. The entry for 04/09/24 was coded 9. Chart code 9 is the equivalent of other/see nurses notes. Resident #6's nurses progress notes were reviewed and contained notes which read in part, 3/12/2024 06:08. Note Text: Levothyroxine Sodium Tablet 75 mcg. Give 1 tablet by mouth one time a day for hypothyroidism not on med cart and 4/9/2024 5:52. Note Text: Levothyroxine Sodium Tablet 50 mcg. Give 1 tablet by mouth one time a day for hypothyroidism not on med cart. Surveyor requested and was provided with a facility policy entitled, Medication Unavailable, STAT/Emergency Medication Cart Usage which read in part, Medication Unavailable. 2. Review STAT medication list for medication available on site . 3. In the event that the medication is unavailable, notify MD to get further instructions/alternate medication or treatment. Surveyor was provided with a list of medications available in the STAT/Emergency Mediation Cart. Levothyroxine 50 mcg was listed as being available. Levothyroxine 75 mcg was not listed. The concern of failing to ensure Resident #6 was free of a significant medication error was discussed with the administrator, director of nursing, assistant director of nursing and regional vice president of operations on 04/25/24 at 4:35 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, the facility staff failed to provide adequate monitoring for residents receiving psychotropic medications for one of 26 residents in the survey sample, resident # 65. This findings included: For resident # 65 the facility staff failed to implement behavior monitoring or nonpharmacologic interventions for several psychotropic medications prescribed. Resident # 65's diagnoses included but were not limited to, anxiety, depression, history of stroke, diabetes and obstructive sleep apnea. The minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/6/24 assigned the resident a brief interview for mental status (BIMS) score of 15 indicating intact cognition . Resident # 65 was coded as feeling down or depressed 2-6 days in the lookback period. No behaviors were noted in the lookback period according to the MDS. Review of the clinical record revealed that resident # 65 was prescribed Abilify 2 mg everyday by mouth for a diagnosis of depression(Abilify is classified as an antipsychotic medication), Sertraline 100 mg daily for depression/anxiety (classified as an antidepressant), Trazodone 50 mg daily for insomnia (classified as an antidepressant, and Lorazepam 0.25 mg twice daily and .25 mg every 4 hours as needed for anxiety. There was no behavior monitoring on the Medication Administration Record (MAR) for the month of April 2024. The progress notes did not indicate that staff were consistently monitoring resident # 65's behaviors. This surveyor interviewed the Assistant Director of Nursing on 4/25/24 at 11:37 AM. When asked where I could expect to find behavior monitoring they stated, it would be on the MAR. Surveyor asked for them to check resident # 65's MAR and produce a copy of the behavior monitoring if they located it. They stated they could not locate it. Surveyor asked if they would expect that a resident on multiple types of psychotropic medications would be expected to have behavior monitoring in place, they stated, yes, I would. Surveyor requested and received a copy of the policy entitled, Behavior Monitoring Policy (psychotropic medications) with a policy date of 5/2017. The document read in part, To maintain the functional ability of the resident by managing behaviors issues that may place the resident or others at risk of injury. Using techniques customized to the residents's needs minimizing the use of medications to manage their behaviors. Regulatory monitoring, with focus on elimination or reduction of psychotropic medications when appropriate for resident. And under the heading Nursing, 1. The documentation of behaviors will be completed using the behavior flowsheets in the MAR; with focus on: a. Behaviors noted b. Non-pharmacological interventions attempted to address behaviors with effectiveness c. Side effects from the medications required noted. On 4/25/24 at 4:20 PM the survey team met with the Administrator, Director of Nursing, and the Assistant Director of Nursing. This concern was discussed at that time. No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review the facility staff failed to ensure 1 of 26 residents was free from unnecessary medications, Resident #44. The findings included: For Resident #44 the facility staff administered the blood pressure medication, Metoprolol outside of the physician ordered parameters. Resident #44's face sheet listed diagnoses which included but not limited to diastolic (congestive) heart failure, and hypertensive heart disease. Resident #44's most recent minimum data set with an assessment reference date of 03/22/24 assigned the resident a brief interview for mental status score of 7 out of 15 is section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #44's comprehensive care plan was reviewed and contained a care plan for .has a health history of Alzheimer's Dementia with anxiety, AFIB (atrial fibrillation), HTN (hypertension [high blood pressure]), age related debility among other co-morbidities. Interventions for this care plan include provide