Every finding on record at Goldsboro Rehabilitation and Healthcare Center

Based on observation, record review, and interviews with staff, Nurse Practitioner and Physician, the facility failed to provide the necessary supervision to prevent an avoidable accident for a resident who had severe cognitive impairment, was on a pureed diet, had a diagnosis of dysphagia (difficulty swallowing), and required staff assistance with eating due to his inability to control the speed and/or quantity of food that entered his mouth (Resident #132). On Saturday, 10/11/25 around 8:30 AM, Nurse Aide #8 left a meal tray in front of Resident #132 so she could pass the remaining meal trays. Shortly after meal trays were passed, Nurse Aide #1 found Resident #132 unresponsive and not breathing. Nurse Aide #1 called for help and code blue (life threatening medical emergency) was called. Cardiopulmonary Resuscitation (CPR) was performed by nursing staff until Emergency Medical Services (EMS) took over when they arrived at the facility. EMS was able to obtain the resident's pulse, and Resident #132 was transferred to the hospital. Resident #132 was intubated (a hollow, plastic tube placed into the windpipe to keep airways open) after he experienced a second cardiac arrest in the emergency department and was transitioned to the Intensive Care Unit (ICU). Hospitalists suspected the resident suffered a severe anoxic brain injury (occurs when the brain does not receive oxygen) and the decision was made on 10/16/25 to transition Resident #132 to comfort measures only. The resident was transferred to hospice care on 10/17/25 and expired on 10/18/25. His death certificate indicated the cause of death was occlusion of airway by bolus of food (when food blocks the throat). This deficient practice affected 1of 3 residents reviewed for accidents.Findings included:Resident #132 was readmitted to the facility on [DATE] with diagnoses including stroke, dementia, and dysphagia. A physician order dated 8/4/22 indicated Resident #132 was a full code status and required CPR during a medical emergency. A physician order dated 7/28/25 revealed that Resident #132 received a regular diet, puree texture, nectar thick liquids, double portions, and pudding at every meal. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #132 was severely cognitively impaired, did not have any swallowing difficulties coded, and required setup/clean up assistance with eating. A care plan last reviewed on 8/28/25 revealed that Resident #132 had an activities of daily living (ADL) self-care performance deficit related to decreased mobility. Interventions included that Resident #132 was dependent on staff for eating, and staff needed to observe intake during meals. The undated Kardex (a summary of resident's needs for nursing staff to review) for Resident #132 revealed that he was dependent on staff for eating and staff were instructed to observe his intake of meals. Speech Therapy notes were reviewed from August through October of 2025. The following details written by the Speech Therapist (ST) related to Resident #132's eating assistance/behaviors were as follows:- 9/3/25: A Nurse Aide was reminded to feed Resident #132 due to impulsive self-feeding.- 9/4/25: Training for Nurse Aides regarding swallowing recommendations was ongoing. Resident #132 remained at high risk of aspiration (when food or liquid goes into your airway and lungs) given the severity of cognitive deficits and extreme impulsiveness with self-feeding.- 9/5/25: Resident #132 continued to be extremely impulsive when feeding himself secondary to severe cognitive deficits. Ongoing training with nursing staff regarding swallowing recommendations included feeding Resident #132 to decrease aspiration risks, small bites, liquid wash following each bite, and nectar thick liquids with a cup only. Response to the training with Nurse Aides was good. - 9/11/25: Discussed Resident #132's status with nursing who reported improved adequacy of intake with decreased coughing by following the Speech Therapist's instructions with no overt signs or symptoms of aspiration. - 9/16/25: Nursing staff were aware of the need for supervision during eating due to Resident #132's impulsivity. An interview was conducted with the Speech Therapist on 12/10/25 at 12:40 PM. She revealed that Resident #132 was referred to her services on 8/19/25 due to coughing and congestion with meals. She performed an assessment and determined that pureed foods with nectar thick liquids were most appropriate. Resident #132 needed to be positioned upright while eating and for 20 minutes after. The Speech Therapist stated that Resident #132 needed a slowed eating rate due to cognition and an impulsive very rapid eating pattern. He also required a drink between each bite to slow down the eating process. From 8/19/25 through 9/16/25, the Speech Therapist stated she educated every Nurse Aide that she could during lunch and supper meals about Resident #132 needing supervision during meals due to his impulsivity and high risk of aspiration/choking. They all expressed understanding. If staff were not present with the meal tray in front of Resident #132, he would eat rapidly and not stop coughing a lot. If he was left unsupervised, the Speech Therapist stated that there was a risk of aspiration, and he could choke on pureed foods. She indicated Resident #132 had no impairment of his upper extremities. A nursing progress note dated 10/11/25 at 9:54 AM written by the Weekend Nurse Supervisor revealed that she responded to a code blue announcement for Resident #132's room. When she entered the room, Nurse #2 and Nurse #3 were in the process of performing CPR on Resident #132. The Weekend Nurse Supervisor called 911. CPR continued as the nurses took turns performing compressions. EMS arrived approximately 10 minutes or less after the call. They took over the situation. After working on Resident #132 for approximately 20 minutes, EMS stated he had a pulse, and they transported him via stretcher to the Emergency Department (ED). Resident #132's family member was contacted and updated of Resident #132's condition.Nurse Aide #8's witness statement dated 10/11/25 at 9:46 AM indicated on 10/11/25 around 8:00/8:30 AM, she (Nurse Aide #8) was passing out meal trays to her assigned rooms, including Resident #132's room. She looked at Resident #132's meal ticket to make sure it was for the correct resident. She recalled Resident #132 received puree consistency with nectar thickened liquids. Nurse Aide #8 made sure Resident #132 was sitting up in bed at a 90-degree angle. She set up his tray and placed it in front of him. Resident #132 was alert with his eyes open and was able to eat the meal tray that was given. She then left the room to pass the rest of her assigned breakfast trays. A telephone interview was conducted with Nurse Aide #8 on 12/09/25 at 3:02 PM. She revealed that she was assigned to Resident #132 on 10/11/25 during the day shift. Before she passed the breakfast meal tray to Resident #132, she made sure she gave him the correct meal tray and that he was sitting up at 90 degrees. Nurse Aide #8 was verbally told by other nurse aides (names unknown) that Resident #132 could feed himself while seated at a 90-degree angle and did not require assistance with eating. She never worked with Resident #132 prior to 10/11/25. She was hired around 9/22/25 and finished her orientation with another Nurse Aide (name unknown) on 10/9/25. A follow up telephone interview was conducted with Nurse Aide #8 on 12/16/25 at 3:02 PM. She clarified that on the morning of 10/11/25 when she served Resident #132 his meal tray, she took the lid off his meal and set up the meal tray, so it was ready for the resident to eat. She stated that she checked the meal ticket and ensured the meal tray she served to Resident #132 had his name on the meal ticket. She could not recall what was on the meal tray. An interview was conducted with Nurse Aide #1 on 12/09/25 at 1:51 PM., She revealed that she was assigned to some of the rooms on Resident #132's hall on 10/11/25 during the day shift. Nurse Aide #1 indicated that she was the one who found Resident #132 unresponsive in his room around 8:30 AM. She noticed the meal trays were put in front of Resident #132 and his roommate, and both residents required assistance with eating. Nurse Aide #1 indicated she noticed that Resident #132 ate some of the food on his plate and was unresponsive but warm to touch. She yelled for Nurse #2 to help and stayed with Resident #132. Nurse #2 entered the room, called for help from Nurse #3, who was in the hallway, and called out for someone to call 911. Code blue was then announced, and Nurse Aide #1 stepped out of the room. Nurse Aide #1 stated she did not see who passed the meal trays for Resident #132 and his roommate. She revealed that if a meal tray was left in front of Resident #132, he would shovel food in his mouth and as a result he needed assistance with eating. Nurse #2 was interviewed on 12/09/25 at 12:59 PM. He revealed that Nurse Aide #1 called him into Resident #132's room on 10/11/25 around 8:30 AM and told him that Resident #132 was not breathing. He then assessed the resident, and he was not breathing and had food in his mouth. Nurse #2 stated that Resident #132 had choked and was not responsive. He could not recall the consistency of the food in his mouth. However, he suctioned out whatever was in Resident #132's mouth during CPR. Nurse #2 explained that he announced code blue for help. He stated he was the first nurse in the room. All nurses responded, and Nurse #3 took charge. CPR was initiated, and someone called 911. EMS arrived shortly after and took over CPR on Resident #132. Nurse #2 stated he was unsure what happened after that. Nurse #2 added that he could not recall the details of the meal tray or meal ticket in Resident #132's room. An interview was conducted with Nurse #3 on 12/10/25 at 4:36 PM. She revealed that on 10/11/25 Nurse #2 yelled out code blue from the room of Resident #132. She was in the hallway and immediately responded. She observed Resident #132 was sitting up. Nurse #3 stated she laid Resident #132 flat to start CPR because he did not have a pulse and was not breathing. She was the only nurse in the room at the time because Nurse #2 went to get the crash cart and make the announcement for code blue. Nurse #3 stated she hollered for suctioning due to food debris in his mouth. As she was performing compressions, more food came up and she removed it by suctioning the resident. EMS arrived and they took over. They were able to get a pulse and Resident #132 was breathing when he left the facility. Nurse #3 stated that Resident #132 was to be supervised while eating because he ate very fast and shoveled food into his mouth. The resident was able to eat without assistance, but in her opinion he should not because he ate too fast and was at risk for aspiration or choking. Nurse #3 reported she did not get a chance to observe Resident #132's meal tray in the room.The Weekend Nurse Supervisor was interviewed on 12/10/25 at 11:26 AM. She revealed that for residents who were diagnosed with dementia, nursing staff should look at the Kardex to identify the photographic picture of the resident in question. Prior to the incident on 10/11/25, nursing staff were instructed to not put the meal tray in front of residents who needed assistance with eating until staff were ready to help. This was due to the risk of aspiration or choking if the residents attempted to eat without supervision, including Resident #132. The Weekend Nurse Supervisor indicated on 10/11/25 around 8:30 AM, she was taking care of another resident when she heard the code blue announcement and saw nurses running toward Resident #132's room. She heard Nurse Aide #1 say, he is not breathing. Nurse #2 and Nurse #3 were performing CPR on Resident #132. Nurse #3 yelled for someone to call 911. Nurse #2 was assigned to Resident #132 that morning. The Weekend Nurse Supervisor indicated she ran out of the room and called 911. She indicated EMS came down the hall 5 to 7 minutes after she called 911. EMS took over CPR when they arrived and were able to obtain a pulse. The hospital discharge summary for Resident #132 dated 10/17/25 revealed that he was admitted on [DATE] after he experienced cardiac arrest (heart stopped beating) from choking on food. Resident #132 was intubated after a second cardiac arrest in the emergency department and was transitioned to the Intensive Care Unit (ICU) for further management. Severe anoxic brain injury (occurs when the brain does not receive oxygen) was suspected by the hospitalists, and the decision was made on 10/16/25 to transition Resident #132 to comfort measures only. He was discharged to hospice care on 10/17/25. A Certificate of Death dated 10/18/25 revealed that Resident #132's cause of death was occlusion of airway by bolus of food.Director of Nursing (DON) #1 was interviewed on 12/10/25 at 11:46 AM. She revealed that she was the previous DON and she trained DON #2 after she (DON #2) started in the DON position on 9/22/25. DON #1 stated that nursing staff should pass out all meal trays for residents who ate independently and leave the meal trays for those who needed assistance with eating on the meal cart, including Resident #132. Staff should only pass meal trays to those who needed assistance with eating when they were ready to provide assistance. DON #1 indicated nursing staff should be present in the room for those who needed assistance, and meal trays should not be left by staff in the room. An interview was conducted with DON #2, the current DON, on 12/11/25 at 3:22 PM. She stated she did not feel comfortable speaking on the incident with Resident #132 that occurred on 10/11/25 because DON #1 was still training her at that time. However, she stated that residents who needed to be supervised during meals should not have access to the meal tray without staff present. The Administrator was interviewed on 12/09/25 at 2:10 PM. She indicated on 10/11/25, she received a phone call from DON #2. She said there was an incident, and Resident #132 was sent to the hospital after being found unresponsive. After the incident on 10/11/25 the Administrator spoke to Nurse Aide #8 who stated that she gave Resident #132 the correct meal tray. The Administrator revealed that Resident #132 had the ability to eat independently but needed to be closely supervised; however, Nurse Aide #8 did not remain in the room on 10/11/25 to supervise Resident #132. The Administrator indicated Nurse Aide #8 was sent home pending an investigation of the choking incident. A follow-up interview was conducted with the Administrator on 12/11/25 at 4:07 PM. She revealed that Nurse Aide #8 should have remained in the room with the meal tray for Resident #132, which was conveyed in the resident's Kardex for nursing staff to review. An interview was conducted with the Nurse Practitioner on 12/11/25 at 9:28 AM. She revealed that Resident #132 was supposed to be supervised during meals. Also, recommendations made by Speech Therapy were important to implement for Resident #132's safety such as, nursing supervision during meals, sitting up straight during and after meals, and slowing down his eating by having the resident take a sip of liquid between each bite. The aspiration risk for Resident #132 was attributed to stroke and cognitive decline. The Nurse Practitioner stated that a meal tray should not have been left with Resident #132 without supervision, and she agreed with Speech Therapy's recommendations/education for nursing staff. A telephone interview was conducted with the Medical Director on 12/11/25 at 9:35 AM. She revealed that she was notified that Resident #132 was left unattended during the meal on 10/11/25. She stated that Resident #132 had the habit of shoveling food into his mouth, causing him to choke and put him at risk of aspiration. The Medical Director stated that Resident #132 should not have been left alone with the meal tray in front of him. The Administrator was notified of Immediate Jeopardy on 12/10/25 at 9:53 AM.The facility provided the following corrective action plan with a completion date of 10/12/25:1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #132 was provided with his breakfast tray by Nurse Aide (NA) #8. Nurse Aide #8 walked out of the resident's room. Shortly after the resident was observed by another NA to be unresponsive. This NA notified the hall nurse, and the hall nurse cleared the patient's airway and suctioned the resident. The hall nurse immediately called 911. The resident was breathing with a pulse and was transferred to the hospital. The resident can feed himself but supervision by staff was recommended by the Speech Language Pathologist (SLP). The SLP provided this education to nursing staff on 9/8/25 related to the high risk of aspiration/choking due to Resident #132's impulsiveness of feeding himself at a rapid rate. The required feeding assistance was noted on the resident's Kardex. The charge nurse completed a Risk Management and Situation Background Assessment Recommendation (SBAR). The SBAR indicated the resident was found unresponsive during breakfast. The Administrator, Director of Nursing, Medical Director, and Responsible Party were all notified by the hall nurse on 10/11/25. Resident #132's diet consistency, supervision needs, and feeding requirements were reviewed by the Director of Nursing and Administrator on 10/11/25. The Registered Dietician confirmed that Resident #132 was appropriate for a puree diet with thickened liquids, with staff supervision required during meals. The root cause analysis was determined by the Administrator, Director of Nursing, and Eastern Regional Administrator on 10/11/25 that Nurse Aide #8 did not provide resident supervision during meal. Nurse Aide #8 was suspended pending investigation. The resident remained in the hospital until transferred to another facility where he expired. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents that require supervision during feeding have the potential to be at risk. Nurse Management/designee reviewed all residents' kardex and audited the assistance level required while feeding, completed 10/11/25. It was concluded that 9 residents were dependent on staff for feeding and 7 residents required supervision of staff. DON #1/designee completed observation rounds during lunch and dinner meals on the identified residents that needed feeding assistance on 10/11/25 with no other concerns identified. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 10/11/25, Nurse Management initiated a facility-wide education for all licensed nurses/NAs on meal delivery and feeding assistance, focusing on proper resident identification, verification of correct diet orders, and adherence to required supervision levels during meals. Licensed nurses/NAs were educated on utilizing the kardex to locate information needed to determine supervision required with feeding. No licensed nurses/NAs are permitted to work after 10/11/25 without education in meal tray delivery until they have completed this required education. All licensed nurses/NAs were educated by Nurse Management or the Administrator via phone or with one-on-one in-service. The only staff that pass resident meal trays are NAs/licensed nurses. The Nurse Manager confirmed this education was completed prior to staff being scheduled and if staff were not scheduled, they were contacted via phone. This training has been added to the orientation program for all licensed nurses/NAs effective 10/11/25. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained The Director of Nursing, Nurse Manager, and Administrator will conduct audits of resident meal tray delivery beginning on 10/11/25. These audits include validation of accurate meal tickets, correct resident identification, and confirmation that residents receive the correct diet with the required level of assistance as indicated on the resident Kardex and diet order. Audits began on 10/11/25. The decision to monitor and take to Quality Assurance Performance Improvement (QAPI) was made on 10/11/25 by the Regional Clinical, Regional Administrator, Administrator, Medical Director, Nurse Management, and Director of Nursing. The audits were completed by observation and occurred on weekdays and weekends for varying meals with all three meals incorporated into the audit. The audits were done two meals per day, five days per week for six weeks. Any concerns identified will be addressed and corrected immediately. Results of these audits will be reviewed during the October QAPI meeting to determine whether additional monitoring is needed. Attendees on 10/22/25 at the QAPI meeting were Medical Director, Administrator, Pharmacist, Social Services, Nursing Management, Environmental Services Manager, Maintenance Director, Infection Preventionist, Therapy Manager, Admissions, and Treatment Nurse. Results were discussed to determine what additional monitoring was needed.The Administrator is responsible for ensuring completion and oversight of this Plan of Correction.Alleged Date of Immediate Jeopardy Removal and Compliance: 10/12/25The facility's corrective action plan was validated on 12/11/25. The validation process included staff interviews, record reviews, review of education provided to nursing staff, and review of initial auditing and monitoring audits. The education for staff included meal delivery and eating assistance, focusing on proper resident identification, verification of correct diet orders, and adherence to required supervision levels during meals. Observations of meal tray service during the investigation were conducted with no concerns. The immediate jeopardy removal date and compliance date was verified as 10/12/25.

