Every finding on record at Grayson Health and Rehabilitation

Based on staff interview, clinical record review and facility document review, the facility staff failed to immediately notify the resident representative of a significant change in resident condition for one of four residents in the survey sample, resident #1.The findings included:Resident #1's diagnoses included but were not limited to chronic atrial fibrillation, chronic obstructive pulmonary disease, pleural effusion, muscle weakness, hypertension, Alzheimer's disease, osteoarthritis, repeated falls, anxiety disorder and acute on chronic congestive heart failure.The annual/5-day minimum data set (MDS) with an assessment reference date of 5/15/25 assigned the resident a brief interview for mental status (BIMS) score of 8 out of 15 indicating moderate cognitive impairment. In section GG- Functional Abilities, resident #1 was coded as requiring substantial/maximal assistance with toileting hygiene and partial/moderate assistance with transfers. Walking was coded as 8/8 not attempted due to medical condition or safety concerns. Resident #1 was coded as having falls within the last 30 days prior to admission, within the last 2-6 months prior to admission and as having a fracture related to a fall within the last 6 months prior to admission.The progress notes were reviewed. A note dated 5/28/25 at 1:46 PM read, CNA (certified nursing assistant) observed resident lying in the bathroom floor. resident did not have nonskid footwear on, did c/o (complain of) left arm and left elbow pain. Resident had multiple skin tear areas to bilateral arms/hands, discoloration to left cheek, and a skin tear to left lower leg. This nurse cleaned skin tears and applied steri strips. NP (nurse practitioner) was notified and ordered x-ray of elbow, arm, hip and pelvis. RP made aware. A note dated 5/28/25 at 2:33 PM read, Spoke with patient and sister at bedside/daughter/POA (power of attorney) via phone. Patient and POA agree to wait on mobile Xray unit to arrive to x-ray arm/left hip. PRN (as needed) medication ordered for acute pain/POA agreed to medication use for pain.According to the document entitled, Fall Investigation Form dated 5/28/25, the fall occurred at 8:45 AM. The document states, CNA (certified nursing assistant) observed res (resident) lying in bathroom floor. The document stated resident got up without assistant, without a walker or wheelchair, without footwear and without using the call light. A Change in Condition document dated 5/28/25 stated the resident fell on 5/28/25 at 8:45 AM and complained of left arm pain. The document states that the physician was notified at 8:50 AM and an x-ray of the left arm was ordered. The document states the resident representative was not notified of the fall until 11:45 AM. On 11/20/25 at 12:56 PM this surveyor interviewed CNA #1. They stated that they observed resident #1 lying in urine in front of the bathroom after breakfast on 5/28/25. CNA #1 could not recall the exact time but stated, I'm pretty sure I was picking up breakfast trays, so it was early. When asked what the resident said when they entered the room they stated, I don't remember exactly but she was able to tell me she fell. CNA #1 stated they did not recall if the call light was on or not, but that resident was able to use the light and frequently did. CNA #1 stated that resident #1 only complained of arm pain all day. They stated that they were in and out of the room multiple times throughout the day and there were no other complaints. This surveyor asked if the pain seemed constant and they stated, no but with moving and going to the bathroom it was pretty bad. CNA #1 stated, I never knew her to try to go without help before.On 11/20/25 at 1:06 PM this surveyor interviewed the Director of Social Services for the facility. They stated they were not aware of any resident or family concerns prior to the fall on 5/28/25. They stated the sister was in the facility that afternoon and that someone from the nursing staff had informed them the family was upset. I went in to see them, and they were concerned that the daughter wasn't notified about the fall that had occurred that morning. I asked if they wanted to file a grievance and they said no that everything was fine and they understood, I think she said, things happen. When asked if they could recall what time they spoke with the resident and her sister they could not say for sure but thought it was after lunch.On 11/20/25 at 1:14 PM this surveyor interviewed the Director of Rehabilitation Services (DOR). They stated, We (another therapist who is no longer employed) went in to see if she was up to therapy, we had heard about the fall and wanted to check on her, she was already on our caseload. She was sitting in her