medications/treatments as ordered. Resident #44's clinical record was reviewed and contained physician's order summary which read in part, Metoprolol Succinate ER (extended release) Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate). Give 1 tablet by mouth one time a day for Afib. Hold if DBP (diastolic blood pressure) < (less than) or = 60. Resident #44's electronic medication administration record for the months of February and March 2024 were reviewed and contained entries as above. The entry for 02/01/24 was coded as administered with a DBP of 60 and on 02/27/24 with a DBP of 58. The entries for 03/11/24 and 03/12/24 were coded as administered, both with a DBP of 60. Surveyor spoke with licensed practical nurse (LPN) #1 on 04/25/24 at 8:50 am. Surveyor asked LPN #1 to review Resident #44's physician's order for Metoprolol, and LPN #1 did so, and stated that the medication is to be held if DBP is 60 or less. Surveyor then asked LPN #1 to review Resident #44's electronic medication administration records for February and March. LPN #1 stated the medication had been administered when it should have been held per the physician's order. Surveyor requested and was provided with a facility policy entitled, Administering Medications which read in part, Medications shall be administered in a safe and timely manner, and as prescribed. The concern of not ensuring Resident #44 was free of unnecessary medications was discussed with the administrator, director of nursing, assistant director of nursing, and regional vice president of operations on 04/25/24 at 4:35. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure medications/supplements were stored in a locked compartment in a resident room for 1 of 24 (Resident #27), failed to label and store medication appropriately on 1 of 4 wings (wing 1), failed to keep medications in direct line of sight until administered for 1 of 4 Residents during a medication pass (Resident #10), and failed to lock an unattended medication cart on 1 of 4 wings (wing 3). The findings include: 1. For Resident #27, the facility staff failed to store supplements in a locked compartment. Resident #27 had been approved to self-administer their supplements these were observed to be kept in an unlocked drawer in the residents room. Resident #27's diagnosis included, but were not limited to, quadriplegia and polyneuropathy. Section C (cognitive patterns) of Resident #27's quarterly MDS (minimum data set) assessment with an assessment reference date (ARD) of 07/22/22 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Resident #27's clinical record included a provider order to keep the following supplements at bedside: coconut oil capsule (09/25/18), ginger root (07/31/19), super B-complex (07/31/19), turmeric (07/31/19), and vitamin D3 (07/31/19). Resident #27's comprehensive care plan included the focus area keeps supplements per her choice, and as approved by MD at bedside, and completes self-administration. These include: Coconut Oil, Ginger Root, Super B Complex, Turmeric, and Vitamin D. Interventions included, but were not limited to, consult MD for discussion with patient should they be noncompliant with self-administration of these medications. Medications to be kept in a lock box in the patients room. Resident #27's clinical record included a self-administration of medications assessment completed on 04/30/21 that was signed by the provider indicating the resident was granted approval for self-administration of medications. 10/12/22 3:40 p.m., the surveyor observed Resident #27 open the second drawer of a small dresser and remove the following supplements Vitamin C, Super B complex, [NAME] Quai, D3, Magnesium, Biotin, Coconut oil. Resident #27 left a container of Hemp cream in the drawer and stated this was used for pain. Resident #27 stated they were going to let the staff administer her medications, she may have had a lock box one time, but she turned it back in. 10/12/22 3:45 p.m., during an end of the day meeting with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) the issue regarding the supplements was discussed. 10/13/22 the facility staff provided the survey team with a copy of a document titled, Medication Storage policy date 03/2016. This document read in part, .A medicine cabinet, container or compartment shall be used for storage of medications prescribed for residents .Medication Storage .The storage area shall be locked . 10/13/22 12:15 p.m., Licensed Practical Nurse (LPN) #1 stated they were returning the supplements to the pharmacy. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. The facility nursing staff failed to label insulin with a Residents name and stored Novolog insulin in a bag labeled Lantus insulin. 10/13/22 12:10 p.m., checked medication cart wing 1 with Registered Nurse (RN) #1. This medication cart contained a clear baggy labeled with the name of Resident #87 and Lantus insulin. Inside this clear baggy was 3 insulin pens 2 Lantus and 1 Novolog. Only 1 insulin pen included a label with Resident #87's name and the type of insulin (Lantus). Resident #87's clinical record included an order for Lantus insulin (04/12/22). The Novolog had been discontinued by the provider on 10/10/22. The clinical record included the diagnosis type 2 diabetes mellitus. 