Based on record review, and staff and Pharmacist interviews, the facility failed to have a copy of a monthly medication regimen review (MRR) available for review for 1 of 5 residents reviewed for unnecessary medications (Resident #4). Findings included: Resident #4 was readmitted to the facility on [DATE] with diagnoses that included hypertension, hyperlipidemia, stroke, peripheral vascular disease, chronic kidney disease, depression and insomnia. Review of Resident #4's medical record revealed that a monthly pharmacist medication regimen review was missing for the month of October 2025. An interview was conducted with the Pharmacist #1 on 12/11/25 at 2:03 PM. She revealed that Pharmacist #2 was traveling out of state and unavailable for interview. Resident #4's pharmacy documentation for October 2025 could not be found. Pharmacist #1 stated that Pharmacist #2 told her she had paper notes related to the October 2025 medication regimen review (MRR) for Resident #4; however, Pharmacist #1 could not locate any documentation to confirm the October MRR was completed. The Director of Nursing (DON) was interviewed on 12/11/25 at 3:24 PM and revealed she received monthly MRRs and recommendations from Pharmacist #2. Residents without any recommendations were included in a general list, and specific recommendations for residents were written out on a separate communication form. The DON stated that the October MRR provided to her by Pharmacist #2 did not have Resident #4's name included on the list. The DON stated that an MRR should be completed by a licensed Pharmacist at least monthly for all residents in the facility. The Administrator was interviewed on 12/11/25 at 4:08 PM. She revealed that the October 2025 MRR for Resident #4 should have been completed in a timely manner by the Pharmacy representative.

Based on observation, record review, and staff interviews, the facility failed to implement their infection prevention program policies and procedures when Nurse Aide (NA) #4 and NA #5 failed to apply personal protective equipment (PPE) during urinary catheter care for a resident on Enhanced Barrier Precautions (EBP). This deficient practice was for 2 of 2 staff members observed for infection control practices (NA #4 and NA #5). The findings included:The facility's Infection Prevention and Control Program (IPCP) policy last revised 10/2018 indicated that the facility was responsible for establishing and maintaining an effective program that provides a safe, sanitary, and comfortable environment and attempts to prevent the development and the transmission of diseases and infections. The policy further noted the importance of infection prevention, which included education of staff to ensure they adhere to proper techniques and procedures.The facility's Enhanced Barrier Precautions (EBP) policy last revised 7/26/22 revealed EBP was to be utilized for all residents with an indwelling medical device which included a urinary catheter. The policy further noted that personal protective equipment (PPE) for EBP was necessary when performing high-contact care activities which included urinary catheter care and required staff to wear gloves and gown when the care was provided.On 12/11/25 at 10:39 am Resident #109 had signage posted at the entrance of the room that alerted staff that the resident was on EBP. The signage noted that providers and staff must wear gloves and gowns for the following high-contact resident care activities which included urinary catheter care. A clear plastic supply holder was observed hung on the door and was stocked with PPE, which included disposable gowns and disposable gloves. A continuous observation of urinary catheter care was conducted on 12/11/25 from 10:40 am through 10:47 am for Resident #109. NA #4 and NA #5 were observed to perform hand hygiene, don clean gloves, and began to perform urinary catheter care for Resident #109. NA #4 and NA #5 performed Resident #109's urinary catheter care without the required gown in place. An immediate interview was conducted with NA #5 on 12/11/25 at 10:48 am who revealed she had been educated on EBP and the need to use PPE when performing urinary catheter care. NA #5 stated she just forgot to use the gown when she assisted NA #4 with Resident 109's urinary catheter care. During an interview with NA #4 on 12/11/25 at 10:49 am she revealed a gown was supposed to have been worn when she provided urinary catheter care to Resident #109. NA #4 stated she was nervous and forgot to put on the gown when the care was provided. An interview was conducted with the Infection Preventionist, who was also the facility's Director of Nursing, on 12/11/25 at 1:34 pm. The Infection Preventionist stated that all facility staff, including NA #4 and NA #5, had received education regarding EBP and the use of PPE when specific tasks were performed. The Infection Preventionist stated the staff were responsible for looking at every resident room entered for signage to see if the resident was on EBP and to use the appropriate PPE as noted. The Administrator was interviewed on 12/11/25 at 4:10 pm and revealed that NA #4 and NA #5 should have donned and doffed the required PPE according to the signage on the door for Resident #109 when they provided the urinary catheter care.