recliner, I asked what happened and she said she fell. She complained of elbow pain, but she wanted to go to the bathroom, so we decided to help with that. After she got off the toilet, she started complaining of lower extremity pain but initially it was just the elbow. We made sure not to let her bear any weight on the arm. She was calm and pleasant when we went in but started crying in pain as soon as we initiated treatment. We supported her left elbow the whole time, we got her back to the chair, she did beautifully, but with the crying in pain we did cue her then not put weight on the left leg either at that point. DOR stated that the sister was present in the room and was aware of the fall at the time. DOR could not recall what time it was but stated it was, near lunch. This surveyor asked if they thought the resident's pain level at the time was indicative of substantial injury, Oh for sure, she was in some real pain. I wasn't surprised about the extent of the injury. She was yelling and crying out the whole time we were getting her up and to the bathroom.On 11/20/25 at 1:17 PM this surveyor conducted a telephone interview with Licensed Practical Nurse (LPN) #1. When asked about resident #1's fall they stated, She got up without help, no walker or gripper socks and fell. When asked if they contacted resident #1's resident representative after the fall they stated, It did not happen right away. Her sister came to visit, and I told her and she asked if I had called the daughter. I told her not yet and explained that I hadn't had time due to dealing with another patient issue. She didn't seem upset, I think she understood. LPN #1 stated that she believes the resident representative was notified after lunch but could not recall for sure. This surveyor asked if the resident had informed them that she had fallen. I don't remember exactly what was said but yes, we were certain it was a fall. I have never thought that it was anything other than a fall so I think she probably did tell us. I know for sure she was capable of telling us what happened. LPN #1 stated that they were not sure at what time they were informed that the left elbow was separated but that the physician and the resident representative were notified immediately of the x-ray results and the resident was sent to the hospital for evaluation. The hip x-ray was negative; they didn't find out about that fracture until she was admitted and x-rays were repeated. We did offer to send her out sooner because it took a while for the mobile x-ray unit to come but they decided to wait. This surveyor asked, Do you think the family should have been notified sooner of the fall and the complaints of pain? LPN #1 stated, Yes, I guess ideally I should have called as soon as I hung up with the doctor but in my mind, I was taking care of the patient and prioritizing all that I had to do.On 11/20/25 at 4:00 PM this surveyor met with the Director of Nursing, the Administrator and the Administrator in training. This concern was reviewed with them at that time. The Administrator asked if it was my understanding that the resident representative was notified in about 3 hours at 11:45 AM. I explained that I am not certain as the nurse stated it was around lunchtime but had entered the note after 1:00 PM. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to follow medical provider orders for 2 of 4 sampled residents (Resident #1 and Resident #4). The findings included: 1. For Resident #1, the facility staff failed to notify the medical provider of blood sugar readings less than 60 or greater than 450 on four (4) separate occasions during the month of April 2024. This was a closed record review. Resident #1's diagnosis list indicated diagnoses, which included, but not limited to Chronic Kidney Disease Stage 5, Type 2 Diabetes Mellitus, Chronic Respiratory Failure, Adult Failure to Thrive, Chronic Obstructive Pulmonary Disease, and Dependence on Renal Dialysis. The minimum data set (MDS) with an assessment reference date (ARD) of 4/10/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #1's comprehensive person-centered care plan included a focus area stating [Resident #1] has Diabetes Mellitus with an intervention for accu-checks as ordered. Resident #1's medical provider orders included an order dated 4/09/24 for accu-checks (blood sugar checks) before meals and at bedtime and notify provider for a blood sugar reading below 60 or above 450. A review of Resident #1's clinical record revealed the following blood sugar (BS) levels which required provider notification however, surveyor was unable to locate documentation of the notification: 4/18/24 9:00 PM - BS 516 4/23/24 9:00 PM - BS 479 4/25/24 5:12 AM - BS 45 4/26/24 4:45 PM - BS 25 On 8/01/24 at 2:30 PM, surveyor met with the Administrator and Director of Nursing (DON) and discussed the concern of staff failing to notify the provider as ordered when Resident #1's blood sugar levels were below 60 or above 450. At 3:10 PM, the DON returned to the surveyor and acknowledged the lack of provider notification and stated they will develop a plan of action to address the concern. No further information regarding this concern was presented to the surveyor prior to the exit conference on 8/01/24. 