10/13/22 1:03 p.m., RN #1 reviewed Resident #87's clinical record and stated the Novolog insulin had been discontinued and they had discarded the unlabeled insulin pens. 10/13/22 the DON staff provided the survey team with a policy titled, Medication Labeling. This policy read in part, .All medications shall remain in the pharmacy issued container, with the legible prescription label or direction label attached . 10/13/22 3:45 p.m., the Administrator, DON, ADON, and LPN #3 were made aware of the issue regarding labeling and storage of the insulin pens. No further information regarding this issue was provided to the survey team prior to the exit conference. 42353 3. The facility staff failed to lock an unattended medication cart and left a medication cup containing an Aspirin 81 mg tablet (nonsteroidal anti-inflammatory) and a Coreg 12.5 mg tablet (beta blocker used to treat heart failure and hypertension) unattended on the top of the medication cart. On 10/12/22 at 9:12 am, during a medication pass and pour observation, licensed practical nurse (LPN) #4 began preparing medications for Resident #10. LPN #4 placed an Aspirin 81 mg tablet and a Coreg 12.5 mg tablet in a medication cup on the top of the medication cart located in the hallway outside of Resident #10's door. LPN #4 then stated they needed to obtain the resident's blood pressure and turned and walked away from the medication cart and down the hall out of the surveyor's sight leaving the medication cart unlocked and the cup containing Aspirin and Coreg on top of the medication cart unattended and out of their sight. Surveyor remained with the medication cart and LPN #4 returned to the cart at 9:13 am with a vital sign machine. LPN #4 then placed the medication cup containing Aspirin and Coreg in a drawer of the medication cart and entered Resident #10's room with the vital sign machine. LPN #4 did not lock the medication cart prior to entering the resident's room and the cart was out of their direct line of sight while obtaining the resident's vital signs. Surveyor requested and received the facility policy entitled Administering Medications which read in part: 9. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to the residents or others passing by. On 10/12/22 at 3:48 pm, the survey team met with the administrator, director of nursing, and assistant director of nursing and discussed the concern of LPN #4 leaving the medication cart unlocked and medications unattended on top of the medication cart. No further information regarding this concern was presented to the survey team prior to the exit conference on 10/13/22.

Based on staff interview, facility document review, and during a medication pass and pour observation, the facility staff failed to maintain an infection prevention and control program to provide a safe, sanitary, environment and help prevent the development and transmission of communicable disease and infections on 1 of 4 facility wings, Wing #3. The findings included: During a medication pass and pour observation, the facility staff failed to perform hand hygiene and failed to sanitize vital sign equipment between resident uses. On 10/12/22 at 8:55 am, during a medication pass and pour observation, surveyor observed licensed practical nurse (LPN) #4 obtain Resident #44's blood pressure and oxygen saturation utilizing a Dinamap vital sign machine. LPN #4 placed the blood pressure cuff on the resident's arm and the oxygen sensor on the resident's finger. LPN #4 failed to sanitize the blood pressure cuff or the oxygen finger sensor following use and immediately returned the Dinamap vital sign machine to the hall storage area. The vital sign machine included an attached compartment with a container of Super Sanicloth sanitizing wipes. LPN #4 also failed to perform hand hygiene prior to exiting Resident #44's room following obtaining vital signs and administering medications. Hand sanitizer was available in Resident #44's room beside the door and a sink was also available in the resident's room. LPN #4 immediately returned to the medication cart and began preparing medications for Resident #10 without performing hand hygiene. A bottle of hand sanitizer was available on top of the medication cart. While preparing Resident #10's medication, LPN #4 stopped and obtained a Dinamap vital sign machine, entered Resident #10's room and obtained a blood pressure, temperature, and oxygen saturation without performing hand hygiene. LPN #4 failed to sanitize the blood pressure cuff or oxygen finger sensor following use and returned the vital sign machine to the hall. The Dinamap vital sign machine included an attached compartment with a container of Super Sanicloth sanitizing wipes. LPN #4 also failed to perform hand hygiene prior to exiting Resident #10's room following obtaining vital signs and administering medications. Hand sanitizer was available in Resident #10's room beside the door and a sink was also available in the resident's room. LPN #4 immediately returned to the medication cart and proceed to prepare medications for another resident without performing hand hygiene. A bottle of hand sanitizer was available on top of the medication cart. On 10/12/22 at 9:43 am, surveyor asked LPN #4 when hand hygiene should be