Based on observation, record review, resident, facility staff, pharmacist, and Nurse Practitioner (NP) interviews the facility failed to obtain a narcotic refill prescription to provide pain medication for 1 of 3 residents reviewed for pain management (Resident #57). The findings included: Resident #57 was admitted to the facility on [DATE] with diagnosis that included osteoarthritis of the right knee, and spinal stenosis. Record review of the Physician order dated 3/5/24, oxycodone-acetaminophen oral tablet 5-325 milligram (mg). Give 1 tablet by mouth every 8 hours as needed for pain (PRN). Review of the controlled drug record sheet for Resident #57 which was received on 7/19/24 revealed the last dose of medication in the card was administered on 8/30/24. Review of the Medication Administration Record (MAR) for Resident #57 dated August 2024 revealed she last received an as needed dose of pain medication on 8/30/24 (Friday) at 9:17 PM. There were no doses recorded as being administered on 8/31/24 (Saturday). Review of an electronic dispensing system report revealed there were no doses of oxycodone-acetaminophen 5-325mg dispensed for Resident #57 from 8/30/24 through 9/5/24. Review of Physician order provided by the pharmacy disclosed a prescription renewal order for Resident #57's oxycodone-acetaminophen 5-325mg was reordered on 9/2/24 at 11:09 AM. The renewal order was required for each time the controlled medication ran out or was close to running out. Review of the controlled drug record of oxycodone-acetaminophen 5-325mg revealed Resident #57's medication card was received on 9/3/24 and the first dose from the new card was administered on 9/3/24. Review of the MAR for Resident #57 dated for the month of September 2024 revealed administration of oxycodone-acetaminophen 5-325mg was administered on 9/3/24. There were no doses recorded as being administered on 9/1/24 (Sunday) or 9/2/24 (Labor Day). On 9/4/24 at 5:08 PM, an interview was conducted with Resident #57, she stated she requested oxycodone-acetaminophen 5-325mg on Saturday (8/31/24), Sunday (9/1/24) and Monday (9/2/24). Nurse #1 told her it was not available. An observation was conducted in conjunction with an interview with Nurse #1 on 9/5/24 at 11:28 AM. During the interview she stated she had provided the last dose from the card to Resident #57 on 8/30/24 and she was unable to obtain the prescription requested from the NP or the on-call service for the narcotic. An observation of Nurse #1 was conducted as she used the medication dispensing system. During the observation the nurse was unable to demonstrate how to obtain narcotics from the electronic medication dispensing system. She scrolled through Resident #57 list and stated there were no narcotics available. She stated she did call the physician several times to follow up on the order on the day of the request. She did not recall if she texted or called the Physician and could not provide evidence that she had made the request for the prescription. When the Nurse Practitioner (NP) was in the facility she gave the request directly to the NP. An interview with Nurse #2 on 9/5/24 at 1:31 PM, revealed to obtain a new narcotic hard script on the weekend or holiday she called the NP, the NP then sent the prescription electronically to the pharmacy. The procedure was to reorder medication when there were 8 pills remaining in the card. An interview with NP on 9/5/24 at 1:46 PM, revealed there was an on-call service for holidays, nights, and weekends. She expected the facility to notify her or the on-call service when the medication count gets low to prevent a delay of obtaining the medications. She explained there was also an electronic medication dispensing system and that was the first back up if a resident was out of medication. When she received a request from the facility for a prescription it was electronically sent to the pharmacy. An interview with the Pharmacist on 9/5/24 at 10:29 AM, via telephone revealed the order for Resident #57's oxycodone-acetaminophen was ordered by the facility on 9/2/24 and delivered to the facility on [DATE]. The Pharmacist reviewed the transactions on the electronic medication dispensing system and indicated it showed nothing was dispensed for Resident #57 from 8/31/24 through 9/2/24. The Pharmacist stated the facility was to order medications when there were 5 doses remaining for the resident. They had not received a request for Resident #57 for oxycodone- acetaminophen until 9/2/24. The Director of Nursing (DON) was interviewed on 9/6/24 at 2:11 pm. She stated the nurses assigned to the medication carts were responsible for ordering medications. The nurse notified the provider for a new narcotic prescription electronically. On the weekends or holidays the nurse called the Provider and had them fax the prescription or send it directly to the pharmacy. The DON stated residents should not go without medications at any time including narcotic medication and all nurses knew how to access the backup medication dispensing machine. When a resident complained of pain, the nurse should check in the electronic backup system first then follow the re-ordering procedure. She also stated there was a recent pharmacy change and it was possible Nurse #1 missed the training of how to obtain narcotics from the medication dispensing system.

Based on record review and staff interviews, the facility failed to accurately document on the electronic Medication Administration Record (eMAR) when cardiac medications were withheld according to parameters defined by the physician's orders for 3 of 3 residents reviewed for medication administration (Resident's #1, #2, and #3). 1. Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] with diagnosis that included atrial fibrillation, nonrheumatic mitral valve insufficiency, atherosclerotic heart disease of the coronary artery, the presence of an automatic implantable cardiac defibrillator, and stroke. Review of the physician orders for Resident #1 revealed the following order : Metoprolol Tartrate Oral tablet 25 MG (Milligram), give 0.25 tablet via peg tube two times a day for hypertension-hold for systolic blood pressure < 93 mmHg (units of Millimeters of mercury) or a heart rate < 60 beats per minute, order date 12/09/23. On 12/10/23 at 8:02 PM the resident had a recorded systolic blood pressure of 90 mmHg, on 12/12/23 at 11:08 AM the resident had a recorded systolic blood pressure of 88 mmHg, and on 12/14/23 at 9:27 AM the resident had a recorded systolic blood pressure of 91 mmHg. On all three occasions the medication was documented as administered. In an interview with Nurse #1 on 02/13/24 at 4:11 PM she stated she had documented in error that the Metoprolol on 12/10/23 at 8:02 PM was administered. She reported that she always took blood pressures before administering any blood pressure medications. She was sure she had not given the medication because she always checked the parameters before administering. She thought she may have been busy and accidentally documented that the medication had been administered when it had not been given. She noted the hall the resident resided on was the rehab hall, it was very busy everyday with admissions, bells ringing and other distractions. In an interview with Certified Medication Aide (CMA) #1 on 02/13/24 at 4:25 PM she stated the Metoprolol on 12/12/23 at 11:08 AM and on 12/14/23 at 9:27 AM for Resident #1 was given as documented but the recorded blood pressures were not the blood pressures she had obtained prior to giving the medications. She stated she had been in a hurry on both days and instead of typing in the blood pressures she had taken, she clicked on the option to document the last recorded vital sign in the system and had not noticed they were out of range. She knew she had taken the blood pressures and the systolic blood pressures had been above the required 93 mmHg because the family was always present and insisted the blood pressure was taken before medications were administered. She noted she should have typed in the blood pressures she had taken instead of using the last recorded values. 2. Resident #2 was admitted to the facility on [DATE] and discharged on [DATE]. He had diagnoses that included essential hypertension, atherosclerotic heart disease of the native coronary artery, and atrial fibrillation. Review of the physician orders for Resident #2 revealed the following order: Metoprolol Tartrate Tablet, give 12.5 MG by mouth two times a day, hold for a systolic blood pressure < 96 mmHg or a heart rate < 60 beats per minute related to unspecified atrial fibrillation, order date 02/07/24. Nurse #4 documented Resident #2 was administered Metoprolol 12.5 MG on 02/10/24 at 9:00 PM with a recorded systolic blood pressure of 94 mmHg. In an interview with Nurse #4 on 02/13/24 at 3:15 PM she stated on 02/10/24 she had taken Resident #2 ' s blood pressure and wrote the result of a systolic blood pressure of 105 mmHg on the 24 hour nurse report but did not enter the result in the computer. Instead, she stated she had clicked on the choice to record the last value recorded in the system and did not realize that value was below the parameter. She noted she was a new nurse and still in orientation. She stated she was not completely familiar with the computer system yet. 3. Resident #3 was admitted to the facility on [DATE] with diagnoses that included: atherosclerotic heart disease of the native coronary artery, essential hypertension, and heart failure. Review of the physician orders for Resident #3 revealed the following order: Losartan Potassium Oral Tablet 50 MG, give 1 tablet by mouth one time a day related to essential (primary) hypertension, hold for a systolic blood pressure < 120 mmHg or a heart rate <60 beats per minute, order date 08/22/23. Nurse #3 documented Resident #3 was administered Losartan 50 MG on 09/10/23 at 9:43 AM with a recorded heart rate of 53. In an interview with Nurse #3 on 02/14/24 at 3:10 PM she stated she did not remember administering the medication back in September but was sure it was not given if the resident had a heart rate of 53. She stated it was a documentation error. She knew not to give the medication if the heart rate was low because she was familiar with the resident and the parameters. She stated she had been busy and accidentally clicked in the computer that the medication had been given when it had been held. CMA #2 documented Resident #3 was administered Losartan 50 MG by CMA #2 on 09/14/23 at 10:45 AM with a recorded heart rate of 54 and on 09/24/23 at 12:51 PM with a recorded heart rate of 57. In an interview with CMA #2 on 02/14/24 at 3:30 PM she stated she knew she would not have given Resident #3 Losartan 50 MG if her heart rate was below 60 beats per minute. She noted she always checked Resident #3 ' s vital signs before she poured her medications because she was familiar with the resident and knew she had parameters on her Losartan medication. She stated she could not remember that far back, but knew she always held this resident ' s cardiac medications according to the vital signs she took herself. She concluded that she had probably been busy and clicked that the medication had been given when it had actually been held. She stated she was 100% sure she had held the medication both times on 09/14/23 and 09/24/23. Nurse #2 documented she had administered Losartan 50 MG to Resident #3 on the following dates with the corresponding heart rate values: -10/04/23 at 11:00 AM with a recorded heart rate of 57 beats per minute -11/10/23 at 11:40 AM with a recorded heart rate of 59 beats per minute -11/13/23 at 8:45 AM with a recorded heart rate of 57 beats per minute -11/23/23 at 10:40 AM with a recorded heart rate of 55 beats per minute -12/27/23 at 14:40 PM with a recorded heart rate of 56 beats per minute -01/02/24 at 11:36 PM with a recorded heart rate of 58 beats per minute In an interview with Nurse #2 on 02/14/24 at 3:45 PM she stated she was familiar with the resident and knew which medications not to give Resident # 3 if her blood pressure or heart rate were below a certain range. She said she held any medications that were outside of the parameters set. She noted she had a habit of passing out all the medications than going back at the end of the medication pass and clicking that all the medications had been administered for each resident. She stated the reason she documented incorrectly was because she did not record each medication as she either held it or gave it. She did not specifically recall any of the dates she documented she gave the medication that she had actually held but was sure she had not given the resident a medication that was to be held if her heart rate was low because she always took the time to take her vital signs before she gave the medications. She concluded she had a teachable moment with the Director of Nursing and now she documents in the computer at the time she either gives or holds a medication. In an interview with the Administrator and the [NAME] President of Clinical Services North Carolina Region on 02/15/24 at 1:15 PM, the Administrator stated she expected the nurses to obtain vital signs at the time a medication was due and accurately document when a medication was held. She noted the eMARs had been changed the previous evening for every physician order that had parameters so that a medication could not be documented as either given or withheld without first typing the vital signs into the medical record.

Based on record review and staff interviews the facility failed to follow physician orders regarding placement of Lidocaine external patch, a local anesthetic, for 1 of 5 residents (Resident #1) reviewed for physician order implementation. Findings include: Resident #1 was admitted into the facility on [DATE] with diagnoses including generalized muscle weakness and other abnormalities of gait and ability and discharged on [DATE]. Resident #1's admission Minimum Data Set, dated dated dated [DATE] revealed that she was cognitively intact, denied any pain in the last 5 days, and was frequently incontinent of bowel and bladder. She required supervision or touching assistance with toileting hygiene, personal hygiene, partial/moderate assistance with shower/bathing, lower body dressing, putting on/taking off footwear, rolling left and right, sit to laying, lying to sitting on the side of the bed, and tub/shower transfers. Substantial to maximal assist with sit to stand, and chair/bed-to-chair transfer. A review of Resident #1's physician orders dated 10/9/2023 included Lidocaine external patch 4% apply to lower back topically one time a day for pain and remove at bedtime. This order was scheduled for 9 AM on the Medication Administration Record (MAR) with the time changed to 6:00 AM on 10/21/23. A review of Resident #1's Physical Therapy evaluation dated 10/8/2023 noted that Resident #1 had pain that interfered/limited her functional activity. Resident #1's MAR revealed on 10/24/23 the Lidocaine patch was not applied to Resident #1's lower back as ordered by the marking of the number 9 in the box indicating other/see progress note. Resident #1's progress note dated 10/24/23 did not contain any information related to why the Lidocaine patch was not marked as applied. A phone interview conducted on 11/14/23 with Nurse #1 at 1:30 PM revealed that she could not remember why the patch had not been applied. An interview with the Administrator on 11/14/23 at 1:45 PM revealed that medications should be administered as ordered or a progress note put in as to why a medication was not given.

Based on observation, record review and staff interview the facility failed to monitor temperatures for 1 of 1 medication refrigerators (300 Hall medication room refrigerator) and failed to discard expired medication for 2 of 3 medications carts (400 Hall medication cart, 500 Hall medication cart). The findings included: 1. An observation was conducted of the 300 Hall medication storage room on 4/25/23 at 9:02 AM with Nurse Supervisor #2. The refrigerator temperature registered at 28 degrees Fahrenheit and there was a large block of ice formed around the freezer section of the refrigerator. The 300 Hall refrigerator contained the following medications 1 Humalog Insulin KwikPen Prefilled syringe, 2 Novolog Insulin FlexPen Prefilled syringes, 3 Mini Bag Intravenous Ertapenem (an antibiotic) and 2 boxes of Tuberculin Purified Protein Derivative. A review of the refrigerator temperature log for the month of April 2023 revealed the refrigerator temp log needed to be at 36 to 46 degrees Fahrenheit (40 degrees Fahrenheit is the ideal temperature for the medication refrigerator was indicated on the refrigerator and freezer temperature log). A review of the temperature log revealed the refrigerator temperatures were out of range on the following dates: 4/5/23 @ 0800- 34 degrees Fahrenheit (Adjusted)The temperature was adjusted but there was no rechecked temperature to see if the temperature was maintained. 4/8/23 @ 1800 32 degrees Fahrenheit (Adjusted) 4/9/23 @ 0810 34 degrees Fahrenheit (Adjusted) 4/9/23 @ 2200 32 degrees Fahrenheit (Adjusted) 4/13/23 @ 1530 30 degrees Fahrenheit (Adjusted) 4/18/23 @ 1600 30 degrees Fahrenheit (Adjusted) 4/19/23 @ 0800 30 degrees Fahrenheit (Adjusted) 4/19/23 @ 1600 20 degrees Fahrenheit (Adjusted) 4/20/23 @ 1500 28 degrees Fahrenheit (Adjusted) An interview was conducted with Nurse Supervisor #2 at 9:38 AM. NS #2 stated the medication refrigerator was checked twice daily and the temperature was adjusted either up or down to maintain the refrigerator within the desired range. NS #2 stated she would remove the medications and place them in another refrigerator. NS#2 stated she would have maintenance look at the refrigerator. An interview was conducted with the Maintenance Director on 4/25/23 at 12:52 PM. The Maintenance Director stated he was made aware of the issue with the refrigerator this morning. He stated that most of the time when the medication refrigerator stopped maintaining its temperature it was due to their being a large block of ice in it. The Maintenance Director stated the medication refrigerator should maintain its ideal temperature with the door closed. He further stated that nursing notified maintenance when the medication refrigerators needed defrosting. An interview was conducted with the Administrator and Regional [NAME] President of Clinical Services on 4/26/23 at 3:09 AM. The Administrator stated the refrigerator temperatures were checked twice daily. She stated if the refrigerator was consistently out of range, then the medications should have been removed, and maintenance should look at the refrigerator. The Administrator stated a work order was placed in the TELS electronic system (a computer system that allows staff to put in work orders for the facility) to notify maintenance personnel. 2 a. During the observation on 4/25/23 at 9:02 AM with Nurse Supervisor #2 the 300 Hall refrigerator contained the following medications 1 Humalog Insulin KwikPen Prefilled syringe, 2 Novolog Insulin FlexPen Prefilled syringes, 3 Mini Bag Intravenous Ertapenem (an antibiotic) and 2 boxes of Tuberculin Purified Protein Derivative. b. An observation of the 400 Hall medication cart on 4/25/23 at 9:45 AM revealed an opened Timolol Maleate Ophthalmic Solution 0.5% dated 3/24/23. An interview was conducted with Nurse #10 on 4/25/23 at 9:58 AM. Nurse #9 stated she did not realize the expired medication was on the cart. Nurse #10 stated the nurse assigned to the cart was responsible for checking for expired medications each shift. c. An observation of the 500 Hall medication cart on 4/25/23 at 10:01 AM revealed an opened bottle of Dorzolamide Opthalmic Solution 0.2% dated 3/24/23. An interview was conducted with Nurse #9 on 4/25/23 at 10:05 AM. Nurse #9 stated she did not realize the expired medication was on the cart. Nurse #9 stated the nurse assigned to the cart was responsible for checking for expired medications. An interview was conducted with the Administrator and Regional [NAME] President of Clinical Services on 4/26/23 at 3:09 AM. The Administrator stated expired medications should be removed prior to their expiration date.

Based on record review, observation, and staff interview, the facility ' s Quality Assurance and Assessment (QAA) Committee failed to maintain implemented procedures and monitor interventions put in place following the recertification and complaint investigation survey of [DATE]. This was for a deficiency in the area of Label/Store Drugs and Biologicals (F761) originally cited on [DATE], recited on a recertification follow up survey on [DATE], and subsequently recited on the current recertification survey of [DATE]. The continued failure of the facility during three federal surveys of record shows a pattern of the facility ' s inability to sustain an effective Quality Assurance program. The findings included: This tag is cross referenced to: F761: Based on observation, record review and staff interview the facility failed to monitor temperatures for 1 of 1 medication refrigerators (300 Hall medication room refrigerator) and failed to discard expired medication for 2 of 3 medications carts (400 Hall medication cart, 500 Hall medication cart). During the previous recertification survey of [DATE], the facility failed to discard a vial of expired influenza vaccine and to date an opened vial of Tuberculin purified protein for 1 of 2 medication rooms reviewed for medication storage. During the recertification follow up survey of [DATE] the facility failed to dispose of 3 insulin pens that were labeled with an opened date of over 28 days and to label three insulin pens with an opened date on one of one medication carts reviewed (the 100 Hall Medication Cart). During an interview with the Administrator and Regional [NAME] President of Clinical Services on [DATE] at 3:09 PM the Administrator stated the Quality Assurance Performance Improvement meeting was held monthly to discuss various concerns in the facility. The Administrator stated the staff were constantly being educated through in-services and all staff meetings about the performance improvement plans. The Administrator stated the facility had faced a lot of administrative turnovers and she felt this change had directly affected the facility ' s ongoing performance improvement plan.

Based on observations record review and staff interviews, the facility failed to post the accurate census on the daily nurse staffing sheets for 2 of 4 days (4/23/23 and 4/24/23) of the recertification survey. The findings included: During the initial tour of the facility on 4/23/23 at 10:00 AM the daily nurse staffing sheet was observed posted on a wall by the nurse's station with a date of 4/23/23 and a census of 117. The Administrator confirmed the correct census was 120. On 4/24/23 at 11:15 AM the staff posting was observed with a date of 4/24/23 and a census of 117. The Administrator confirmed the correct census was 120. An interview was completed on 4/25/23 at 11:56 AM with the Staffing Manager. She indicated weekend daily nurse staffing sheets were posted prior to the end of her shift on Friday. The Staffing Manager stated the weekend unit manager was responsible for updating the census on Saturday and Sunday. Multiple attempts to contact the weekend unit manager were unsuccessful. An interview was completed on 4/26/23 at 2:05 PM with the Administrator. She stated the current census was discussed during the facility's daily morning meeting and was updated on the staffing sheets when needed. The Administrator indicated the facility failed to have the morning meeting on 4/24/23, therefore the Staffing Manager was not aware the correct census for 4/23/23 and 4/24/23 was 120. She stated she expected that the staff posting would be up to date and reflect the current census of the building.

Based on observations, staff interview and review of the facility's infection control and COVID-19 policy, the facility failed to conduct the complete COVID-19 screening process for 3 of 3 visitors upon entry to the facility. Findings included: A review of the facility's Infection Control Policy dated 03/03/ under Screening Process for Visitors read in part, the center uses an electronic screening system kiosk to screen visitors for signs and symptoms consistent with COVID-19 infection. As part of the screening process, visitors will identify whether they have worked in a nursing center, medical office, or other healthcare setting that has confirmed COVID-19 cases in the past 14 days. This information will be evaluated as part of the screening process to determine eligibility to enter the building. A review of Screener #1's education provided by the Facility Administrator on 06/02/2022 revealed the education content included be sure each visitor or vendor screens into the building by using the electronic screening system kiosk which prints a sticker for the visitor indicating clearance to enter the building. On 06/06/2022 at 8:34 am, Screener #1 unlocked the front door of the facility and permitted surveyors to enter the building. When the surveyors entered the building, Screener #1 directed the surveyors to use a separate wall unit temperature reader to record temperature. The surveyors were not directed to the electronic kiosk for COVID-19 screening questions prior to being escorted to the facility's conference room. The electronic screening kiosk records temperature as well as asks COVID-19 screening questions and requires visitors to sign in at entry and sign out at exit. Interview with Screener #1 on 06/06/2022 at 08:45 am revealed she was the screener for the facility and screened visitors every day. Interview with the Administrator on 06/06/2022 at 9:02 am revealed Screener #1 was educated and trained to have visitors use the electronic screening system kiosk upon entry to the building which includes answering all COVID-19 screening questions. The Administrator stated she was not sure why Screener #1 did not screen the surveyors appropriately unless she may have gotten nervous. An interview with the Infection Preventionist (IP) on 06/06/2022 @ 9:28 am revealed Screener #1 should have directed the surveyors to the electronic screening Kiosk located at the front desk upon entry of the building. She stated the wall temperature reader only records temperature and does not ask COVID-19 screening questions like the kiosk. An additional interview with the Screener #1 on 06/06/2022 at 9:34 am revealed, I panicked at the time. Screener #1 also stated she had been educated on the electronic screening kiosk and should have asked the surveyors to use this system to be cleared to enter the building.