performed during medication passes and they stated they usually use hand sanitizer when coming out of a resident's room and wash hands after every couple of rooms. Surveyor also asked LPN #4 how shared medical equipment was handled between resident use, they stated it was sanitized with wipes after every couple of residents. Surveyor requested and received the facility policy entitled Shared Medical Equipment (Tube Feeding Machines, IV Machines, EKG Machine, Bladder Scanner, Dinamaps, Temporal Thermometer) which read in part: 7. For daily use of Dinamaps, clean after each resident use with approved germicidal cleaner (Oxovir). Wipe down the machine, all cords (cuff and pulse ox) and temporal thermometer and allow to dry for 1 minute before use on another resident. On 10/12/22 at 3:48 pm, survey team met with the administrator, director of nursing, and assistant director of nursing and discussed of concern of LPN #4 failing to perform hand hygiene and sanitize shared medical equipment between resident uses. No further information regarding this concern was presented to the survey team prior to the exit conference on 10/13/22.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure drug regimen reviews were acted upon for 2 of 5 residents in the survey sample reviewed for unnecessary medications, Resident #75 and #37. The findings included: 1. For Resident #75, the facility staff failed to address drug regimen reviews completed by the pharmacist for the months of April 2022, June 2022, July 2022, and August 2022 each requesting a gradual dose reduction (GDR) review for the antidepressant medications Sertaline and Trazodone. Resident #75's diagnosis list indicated diagnoses, which included, but not limited to Chronic Diastolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease, Paroxysmal Atrial Fibrillation, Major Depressive Disorder, and Generalized Anxiety Disorder. The most recent annual minimum data set (MDS) with an assessment reference date (ARD) of 9/02/22 assigned the resident a brief interview for mental status (BIMS) summary score of 10 out of 15 indicating the resident was moderately cognitively impaired. Upon review of Resident #75's clinical record on 10/13/22, surveyor was unable to locate drug regimen reviews completed by the pharmacist for the months of April 2022, June 2022, July 2022, and August 2022. On 10/13/22 at approximately 8:15 am, surveyor spoke with the director of nursing (DON) and requested the drug regimen reviews. On 10/13/22 at 12:10 pm, licensed practical nurse (LPN) #3 provided surveyor with copies of Resident #75's drug regimen reviews for April 2022, June 2022, July 2022, and August 2022. The drug regimen reviews were not signed by the physician and there was no documentation indicating the drug regimen reviews were reviewed by the physician. LPN #3 stated they did not have physician signed pharmacy reviews for April 2022, and June through August 2022. LPN #3 stated the drug regimen reviews were received monthly from the pharmacy, given to the physician liaison who then distributed to the Unit Managers for review and then returned to the physician liaison who provided to the physician for review. LPN #3 stated for any resident followed by Dr. (name omitted) (geriatric psychiatry), drug regimen reviews were sent to them and there seemed to be an issue with getting the reviews back as sometimes they would return the reviews directly to the pharmacy. Resident #75's April 2022 drug regimen review stated in part .Please review the following orders for the possibility of a GDR: 1. Sertraline 50 mg qd (once a day) 2. Trazodone 25 mg HS (at bedtime) . Resident #75's June and July 2022 drug regimen reviews each stated in part .I apologize if this was already addressed but I could not find a response in the eChart or email .Please review the following orders for the possibility of a GDR: 1. Sertraline 50 mg qd 2. Trazodone 25 mg HS . The August 2022 drug regimen review stated in part .Please ensure Dr. (name omitted) receives this review, as this is the third attempt for a GDR that I do not think Dr. (name omitted) has seen .Please review the following orders for the possibility of a GDR: 1. Sertraline 50 mg qd 2. Trazodone 25 mg HS . Surveyor requested and received the facility policy entitled Drug Regimen Review which read in part: 3. When there are pharmacy recommendations due to the finding of the drug regimen review, a detailed recommendation will be promptly provided to the attending physician, designee or psychiatrist and director of nursing. A. All pharmacy reviews identifying specific recommendations will require action to be taken in the form of a written response to the drug regimen review. On 10/13/22 at 3:48 pm, the survey team met with the administrator, DON, assistant DON, and LPN #3 and discussed the concern of Resident #75's drug regimen reviews not being addressed by the facility. No further information regarding this concern was presented to the survey team prior to the exit conference on 10/13/22. 