Based on observations, record review and staff interviews the facility failed to discard a vial of Influenza vaccine, which was expired, and date an open vial of [MEDICATION(S)] purified protein for 1 of 2 medication rooms reviewed for medication storage. (100 Hall medication room) The findings included: The medication storage room on hall 100 was observed on 12/16/21 at 10:46 AM in the presence of the Director of Nursing (DON). The observation revealed an Influenza Vaccine was opened on 11/15/21. The manufacturer's storage instruction for the Influenza Vaccine was to be discarded 30 days after first use. Additional observation revealed a [MEDICATION(S)] purified protein/5tu was open and used but not dated. The manufacturers instruction for the [MEDICATION(S)] was to be discarded 30 days after first use. An interview with the DON on 12/16/21 at 10:51 AM, she stated that she has supervisors who spot check for expired medications and the cleanliness of the medication storage room and carts. An interview with a 100 hall Nurse supervisor on 12/16/21 at 11:20AM stated that the medication room was cleaned daily, and the storage bins and refrigerator are cleaned once weekly on the 11 PM- 7AM shift. An interview with the facility Administrator on 12/16/21 at 11:32 AM stated that nursing staff were supposed to take out any expired medications.

Based on observations, record review, Medical Director interview and staff interviews, the facility failed to follow posted Enhanced Droplet Contact Precautions signage on the quarantine/observation hall by not wearing the required Personal Protective Equipment (PPE) when entering resident rooms for 2 of 2 residents, (Resident #1 and Resident #2). Additionally, the facility failed to follow recommendations of the Centers for Disease Control and Prevention (CDC) guidelines for the use of Personal Protective Equipment (PPE) or follow the facility's visitation policy by conducting indoor visitation, beyond [MEDICATION NAME] care, after two new confirmed cases of COVID-19 were identified in the facility for Resident #3 and Resident #4. These failures occurred during the COVID-19 pandemic. 1. A review of the facility's Infection Control Policy and Procedure section, Isolation Precautions dated 07/29/2020 revealed Full PPE would be worn on Admission Units, Observation Units & Suspected or Confirmed COVID-19 regardless of the presence of symptoms. Full PPE was defined as wearing a N95 mask, gloves, gown, face shield and/or goggles. A review of The CDC guideline entitled Responding to Coronavirus (COVID-19) in Nursing Homes last reviewed and updated on 04/30/2020 indicated the following statements: *All recommended COVID-19 PPE should be worn during the care of residents under observation which includes use of N95 or higher-level respirator (or facemask if respirator is not available), eye protection, (goggles or a disposable face shield that covers the front and sides of the face), gloves and gown. A floor plan of the facility was given to the surveyor upon entry on 03/02/2021. The observation/quarantine halls (400 & 500) were highlighted by the Director of Nursing. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #1's medical record revealed a physician order [REDACTED]. The order was active on date of observation, 03/02/2021. Resident #2 was admitted to the facility on [DATE] A review of Resident #2 ' s medical record revealed a physician order [REDACTED]. The order was active on date of observation, 03/02/2021. An observation on 03/02/2021 at 12:16 pm revealed a sign on the door of Resident #1 and Resident #2 that read in part: Stop - Enhanced Droplet Contact Precautions - perform hand hygiene before entering room and wear gown, a N95 mask and gloves when entering the room. Both Resident #1 and #2 resided on the 400 hallway, one of the two halls designated for resident observation/quarantine. A cart with personal protective equipment (PPE) was observed in the hallway near Resident #2 ' s room. NA #1 was observed entering into Resident # 1 ' s room carrying a lunch tray and was not wearing a gown or gloves. NA #1 was wearing a N95 mask and a face shield. Resident #1 was sitting in a chair beside the bed with the bedside table in front of her. NA#1 placed the lunch tray on the bedside table, removed the lid and pushed it closer to Resident #1. NA #1 opened the milk carton, removed the lid from a cup of liquid beverage, opened the eating utensils and handed them to Resident #1. NA #1 exited the room without using hand sanitizer or washing her hands and proceeded to the food cart located in the hallway. NA #1 did not change her mask upon exiting Resident #1 ' s room. NA #1 picked up a food tray from the food cart and entered into Resident #2 ' s room without a gown, gloves and had not sanitized her hands. Resident #2 was in bed with the bedside table beside the bed. NA#1 placed the lunch tray on the bedside table and positioned it within reach of Resident #2. NA #1 removed the lid from the lunch tray, opened the eating utensils and handed them to Resident #2. NA #1 exited the room without using hand sanitizer or washing her hands. An interview on 03/02/2021 at 12:26 pm was conducted with NA #1. She stated she hadn't put on gloves or a gown prior to entering Resident #1 ' s or Resident #2 ' s room. NA #1 stated she was aware of the meaning of enhanced droplet contact precautions signage and should have gowned, gloved and sanitized her hands prior to entering the Resident #1 and Resident #2 ' s room. She stated she was not sure why she didn't wear full PPE but was only going to be in each room for a few minutes. She stated she should have worn the required PPE and followed the procedure and instructions posted and outlined on the resident ' s door. She added the facility conducted frequent in-services regarding PPE and she had been trained on the use of wearing full PPE for meal delivery. She stated her normal practice was to follow the guidance posted on the precaution signs for each resident. An interview with Nurse #1 at 12:44 pm revealed 400 & 500 halls were designated for the observation/quarantine halls which housed new admissions and residents with respiratory signs and symptoms. She stated both halls required staff to don full PPE including gowns, gloves, face shields/goggles and N95 masks including during meal delivery. She added all residents on these halls had signage for enhanced droplet contact precautions posted on each door. An interview with the Director of Nursing (DON) on 03/02/2021 12:49 pm revealed all staff were required to wear full PPE when entering resident ' s rooms with posted enhanced droplet contact precaution signage. She added NA#1 should have worn a gown, gloves and sanitized her hands prior to entering the room as the sign indicated. A phone interview with the Administrator on 03/05/2021 at 4:42 pm revealed employees are required to wear full PPE when entering rooms located on the 400 & 500 halls of the facility. She added the 400 & 500 halls were the facility ' s observation/quarantine halls. She stated employees should always follow the isolation signage posted on resident ' s doors. 2. A review of the county ' s positivity rate revealed the rate remained below 10% and the facility was not conducting outbreak testing between the dates of 02/07/2021 - 03/02/2021. A review of the facility ' s Tool Kit A Section I of the COVID-19 Infection Control Policy and Procedure dated 03/04/2021 labeled indoor visitation revealed the following: Centers must meet the following prerequisites prior to allowing indoor visitation beyond [MEDICATION NAME] care visits: o No new onset of COVID-19 cases in the last 14 days. o Center is not conducting outbreak testing. o Only low (less than 5%) and medium (5%-10%) category positivity rates are eligible for indoor visitation. Centers with high (10%) positivity rate can only conduct indoor visitation in [MEDICATION NAME] care situations. A review of the facility's visitation logs dated 02/07/2021 - 03/02/2021 revealed the facility conducted indoor visitation, beyond [MEDICATION NAME] care situations, in the facility's dining room. Visitation sessions were conducted every Monday-Friday from 1:30 pm - 4:30 pm. Family visits were scheduled every hour during the designated times and were for one resident and family member at a time. The first 30 minutes of each hour were used for resident and family visiting and the remaining 30 minutes were used to disinfect the visitation area in preparation for the next resident ' s visit. A review of screening logs dated 02/07/2021 - 03/02/2021 revealed each visitor was screened for COVID-19 prior to being allowed in the facility. The screening documentation included temperature of the visitor at time of entry, any signs and symptoms of COVID-19 and were required to sanitize hands in addition to wearing surgical masks. Resident #3 was admitted to the facility on [DATE]. A review of lab results revealed Resident #3 tested positive for COVID-19 on 02/08/2021. Resident # 3 was moved from the 100 hall to the facility ' s COVID-19 unit on 02/08/2021. Resident #4 was admitted to the facility on [DATE]. A review of lab results revealed Resident #4 tested positive for COVID-19 on 02/10/2021. Resident # 4 was moved from the 500 hall to the facility ' s COVID-19 unit on 02/10/2021. An observation of a visitation session in the facility's dining hall on 03/02/2020 at 2:44 pm revealed Resident #6 sitting at a table visiting with a family member. There was a plexiglass-style plastic divider in the middle of the table resting between Resident #6 and their visitor. A staff member was sitting at a nearby table supervising the visit in its entirety. When the resident and family member ' s visitation session ended, staff cleaned the table, chairs and plexiglass divider with Clorox wipes. The county ' s positivity rate was 3.6 % on date of observation, 03/02/2021. An interview with the Activity ' s Director on 03/02/2021 at 3:16 pm revealed the facility conducted visitation in the dining area for non-[MEDICATION NAME] care visits every Monday-Friday afternoon and stated she was responsible for making the schedule for the indoor visitation sessions. She added the visits were always supervised by a staff member. In addition, she stated the plexiglass divider, table and chairs were sanitized with bleach wipes between each visit to ensure the area was clean for the next resident visitation session. She stated [MEDICATION NAME] care visits at the facility were held in the specific room of each resident if needed. An interview with the Activity's Assistant on 03/02/2021 at 3:46 pm revealed she frequently supervised the facility's visitation sessions and supervised the one on 03/02/2021. She stated the visitation sessions have occurred every Monday through Friday from 1:30 pm - 4:30 pm beginning January 18, 2021 for one resident at a time for 30 minutes. She added the hour-long timeframes include 30 minutes for the resident to visit with family and the remaining 30 minutes was used for cleaning and sanitizing the tables, plexiglass divider and chairs. She included each visitor is screened at the same entrance the employees use and must wear a surgical mask, answer COVID-19 screening questions, sanitize hands and record their temperature. A phone interview with the Infection Preventionist on 03/05/2021 at 10:00 am revealed she was new to the facility as of 02/15/2021. She stated she was aware of the (CMS) memorandum QSO-20-39-NH dated 09/17/2020 regarding indoor visitation but had not expressed concerns about the indoor visitation sessions to the (DON) or Administrative staff because she was so new to the facility and was still in orientation. An interview with the DON on 03/02/2021 at 4:14 pm revealed the facility was deemed a COVID-19 facility and each resident in the facility who tested positive for COVID-19 was immediately moved to the covid unit. She added the COVID-19 unit was a separate entity from the facility which meant the facility could conduct indoor visitation because the residents on the covid unit did not cross over to the main building of the facility. She stated the facility conducted a Quality Assurance Performance Improvement (QAPI) meeting on 01/13/2021 regarding indoor visitation and the decision was made transition outdoor visitation to indoor visitation. She stated she was familiar with the (CMS) memorandum QSO-20-39-NH dated 09/17/2020 but her understanding was the facility's covid unit was separate from the other areas of the facility. She included Resident #1 tested positive on 02/07/2021 and was moved from the 100 hall to the covid unit the same day. She included Resident #2 tested positive on 02/10/2021 and was moved from the 500 hall, one of the facility ' s quarantine halls, to the covid unit the same day. A phone interview with the facility ' s Medical Director on 03/05/2021 at 8:00 am revealed Administrative staff met on January 13, 2021 regarding indoor visitation. He stated discussion topics during the meeting included halting outdoor visitation due to the inclement weather during the previous months. He stated families were upset regarding not being able to visit inside the facility leaving them no alternative but to visit at a resident ' s window. He included the window visits prompted the residents to get out of bed without assistance which placed them at an increased risk for falls. He stated discussions continued during the meeting regarding the CMS indoor visitation guidelines, the safety of residents, and the possibility of utilizing the facility ' s dining room for indoor visitation. He added the openness of the room would allow for the proper amount of social distancing and plexiglass dividers could be placed on top of the tables to keep visitors and residents safe. He included CMS was not aware of the facility ' s building layout and its separation between residents and the dining room. He stated the Administrative staff decided to move forward with indoor visitation beginning on 01/15/2021. He included he was aware Resident #1 and Resident #2 tested positive on February 7th & February 10th. An interview with the Administrator on 03/05/2021 at 4:42 pm revealed a QAPI meeting was held on January 13, 2021 regarding indoor visitation. She added she was aware of the CMS memorandum QSO-20-39-NH dated 09/17/2020. She stated she was not sure why indoor visitation was not halted after Resident #1 tested positive for COVID-19 on 02/07/2021. In addition, she added indoor visitation should have been suspended after receiving the COVID-19 positive result on 02/07/2021.

Based on record review, observation and staff interviews the facility failed to provide privacy during visitation for 1 of 1 resident, Resident #6. Findings include: A review of the facility's visitation log dated 03/02/2021 revealed Resident #6 was visited by a family member during an indoor visitation session in the facility's dining room. An observation of a visitation session in the facility's dining hall on 03/02/2020 at 2:44 pm revealed Resident #6 sitting at a table visiting with a family member. There was a plexiglass-style plastic divider in the middle of the table resting between Resident #6 and their visitor. A staff member was sitting at a nearby table supervising the visit in its entirety. An interview with the facility ' s Activity Director on 03/02/2021 at 3:16 pm revealed the facility conducted visitation in the dining area for non-[MEDICATION NAME] care visits every Monday-Friday afternoon and stated she was responsible for making the schedule for the indoor visitation sessions. She added the visits were always supervised by a staff member due to COVID-19 social distancing concerns. In addition, she stated there was a plexiglass divider between the resident and the visitor. An interview with the facility ' s Activities Assistant on 03/02/2021 at 3:46 pm revealed she frequently supervised the facility's visitation sessions and supervised the session on 03/02/2021 for Resident #6. She stated the visitation session only allow one resident at a time for 30 minutes. An interview with the Director of Nursing on 03/02/2021 at 4:14 PM revealed resident visitation sessions were held in the facility ' s dining room and supervised by a staff member to ensure COVID-19 social distancing guidelines were followed.

Based on observations, staff interviews, and record review, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 26 medication opportunities, resulting in a medication error rate of 7.6% for 2 of 5 residents (Resident #77 and Resident #68) observed during medication pass. The findings included: 1) Resident #77 was admitted to the facility on [DATE] with a cumulative [DIAGNOSES REDACTED]. A review of Resident #77 ' s active Physician order [REDACTED]. [MEDICATION NAME] Respimat is an inhaled medication containing a combination of two medications, [MEDICATION NAME] and [MEDICATION NAME]. It is used for the management of [MEDICAL CONDITION]. On 12/12/18 at 4:26 PM, Medication Aide (Med Aide) #1 was observed as she prepared to administer 20/100 mcg [MEDICATION NAME] Respimat to Resident #77. The med aide opened a box containing a new 20/100 mcg [MEDICATION NAME] Respimat inhaler. After she inserted the cartridge into the delivery mouthpiece, she primed the system by depressing the [MEDICATION NAME] one time only; a fine mist (spray) was observed at that time. The [MEDICATION NAME] Respimat inhaler was brought to Resident #77 and one puff of the medication was administered. A review of the manufacturer ' s instructions on the preparation for use and priming of the [MEDICATION NAME] Respimat inhaler was conducted. These instructions read, in part: Instruct patients that priming [MEDICATION NAME] Respimat is essential to ensure appropriate content of the medication in each actuation. When using the unit for the first time, the [MEDICATION NAME] Respimat cartridge is inserted into the [MEDICATION NAME] Respimat inhaler and the unit is primed. [MEDICATION NAME] Respimat patients are to actuate the inhaler toward the ground until an aerosol cloud is visible and then repeat the process three more times. The unit is then considered primed and ready for use. An interview was conducted on 12/12/18 at 4:45 PM with Med Aide #1. During the interview, the manufacturer ' s instructions were taken out of the [MEDICATION NAME] Respimat inhaler ' s box and the directions for priming the inhaler were reviewed. Upon inquiry, the med aide reported she primed the inhaler by actuating it one time only. She confirmed the manufacturer ' s directions indicated this process needed to be repeated three more times in order to prime the inhaler. An interview was conducted on 12/13/18 at 3:16 PM with the facility ' s Director of Nursing (DON). During the interview, the DON reported her expectation was for her nurses (and med aides) to know how to administer the medications they were giving. The DON also stated she would expect for them to receive the education and have the knowledge to administer the medications properly. 2) Resident #68 was admitted to the facility on [DATE] with a cumulative [DIAGNOSES REDACTED]. A review of Resident #68 ' s active Physician order [REDACTED]. The physician's order [REDACTED]. Do not swallow. [MEDICATION NAME] is an inhaled medication containing a combination of two medications, [MEDICATION NAME] (a steroid) and [MEDICATION NAME]. It is used for the management of asthma and/or [MEDICAL CONDITION]. On 12/12/18 at 8:25 AM, Nurse #1 was observed as she prepared and administered medications to Resident #68. The medications pulled for administration included 80 mcg / 4.5 mcg [MEDICATION NAME]. The resident was observed as she inhaled two puffs of the aerosol medication. The nurse did not prompt the resident to rinse her mouth out with water; no water was offered to the resident after the [MEDICATION NAME] inhaler was used. A review of the package insert from the manufacturers of [MEDICATION NAME] (Revised 12/2017) included the following Administration Information, in part: [MEDICATION NAME] should be administered as 2 inhalations twice daily (morning and evening, approximately 12 hours apart), every day by the orally inhaled route only. After inhalation, the patient should rinse the mouth with water without swallowing. Additionally, the Patient Information Guide (Revised 12/2017) for [MEDICATION NAME] specified the following administration guidelines: Rinse your mouth with water and spit the water out after each dose (2 puffs) of [MEDICATION NAME]. Do not swallow the water. This will help to lessen the chance of getting a fungus infection (thrush) in the mouth and throat. An interview was conducted on 12/12/18 at 8:45 AM with Nurse #1. During the interview, the nurse confirmed she did not provide water or instruction to Resident #68 to rinse her mouth with water after using the [MEDICATION NAME] inhaler. An interview was conducted on 12/13/18 at 3:16 PM with the facility ' s Director of Nursing (DON). During the interview, the DON reported her expectation was for her nurses (and med aides) to know how to administer the medications they were giving. The DON also stated she would expect for them to receive the education and have the knowledge to administer the medications properly.

FACILITY QAA and QAPI Based on staff interview and record review, the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the recertification survey of 01/12/2018. This was for one deficiency which was recited during the recertification survey of 12/14/2018 in F761. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance program. The findings included: This citation is cross referenced to: F761 Based on observations, record review and staff interviews the facility failed to 1) failed to remove expired medications from 1 of 3 medication carts observed (200 West Med Cart); 2) failed to label medications with a shortened expiration date in 1 of 3 medication carts observed (200 West Med Cart); and, 3) failed to store medications as specified by the manufacturer in 2 of 3 medication carts observed (100 Hall Med Cart and 200 West Med Cart). From the previous survey of 01/12/2018, the facility failed to dispose of expired medications. On 12/14/18 at 4:30 PM the Administrator acknowledged understanding of the reciting of the repeated deficiency F761 from the recertification survey of 01/12/2018 . The Administrator stated he was aware of medication storage issues, and they were addressing concerns on an ongoing basis.