47299 2. For resident # 37, the facility staff failed to ensure that the drug regimen review for August 2022, was reviewed and the recommendation for a gradual dose reduction was addressed by the attending physician. Resident #37's diagnosis list includes, but is not limited to the following: mood disorder with major depressive like episode, insomnia, type 2 diabetes mellitus, hemiplegia following cerebral infarction, dysphagia and aphasia. The most recent quarterly minimum data set (MDS) with an assessment reference date of 08/01/2022, assigned the resident a BIMS (brief interview for mental status) summary score of 11 out of 15 in section C, cognitive patterns, indicating the resident was moderately cognitively impaired. Upon review of resident #37's clinical record, surveyor was unable to locate the August 2022 drug regimen review completed by the pharmacist. On 10/12/2022 at 6:25 pm, surveyor spoke with the Director of Nursing (DON), who stated the review had not been scanned into the medical record yet and she would have that done as soon as possible. On 10/13/2022 at 8:00 a.m., surveyor noted that the medical record had been updated with a form entitled, Physician Recommendation From Pharmacist, dated 8/24/2022. The form indicated that the pharmacist had recommended a gradual dose reduction for trazodone (an antidepressant medication) 50 mg at hour of sleep for insomnia and depression. There was no indication on the form that a physician had seen the recommendation, the form was devoid of a physician's response or signature. On 10/13/22 at 12:10 pm, licensed practical nurse (LPN) #3 stated the drug regimen reviews were received monthly from the pharmacy, given to the physician liaison, who then distributed to the Unit Managers for review. Once reviewed by the unit manager, pharmacy reviews are then returned to the physician liaison, who provides them to the physician. LPN #3 stated for any resident followed by Dr. (name omitted) (geriatric psychiatry), drug regimen reviews were sent to them, and there seemed to be an issue with getting the reviews back, as sometimes they would return the reviews directly to the pharmacy. Surveyor requested and received the facility policy entitled Drug Regimen Review which read in part: 3. When there are pharmacy recommendations due to the finding of the drug regimen review, a detailed recommendation will be promptly provided to the attending physician, designee or psychiatrist and director of nursing. A. All pharmacy reviews identifying specific recommendations will require action to be taken in the form of a written response to the drug regimen review. On 10/13/22 at 3:48 pm, the survey team met with the administrator, DON, assistant DON, and LPN #3 and discussed the concern of Resident #37's drug regimen review not being addressed by the facility. No further information regarding this concern was presented to the survey team prior to the exit conference.

Based on observation, staff interview and clinical record review the facility staff failed to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for one of 28 residents, Resident #41. The findings included: For Resident #41 the facility staff failed to ensure personal hygiene was maintained. Resident #41's face sheet included [DIAGNOSES REDACTED]. Resident #41's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 10/22/19 assigned the resident a BIMS (brief interview for mental status) score of 7 out of 15 in section C, cognitive patterns. Section E, behaviors, indicated the resident has no behaviors of rejecting care. Section G, functional status, coded the resident as needing extensive physical assistance of one person in the areas of personal hygiene and bathing. Resident #41's comprehensive care plan was reviewed and contained a care plan for .has a self-care deficit in performing ADL's (activities of daily living) r/t (related to) Activity Intolerance, Deconditioning, Confusion, Dementia, Impaired balance, Limited Mobility. Interventions for this care plan include PERSONAL HYGIENE/ORAL CARE: .requires up to extensive assistance, and BATHING: .requires physical help in part of bathing of 2 staff. Check nail length and trim and clean on bath day and as necessary . Surveyor observed Resident #41 on 12/03/19 at approximately 4:10 pm. Resident was alert and oriented to person only. Resident was resting in bed. Hair was dirty and disheveled. Surveyor observed resident again on 12/04/19 at approximately 10:30 am. Resident was seated in wheelchair in common area. Resident was dressed in street clothes and hair was combed but dirty. Surveyor, along with the unit manager, observed Resident #41 again on 12/05/19 at approximately 2:40 pm. Resident was resting in bed. Surveyor asked unit manager about resident's hair, and unit manager replied, It's dirty. Surveyor observed, at this time that resident's fingernails were long and there was a brownish substance on resident's hand. Surveyor asked the unit manager if resident ever refused care, and unit manager stated, Sometimes, it depends on --- dementia. Surveyor then asked unit manager if it should be documented if the resident refused care, and the unit manager stated yes. Unit manager stated to surveyor that resident should get a shower today, since her shower days are Monday and Thursday. Surveyor spoke with CNA #1 on 12/05/19 at approximately 9:50 am. Surveyor asked CNA #1 if Resident #41 ever refused care, and CNA #1 stated that resident does not really say no, and that you can get --- to do what you ask. Surveyor