Based on observations, staff interviews, and record review, the facility: 1) failed to remove expired medications from 1 of 3 medication carts observed (200 West Med Cart); 2) failed to label medications with a shortened expiration date in 1 of 3 medication carts observed (200 West Med Cart); and, 3) failed to store medications as specified by the manufacturer in 2 of 3 medication carts observed (100 Hall Med Cart and 200 West Med Cart). The findings included: 1-a) Accompanied by Nurse #1, an observation of the 200 West Medication Cart was conducted on 12/12/18 at 8:17 AM. The observation revealed an opened bottle of 0.005 % latanoprost ophthalmic solution (an eye drop medication used to treat [MEDICAL CONDITION]) labeled for Resident #57 was stored on the cart. A hand-written notation on the bottle indicated the lantanoprost eye drops were opened on 9/4/18. An auxiliary label placed on the lantanoprost eye drop bottle by the pharmacy read, Refrigerate until opened. Discard 6 weeks after opening. Nurse #1 confirmed both the date the latanoprost bottle was opened and the presence of the pharmacy auxiliary sticker which indicated the opened bottle of latanoprost had a shortened expiration date. Based on date the latanoprost had been opened, the shortened expiration date of the eye drops was 10/16/18. A review of the manufacturer ' s storage instructions for latanoprost ophthalmic solution indicated once opened, the container may be stored at room temperature up to 25o C (77o F) for 6 weeks. A review of Resident #57 ' s current Physician order [REDACTED]. An interview was conducted on 12/13/18 at 2:45 PM with the facility ' s Director of Nursing (DON). During the interview, the DON reported her expectation was for all medications to be dated appropriately as to when they were opened and when there was an expiration date, as well. She stated an expired medication needed to be disposed of or sent back to the pharmacy. 1-b) Accompanied by Nurse #1, an observation of the 200 West Medication Cart was conducted on 12/12/18 at 8:17 AM. The observation revealed an opened [MEDICATION NAME] (a rapid-acting insulin) dispensed by the pharmacy on 11/6/18 and labeled for Resident #62 was stored on the medication cart. A hand-written notation on the [MEDICATION NAME] appeared to indicate the pen was opened on 11/1/18 (which would indicate the insulin ' s shortened expiration date was 11/29/18). Nurse #1 was asked to carefully review the hand-written date to help determine if the pen was possibly opened on 11/7/18 (which would indicate the insulin expired on 12/5/18). However, Nurse #1 stated the insulin pen appeared to be dated as having been opened on 11/1/18. A review of the manufacturer ' s storage instructions for a [MEDICATION NAME] indicated once in use, the insulin pen should be stored at temperatures less than 30o C (86o F) and used within 28 days. A review of Resident #62 ' s current Physician order [REDACTED]. An interview was conducted on 12/13/18 at 2:45 PM with the facility ' s Director of Nursing (DON). During the interview, the DON reported her expectation was for all medications to be dated appropriately as to when they were opened and when there was an expiration date, as well. She stated an expired medication needed to be disposed of or sent back to the pharmacy. 2) Accompanied by Nurse #1, an observation of the 200 West Medication Cart was conducted on 12/12/18 at 8:17 AM. The observation revealed a box of 0.25 milligrams (mg) / 2 milliliters (ml) [MEDICATION NAME] inhalation suspension vials (an inhaled steroid medication used in the treatment of [REDACTED].#61 was stored on the med cart. The box contained one opened, undated foil pouch with 4 vials of [MEDICATION NAME]. Five additional vials of [MEDICATION NAME] inhalation suspension were stored in the box outside of a foil pouch (there was no empty foil pouch in the box). Nurse #1 confirmed the observed storage of the [MEDICATION NAME] inhalation suspension vials inside of the undated foil pouch and the vials stored without a foil pouch. A review of the manufacturer ' s storage instructions for [MEDICATION NAME] inhalation suspension indicated once the aluminum package was opened, the solution should be used within 2 weeks. A review of Resident #61 ' s current Physician order [REDACTED]. An interview was conducted on 12/13/18 at 2:45 PM with the facility ' s Director of Nursing (DON). During the interview, the DON reported if there is a foil pouch for inhalation solutions, the medication needed to be stored inside of that foil pouch. She also stated her expectation was for all medications to be dated appropriately as to when they were opened and when there was an expiration date as well. She stated an expired medication needed to be disposed of or sent back to the pharmacy. 3-a) Accompanied by the facility ' s Administrator and joined by Nurse #2, an observation of the 100 Hall Medication Cart was conducted on 12/12/18 at 9:30 AM. The observation revealed two vials of 0.5 milligram (mg)-2.5 mg / 3 milliliter (ml) [MEDICATION NAME]/[MEDICATION NAME] inhalation solution (an inhaled medication used for the management of [MEDICAL CONDITION]) were stored outside of the foil pouch and placed on top of a manufacturer ' s box inside the medication cart. A review of the manufacturer ' s storage instructions for [MEDICATION NAME]/[MEDICATION NAME] inhalation solution indicated vials should be protected from light before use. Unused vials should be placed in the foil pouch for storage. An interview was conducted on 12/13/18 at 2:45 PM with the facility ' s Director of Nursing (DON). During the interview, the DON reported if there is a foil pouch for inhalation solutions, the medication needed to be stored inside of that foil pouch. 3-b) Accompanied by the facility ' s Administrator and joined by Nurse #2, an observation of the 100 Hall Medication Cart was conducted on 12/12/18 at 9:30 AM. The observation revealed two single-use containers of 5% Xiidra ophthalmic solution (an eye medication used to treat dry eye disease) were lying outside of and on top of the foil pouch while stored in the medication cart. The Xiidra ophthalmic solution was labeled as having been dispensed for Resident #34. According to the product manufacturer, single-use containers of Xiidra should be stored in the original foil pouch. A review of Resident #34 ' s current Physician order [REDACTED]. An interview was conducted on 12/13/18 at 2:45 PM with the facility ' s Director of Nursing (DON). During the interview, the DON reported if there is a foil pouch, the medication needed to be stored inside of that foil pouch. 3-c) Accompanied by Nurse #1, an observation of the 200 West Medication Cart was conducted on 12/12/18 at 8:17 AM. The observation revealed an unopened bottle of 0.005 % latanoprost ophthalmic solution (an eye drop medication used to treat [MEDICAL CONDITION]) labeled for Resident #58 was stored on the cart. The labeling on the latanoprost bottle indicated it had been dispensed from the pharmacy on 12/6/18. A pharmacy auxiliary sticker placed on the latanoprost read, Refrigerate until opened. Discard 6 weeks after opening. A review of the manufacturer ' s storage instructions for latanoprost eye drops indicted intact (unopened) bottles should be stored under refrigeration at 2o Celsius (C) to 8o C or 36o Fahrenheit (F) to 46o F. An interview was conducted on 12/13/18 at 2:45 PM with the facility ' s Director of Nursing (DON). During the interview, the DON reported she expected medications would be stored in the refrigerator when indicated and pulled from the refrigerator when they were needed.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments for: 1) the classification of a medication received by 1 of 27 sampled residents reviewed for the accuracy of assessments (Resident #105); and, 2) nutritional approaches provided for 1 of 27 sampled residents reviewed for the accuracy of assessments (Resident #36). The findings included: 1) Resident #105 was admitted to the facility on [DATE] from a hospital. Her cumulative [DIAGNOSES REDACTED]. A review of the resident ' s 11/5/18 admission medication orders included 75 milligrams (mg) [MEDICATION NAME] (an antiplatelet medication) to be given as one tablet by mouth once daily. A review of Resident #105 ' s admission Minimum Data Set (MDS) assessment dated [DATE] was completed. Section N of the MDS indicated the resident received an anticoagulant medication on 7 out of 7 days during the look back period. An interview was conducted on 12/13/18 at 3:30 PM with MDS Coordinator #1. During the interview, the MDS Coordinator reported she had completed Resident #105 ' s admission MDS assessment. She reviewed Section N of the assessment and confirmed this MDS indicated the resident received an anticoagulant medication on 7 out of 7 days during the look back period. MDS Coordinator #1 reported she would have coded [MEDICATION NAME] as an anticoagulant. However, the MDS Coordinator stated she needed to check with the Resident Care MDS Director as to whether or not this was coded correctly. An interview was conducted on 12/14/18 at 10:54 AM with the facility ' s Resident Care MDS Director in regards to the coding of [MEDICATION NAME] as an anticoagulant on Resident #105's MDS assessment. During the interview, the MDS Director confirmed [MEDICATION NAME] should not have been coded as an anticoagulant. She reported the resident ' s admission MDS had been coded incorrectly and stated this assessment has now been corrected. An interview was conducted on 12/14/18 at 2:06 PM with the facility's Director of Nursing (DON). During the interview, the coding of the residents ' MDS assessments were discussed. The DON reported she was told about the concerns identified with the coding of the assessments. She stated her expectation would be, For the MDS coding to be done correctly and that we are fully educated on how to code the MDS. 2) Resident #36 was admitted on [DATE] with re-entry to the facility on [DATE] from a hospital. Her cumulative [DIAGNOSES REDACTED]. A review of Resident #36 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] was completed. Section K of the MDS indicated Resident #36 received [MEDICATION NAME]/intravenous feeding while a resident in the facility within the last 7 days. However, a review of Resident #36 ' s medical record revealed there was no documentation to indicate the resident received [MEDICATION NAME]/intravenous feeding while she was a resident in the facility between 10/23/18 and 10/29/18. An interview was conducted on 12/13/18 at 3:30 PM with MDS Coordinator #1. During the interview, the MDS Coordinator reported she had completed Resident #36 ' s quarterly MDS assessment dated [DATE]. She reviewed Section K of the assessment and confirmed this MDS indicated the resident received [MEDICATION NAME]/intravenous feeding while she was a resident in the facility within the previous 7 days. MDS Coordinator #1 requested an opportunity to review the resident's medical records more carefully before commenting on the coding of this MDS assessment. An interview was conducted on 12/14/18 at 10:54 AM with the facility ' s Resident Care MDS Director in regards to the coding of Section K on Resident #36's MDS assessment. During the interview, the Director reported the 10/29/18 MDS assessment had already been corrected to reflect that no [MEDICATION NAME]/intravenous fluids were provided to Resident #36 during the 7-day look back period while she stayed at the facility. Upon further inquiry, the MDS Director confirmed the quarterly MDS dated [DATE] had not been coded correctly. An interview was conducted on 12/14/18 at 2:06 PM with the facility's Director of Nursing (DON). During the interview, the coding of the residents ' MDS assessments were discussed. The DON reported she was told about the concerns identified with the coding of the MDS. She stated her expectation would be, For the MDS coding to be done correctly and that we are fully educated on how to code the MDS.

Based on observation, resident and staff interviews, and record review the facility failed to keep fingernails trimmed for 1 of 3 residents reviewed for activities of daily living care. (Resident #4) Findings included: Resident #4 was re-admitted to the facility on [DATE]. His active [DIAGNOSES REDACTED]. Resident #4 did not have a [DIAGNOSES REDACTED]. Review of Resident #4 ' s most recent quarterly minimum data set assessment dated [DATE] revealed Resident #4 was assessed as moderately cognitively impaired. He had no behaviors of rejecting care. Resident #4 was totally dependent on staff for personal hygiene and had impairment on both sides of his upper extremities. Review of Resident #4 ' s care plan dated 12/5/17 revealed the resident was care planned for limited physical mobility and functional impairments. An intervention was to provide supportive care as needed for activities of daily living. During observation on 5/15/18 at 9:49 AM Resident #4 was observed to have long fingernails. During observation on 5/15/18 at 11:42 AM Resident #4 was observed to have long fingernails. During an interview on 5/15/18 at 11:43 AM Resident #4 stated that his fingernails were long and that staff did not cut them like they should. He further stated he would ask a nurse aide to cut his fingernails and they would tell him they would come back later but they never did. During an interview on 5/15/18 at 12:15 PM Nurse Aide #1 stated that she did not cut Resident #4 ' s fingernails because he was diabetic and staff could not cut fingernails of residents who had diabetes and would just file them if they got chipped or hurt. She further stated she did not think any staff was allowed to clip diabetic fingernails so she would only check and see if they needed to be filed. She further stated she did not remember if he had asked to have his nails trimmed recently, but she would file them for him if they were chipped. She further stated that diabetic fingernails could not be clipped by facility staff but that a podiatrist did come to the facility to cut nails. During an interview on 5/15/18 at 12:43 PM Nurse #1 stated that nurses would clip resident fingernails when they requested it. She further stated no staff or nurse aides had informed her Resident #4 would like to have his fingernails clipped. She stated she oversaw the medication aide and nurse aide on Resident #4 ' s hall and that if he did request to have his nails trimmed, it should be reported to her. During an interview on 5/15/18 at 12:21 PM the Director of Nursing stated Resident #4 was able to make his needs known and could communicate if he wanted his nails trimmed or not. She stated nurse aide ' s rarely trimmed residents ' nails. The Director of Nursing stated nurses were responsible for clipping the residents ' fingernails and not the podiatrist. She further stated upon observation of Resident #4 ' s fingernails that his nails were very long, and it was her expectation that a staff member would have brought it to her attention so she could get a nurse to clip them. She further stated she would clip Resident #4 ' s fingernails after the interview.