reviewed Resident #41's ADL-bathing forms, located under the tasks section of the electronic clinical record. There were only two documented showers for the month of (MONTH) and two documented showers for the month of November. The bathing forms indicate that the resident went from 10/01/19-10/23/19 only receiving 5 partial baths and 2 bed baths. The bathing forms indicate that the resident went from 11/07/19-11/28/10 only receiving 3 partial baths and 2 bed baths. Surveyor reviewed Resident #41's progress notes, located under the progress notes section of the electronic clinical record. Surveyor could not locate any progress notes stating that the resident has been refusing care. The concern of facility staff not ensuring personal hygiene was maintained for Resident #41 was discussed during a meeting with the administrative staff (administrator, director of nursing, assistant director of nursing) during a meeting on 12/05/19 at approximately 4:50 pm . No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to store expired biological's in 2 of 4 medication rooms (unit 1 and unit 2) and failed to properly store an unused IV antibiotic for 1 of 28 Residents, Resident #94. The findings included: 1. The medication storage rooms on unit 1 and unit 2 included 3 bottles of expired [MEDICATION NAME] (urine test strips). These bottles had expired on [DATE]. On [DATE] at approximately 3:28 p.m., the surveyor checked the medication storage room on unit 1 with RN (registered nurse) #1. This medication room included 1 bottle of expired [MEDICATION NAME]. RN #1 reviewed the label with the surveyor, verbalized the strips were out of date, and stated they would toss the expired bottle. On [DATE] at 3:41 p.m., the surveyor and RN #1 checked the medication storage room on unit 2. This medication storage room included 2 bottles of expired [MEDICATION NAME]. RN #1 reviewed the [MEDICATION NAME] labels with the surveyor, verbalized both bottles were out of date, and stated they would toss them. During an end of the day meeting on [DATE] beginning at approximately 4:46 p.m., the administrator, DON (director of nursing), and director of health care operations were notified of the expired [MEDICATION NAME]. On [DATE], the facility provided the surveyor with a copy of their policy/procedure titled, EXPIRED MEDS. This policy/procedure read in part, .Expired items are pulled off shelves and removed from the inventory . No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #94, the facility staff failed to properly store the unused IV antibiotic medication [MEDICATION NAME]. This medication was observed to be on the Residents bedside table. This medication had been discontinued on [DATE]. The Residents clinical record was reviewed on [DATE]. Resident #94's clinical record included the [DIAGNOSES REDACTED]. Section C (cognitive patterns) of Resident #94's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of [DATE] included a BIMS (brief interview mental status) summary score of 10 out of a possible 15 points. On [DATE] at 3:34 p.m., while speaking with Resident #94 the surveyor observed an unopened silver packet labeled [MEDICATION NAME] ([MEDICATION NAME]) injection in 5% [MEDICATION NAME] on the Residents bedside table. Beside of the Residents bed the surveyor observed an IV pole. There were 2 bottles of IV fluids hanging on this IV pole. On [DATE] at 3:39 p.m., the surveyor approached the nurse's station and spoke with LPN (licensed practical nurse) #1 and LPN #2. Both of these nurses verbalized to the surveyor that the Resident was not currently on IV antibiotics. LPN #2 verbalized to the surveyor that the Resident was never started on IV antibiotics and was placed on oral antibiotics. LPN's #1 and #2 reviewed the EHR (electronic health record) and stated the order for the IV [MEDICATION NAME] had been written on [DATE] and discontinued the same day. The surveyor notified LPN #1 and LPN #2 that Resident #94 had an unopened packet of IV [MEDICATION NAME] on their bedside table. LPN #2 accompanied the surveyor to Resident #94's room and after visualizing the [MEDICATION NAME] stated they would get rid of the medication. On [DATE] at 4:04 p.m., the DON (director of nursing) was notified of that Resident #94 had IV [MEDICATION NAME] on their over the bedside table and that this medication had never been used for this Resident. During an end of the day meeting on [DATE] beginning at approximately 4:46 p.m., the administrator, DON (director of nursing), and director of health care operations was made aware of the above findings. On [DATE] at 2:50 p.m., the DON provided the surveyor with a copy of policy/procedure titled, Medication and Treatment Administration. This policy/procedure read in part, .Medications .as well as .IV medications are not to be left in a resident's room or unattended anywhere except in the locked medication cart/treatment cart or medication room . No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, facility document review and in the course of a complaint investigation it was determined that the facility staff failed to follow Standards of Professional Practice related to medication administration for the facility's residents. The Findings Included: On (MONTH) 31, (YEAR) at 2 p.m., the surveyor reviewed a document provided to the survey team about medication administration. The document was labeled, (name of facility withheld) South Med (medication) Pass Times. The document read: Our liberalized medication administration program establishes the following primary medication administration times: 1) Early from 5 am to 7 am 2) Morning from 8 am to 11 am 3) Mid-day from 2 pm to 5 pm 4) Evening 6 pm to 10 pm. (sic) During the survey process, the survey team interviewed the residents of the facility. The residents voiced concerns regarding timeliness of medication administration. The residents stated that that the facility had too many agency nurses and that they were often late getting their medications. On (MONTH) 1, (YEAR) at 3 p.m., a surveyor had a Resident Council meeting with seven alert and oriented residents. The residents stated that the facility medication schedule is erratic. The residents stated that sometimes there is only one nurse per hall, and the facility has recently went to a staffing with agency nurses. The residents stated that having the agency nurses takes the personal part out of the medication administration, and that temporary people do not have a routine. The residents also stated that the medication window is too big. The residents stated that it bothers them that they have so many different nurses giving medications at the facility. On (MONTH) 1, (YEAR) at 4:38 p.m., the survey team met with the Administrator (Adm) and Director of Nursing (DON). The surveyor notified the Administrative Team (AT) of a Complaint that was received in the State Agency regarding timeliness of medications. The survey team notified the AT that the residents stated that their medications were given erratically and that their medications were often late being given. The survey team reviewed the facility document about medication pass times. This surveyor asked for the facility's professional standards for medication administration. The DON and Adm did not acknowledge this surveyors' request for the professional standard for medication administration. The survey team informed the AT that professional standards do not allow the nursing staff a window of 3-4 hours as identified on the medication pass times form. The survey team notified the AT that professional standards only allow 1 hour before or one hour after the scheduled time for the medication administration. The survey team notified the AT that if the medication was administered outside of the two- hour window, of one hour before or one hour after, then a medication error was made. The survey team informed the AT that professional standards do not allow a three or four hour window for medication administration. The surveyor requested the facility policy and procedure for medication administration. On (MONTH) 2, (YEAR) at 10:30 a.m., the survey team met with the Adm, DON, Medical Director and Pharmacist. The survey team spoke to the AT about the facility's liberalized medication administration program. During the meeting the surveyor asked what was the facilities professional standard regarding medication administration. The AT did not answer the surveyors' question. The surveyor requested a professional reference either from the pharmacy or from the DON regarding professional standards related to medication administration. Once again, the AT did not acknowledge the surveyors' request for a professional standard related to medication administration. The AT hand delivered a policy and procedure titled, Administering Medications. The policy and procedure read in part . Purpose: Medications shall be administered in a safe and timely manner, and as prescribed. Procedure: .6. The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. Reference: The institute for Safe Medication Practices (ISMP) - 2. Medications administered more frequently than daily but not more frequently than every 4 hours (e.g., BID, TID, q4h, q6h) Administer these medications within 1 hour before or after the scheduled time. Current information technology associated with medication use may require vendor updates to: accommodate more than a single time interval to trigger an alert for delayed and early doses with bar-coding technology; change the appearance of a medication entry for delayed doses in electronic medication administration records (eMARs); and set different time limits for the removal of scheduled medications from automated dispensing cabinets. Challenges also exist with highlighting time-critical scheduled medications on eMARs and differentiating between first doses and subsequent scheduled doses when using these technologies. ISMP is aware of these limitations and has been encouraging vendors to address them in updated versions of their technology. No additional information was provided to the survey team prior to exiting the facility as to why the facility failed to follow/have a professional standard related to medication administration. The facility staff were administering the residents their medications outside of the two-hour window. The facility was allowing the facility staff a three to four hour window to administer medications, which was outside of the professional standards of practice related to medication administration. This is a Complaint Deficiency.