Based on observation, resident and staff interview, and record review, the facility failed to treat a resident's pain for one of three residents assessed for pain (Resident #8). Findings included: A review of the medical record revealed Resident #8 was admitted [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE], noted Resident #8 to be impaired for cognition and needed extensive assistance for all Activities of Daily Living (ADLs), with the physical assistance of one to two persons. The care plan for Resident #8 dated 2/20/2018 noted a focus of actual pain related to [MEDICAL CONDITION] with vertebral destruction, previous spinal fusion and [MEDICAL CONDITION] arthritis. The goal was Resident #8 would have pain alleviated with both pharmacological and non-pharmacological interventions, with evidence of pain relief through both verbal and non-verbal indicators, such as grimacing, groaning and crying through next review. Interventions included: Provide diversion activities such as positioning, television and music. Notify MD of unrelieved pain. A review of the medical record revealed a nursing admission assessment dated [DATE] which indicated Resident #8 stated she had pain or hurting in the last five days. Resident #8 was asked to rate her current pain on a zero to ten scale with zero as no pain and ten as the worst pain. Resident #8 rated the pain as a five. A review of the pain observation level in the Medication Administration Record [REDACTED]. A review of the MAR indicated [REDACTED]. On 2/28/2018 at 8:30 AM, Resident #8 was observed in bed and she stated had some pain in her back and legs. Resident #8 stated she started to get some pain medication recently and that helped ease her pain. Resident #8's family member was interviewed on 2/28/2018 at 9:00 AM. The family member was adamant Resident #8 was in pain and had taken [MEDICATION NAME] at home for an extended time. The family member stated she had received pain medication in the hospital and did not know why the facility had not given Resident #8 anything for her pain. The family member stated they had gone to Resident #8's regular pain physician's office, obtained a prescription for her usual pain medication, had the prescription filled at a local pharmacy and brought it to the facility. The family member indicated they were told the facility could not give Resident #8 the medication the family had obtained, took the medication and kept it. The family member noted the family was upset, because they felt Resident #8 needed something for pain. The family member said Resident #8 is my main concern. In an interview on 2/28/2018 at 3:30 PM, the Director of Nursing (DON) stated she did not know why Nurse #1 did not get an order for [REDACTED].#8's family had brought a prescription bottle to the facility and the DON had explained to them the facility could not use that prescription, and the DON had locked the prescription in her office. On 3/1/2018 at 10:00 AM, Nurse #1 stated if the pain assessment is positive, I notify the physician. Nurse #1 indicated the facility had no standing orders. Nurse #1 noted she had assessed Resident #8 at a five on the pain scale and did not notify the physician. Nurse #1 stated she did not remember why she did not call the physician. On 3/1/2018 at 2:00 PM in an interview, the MDS nurse stated she had done the Pain Assessment Interview of the MDS Section J, with Resident #8 on 2/22/2018. The Nurse stated when Resident #8 stated a pain level of a nine on the zero to ten pain scale, she told Nurse #1. The MDS nurse stated she did not document she told Nurse #1. In an interview on 3/1/2018 at 3:30 PM, Nurse #2 stated Resident #8 had no complaints of pain on the previous shift on 2/25/2018, and had no complaints of pain until the evening when Resident asked for Tylenol for back pain. Nurse #2 stated Resident #8 was asked if she would like to go back to bed and Resident #8 refused. Nurse #1 stated family members asked for Tylenol for Resident #8 and were informed there was no order and Nurse #2 would have to call the physician. Nurse #2 stated she conferred with her charge nurse about a contraindication between Tylenol and an arthritis drug Resident #8 was taking, and did phone the physician for an order for [REDACTED]. A review of the Medication Administration Record [REDACTED]. This was given one time on 2/25/2018. The pain level listed on the MAR indicated [REDACTED]. On 3/1/2018 at 5:00 PM, in an interview, the Director of Nursing stated her expectation was nurses would get an order for [REDACTED]. In a telephone interview on 3/5/2018 at 2:45 PM, Resident #8's physician stated if the Resident was having pain, he would expect the nurse to notify him and he could order something. On 3/28/2018 at 9:40 AM, Nursing Assistant (NA) #1 stated Resident #8 could tell you if she had pain. NA #1 stated she had worked with Resident #8 twice and if Resident #8 told me she had pain, I got the nurse to assess it. Resident #8 did not make faces or anything, she just told me she was having pain. In an interview on 3/28/2018 at 10:15 AM, NA #2 stated she had taken care of Resident #8 since the resident had moved to that hall. NA #2 stated Resident #8 would tell her if she was having pain. NA #2 indicated Resident #8 did not say how much her pain was, but would say I am hurting and I need something for pain. NA #2 stated she would tell the nurse. NA #3 was interviewed on 3/28/2018 at 3:40 PM and stated Resident #8 had told NA #3 she was really hurting but NA #3 noted she did not remember when that occurred, or if Resident #8 said where her pain was, and NA #3 got the nurse. On 3/28/2018 at 3:45 PM Nurse #3 was interviewed and stated Resident #8 would ask for pain medication and would say that her back was hurting. At that time Resident #8 had an order for [REDACTED].

Based on observation, resident and staff interview, and record review, the facility neglected to treat a resident's pain for one of three residents assessed for pain (Resident #8). Findings included: A review of the medical record revealed Resident #8 was admitted [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE], noted Resident #8 to be impaired for cognition and needed extensive assistance for all Activities of Daily Living (ADLs), with the physical assistance of one to two persons. The care plan for Resident #8 dated 2/20/2018 noted a focus of actual pain related to [MEDICAL CONDITION] with vertebral destruction, previous spinal fusion and [MEDICAL CONDITION] arthritis. The goal was Resident #8 would have pain alleviated with both pharmacological and non-pharmacological interventions, with evidence of pain relief through both verbal and non-verbal indicators, such as grimacing, groaning and crying through next review. Interventions included: Provide diversion activities such as positioning, television and music. Notify MD of unrelieved pain. A review of the medical record revealed a nursing admission assessment dated [DATE] which indicated Resident #8 stated she had pain or hurting in the last five days. Resident #8 was asked to rate her current pain on a zero to ten scale with zero as no pain and ten as the worst pain. Resident #8 rated the pain as a five. A review of the pain observation level in the Medication Administration Record [REDACTED]. A review of the MAR indicated [REDACTED]. On 2/28/2018 at 8:30 AM, Resident #8 was observed in bed and she stated had some pain in her back and legs. Resident #8 stated she started to get some pain medication recently and that helped ease her pain. Resident #8's family member was interviewed on 2/28/2018 at 9:00 AM. The family member stated Resident #8 had taken pain medication for years, related to her back issues, and saw a local pain physician for her medication. The family member stated she had received pain medication in the hospital and did not know why the facility had not given Resident #8 anything for her pain. The family member stated they had gone to the pain physician's office, obtained a prescription for her usual pain medication, had the prescription filled at a local pharmacy and brought it to the facility. The family member indicated they were told the facility could not give Resident #8 the medication the family had obtained, took the medication and kept it. The family member noted the family was upset, because they felt Resident #8 needed something for pain. The family member said Resident #8 is my main concern. The resident taken [MEDICATION NAME] 15 mg to be taken 4 times daily previously. In an interview on 2/28/2018 at 3:30 PM, the Director of Nursing (DON) stated she did not know why Nurse #1 did not get an order for [REDACTED].#8's family had brought a prescription bottle to the facility and the DON had explained to them the facility could not use that prescription, and the DON had locked the prescription in her office. On 3/1/2018 at 10:00 AM, Nurse #1 stated if the pain assessment is positive, I notify the physician. Nurse #1 indicated the facility had no standing orders. Nurse #1 noted she had assessed Resident #8 at a five on the pain scale and did not notify the physician. Nurse #1 stated she did not remember why she did not call the physician. On 3/1/2018 at 2:00 PM in an interview, the MDS nurse stated she had done the Pain Assessment Interview of the MDS Section J, with Resident #8 on 2/22/2018. The Nurse stated when Resident #8 stated a pain level of a nine on the zero to ten pain scale, she told Nurse #1. The MDS nurse stated she did not document she told Nurse #1. In an interview on 3/1/2018 at 3:30 PM, Nurse #2 stated Resident #8 had no complaints of pain on the previous shift on 2/25/2018, and had no complaints of pain until the evening when Resident asked for Tylenol for back pain. Nurse #2 stated Resident #8 was asked if she would like to go back to bed and Resident #8 refused. Nurse #1 stated family members asked for Tylenol for Resident #8 and were informed there was no order and Nurse #2 would have to call the physician. Nurse #2 stated she conferred with her charge nurse about a contraindication between Tylenol and an arthritis drug Resident #8 was taking, and did phone the physician for an order for [REDACTED]. A review of the Medication Administration Record [REDACTED]. This was given one time on 2/25/2018. The pain level listed on the MAR indicated [REDACTED]. On 3/1/2018 at 5:00 PM, in an interview, the Director of Nursing stated her expectation was nurses would get an order for [REDACTED]. In a telephone interview on 3/5/2018 at 2:45 PM, Resident #8's physician stated if the Resident was having pain, he would expect the nurse to notify him and he could order something. On 3/28/2018 at 9:40 AM, Nursing Assistant (NA) #1 stated Resident #8 could tell you if she had pain. NA #1 stated she had worked with Resident #8 twice and if Resident #8 told me she had pain, I got the nurse to assess it. Resident #8 did not make faces or anything, she just told me she was having pain. In an interview on 3/28/2018 at 10:15 AM, NA #2 stated she had taken care of Resident #8 since the resident had moved to that hall. NA #2 stated Resident #8 would tell her if she was having pain. NA #2 indicated Resident #8 did not say how much her pain was, but would say I am hurting and I need something for pain. NA #2 stated she would tell the nurse. NA #3 was interviewed on 3/28/2018 at 3:40 PM and stated Resident #8 had told NA #3 she was really hurting but NA #3 noted she did not remember or if Resident #8 said where her pain was, and NA #3 got the nurse. On 3/28/2018 at 3:45 PM Nurse #3 was interviewed and stated Resident #8 would ask for pain medication and would say that her back was hurting. At that time Resident #8 had an order for [REDACTED]. Although the resident indicated that she was in pain on admission 2/08/18 the facility neglected to obtain medication to treat the pain until 2/25/18.

Based on observation, resident, staff and physician interview, and record review, the facility failed to notify the physician about a resident's pain for one of three residents assessed for pain (Resident #8) which resulted in the Resident experiencing pain from the admitted until seventeen days later. Findings included: A review of the medical record revealed Resident #8 was admitted [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE], noted Resident #8 to be impaired for cognition and needed extensive assistance for all Activities of Daily Living (ADLs), with the physical assistance of one to two persons. The care plan for Resident #8 dated 2/20/2018 noted a focus of actual pain related to [MEDICAL CONDITION] with vertebral destruction, previous spinal fusion and [MEDICAL CONDITION] arthritis. The goal was Resident #8 would have pain alleviated with both pharmacological and non-pharmacological interventions, with evidence of pain relief through both verbal and non-verbal indicators, such as grimacing, groaning and crying through next review. Interventions included: Provide diversion activities such as positioning, television and music. Notify MD of unrelieved pain. On 2/28/2018 at 8:30 AM, Resident #8 was observed in bed and, in an interview, stated she had some pain in her back and legs. Resident #8 stated she started to get some pain medication recently and that helped ease her pain. A review of the medical record revealed an admission nursing assessment for pain dated 2/8/2018 which noted Resident #8 stated she had pain or hurting in the last five days. Resident #8 was asked to rate the worst pain over the last five days on a zero to ten scale with zero as no pain and ten as the worst pain. Resident #8 rated the pain as a five. Nurse #1 was interviewed on 3/1/2018 at 10:00 AM, and stated she had done the assessment and acknowledged Resident #8 had stated her pain was a five on the zero to ten pain scale. Nurse #1 noted she would notify the physician if a resident was having pain on admission with no order for pain medication. Nurse #1 stated she did not notify Resident #8's physician and could not remember why. On 3/1/2018 at 2:00 PM in an interview, the MDS nurse stated she had completed Section J of the MDS pain interview with Resident #8 on 2/22/2018. The Nurse stated when Resident #8 stated a pain level of a nine on the zero to ten scale, she told Nurse #1. The MDS nurse stated she did not document telling Nurse #1. In a telephone interview on 3/2/2018 at 10:47 AM, Nurse #1 stated she was not informed about Resident #8's pain on 2/22/2018. A review of the Medication Administration Record [REDACTED]. Initiated on 2/25/2018. On 3/1/2018 at 5:00 PM, in an interview, the Director of Nursing stated her expectation was nurses would notify a resident's physician if a resident was assessed for pain and had nothing ordered. In a telephone interview on 3/5/2018 at 2:45 PM, Resident #8's physician stated if the Resident was having pain, he would expect the nurse to notify him and he could order something. On 3/28/2018 at 9:40 AM, Nursing Assistant (NA) #1 stated Resident #8 could tell you if she had pain. NA #1 stated she had worked with Resident #8 twice and if Resident #8 told me she had pain, I got the nurse to assess it. Resident #8 did not make faces or anything, she just told me she was having pain. In an interview on 3/28/2018 at 10:15 AM, NA #2 stated she had taken care of Resident #8 since the resident had moved to that hall. NA #2 stated Resident #8 would tell her if she was having pain. NA #2 indicated Resident #8 did not say how much her pain was, but would say I am hurting and I need something for pain. NA #2 stated she would tell the nurse. NA #3 was interviewed on 3/28/2018 at 3:40 PM and stated Resident #8 had told NA #3 she was really hurting but NA #3 noted she did not remember when that occurred, or if Resident #8 said where her pain was, and NA #3 got the nurse.