2. For Resident #4, the facility staff failed to obtain a blood sugar reading as ordered by the medical provider. Resident #4's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Heart Failure, and Hemiplegia and Hemiparesis following Cerebral Infarction. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 5/31/24 assigned the resident a brief interview for mental status (BIMS) summary score of 13 out of 15 indicating the resident was cognitively intact. Resident #4's current comprehensive person-centered care plan included a focus area stating [Resident #4] has Diabetes Mellitus with an intervention for Accu-checks as ordered by doctor. A review of Resident #4's clinical record revealed a nursing progress note dated 7/09/24 11:37 PM which read in part Resident approaching this nurse since shift started with low blood sugars. Dexcom reading 78, 69, 67, 73, 59, 51 then only read as low. [Medical provider] contacted snacks, food, drinks given. N/o [new order] to decrease Glargine to 20 units. Administered. Resident Dexcom read low. Dr. recommended glucagon and send out. During transfer process resident requested finger stick which read 474. And resident decided not to go to the hospital. [Medical provider] ordered to recheck in one hour and give 6 units of novolog if still over 400. Surveyor reviewed Resident #4's clinical record and was unable to locate documentation of the blood sugar recheck. On 8/01/24 at 2:30 PM, surveyor met with the Administrator and Director of Nursing (DON) and discussed the concern of staff failing to recheck Resident #4's blood sugar on 7/09/24 as ordered by the provider. At 3:10 PM, the DON returned to the surveyor and acknowledged there was no evidence of the blood sugar recheck and stated they will develop a plan of action to address the concern. No further information regarding this concern was presented to the surveyor prior to the exit conference on 8/01/24.

Based on staff interview and facility document review, the facility staff failed to ensure 2 of 4 sampled residents were free of significant medication errors (Resident #1 and Resident #4). The findings included: 1. For Resident #1, the facility staff failed to follow the medical provider orders for the administration of Novolog, a fast-acting insulin used to lower blood sugar levels, on 28 separate occasions. This was a closed record review. Resident #1's diagnosis list indicated diagnoses, which included, but not limited to Chronic Kidney Disease Stage 5, Type 2 Diabetes Mellitus, Chronic Respiratory Failure, Adult Failure to Thrive, Chronic Obstructive Pulmonary Disease, and Dependence on Renal Dialysis. The minimum data set (MDS) with an assessment reference date (ARD) of 4/10/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #1's comprehensive person-centered care plan included a focus area stating [Resident #1] has Diabetes Mellitus with an intervention stating Diabetes medication as ordered by doctor . Resident #1's medical provider orders included an order dated 4/12/24 for Novolog subcutaneously every six hours as needed per sliding scale: 70-150 = 0 units, 151 - 200 = 1 unit, 201 - 250 = 2 units, 251 - 300 = 3 units, 301 - 350 = 4 units, 351 - 400 = 6 units. The resident's orders also included an order dated 4/06/24 for Novolog 8 units subcutaneously before meals and at bedtime and hold for a blood sugar less than 400. Resident #1 was seen by the physician on 4/26/24, the progress note read in part .Resident on rounds for eval .DM [Diabetes Mellitus] . Blood sugars remain labile at baseline but no hypoglycemia since my last evaluation completed with a low of 89 and a high of 400 .short acting low-dose sliding scale available from the hospital with hold parameters cautiously in place A review of Resident #1's April 2024 Medication Administration Record (MAR) revealed Novolog 8 units was administered on 4/16/24 at 11:00 AM for a blood sugar of 218 instead of 2 units per the sliding scale order. On 4/21/24 at 4:00 PM, 8 units of Novolog was administered for a blood sugar of 385 instead of the ordered amount of 6 units. According to Resident #1's April 2024 MAR, Novolog every 6 hours per sliding scale was not administered as ordered on 26 occasions from 4/12/24 through 4/27/24. On each of the 26 occasions, Novolog was not administered despite the resident requiring Novolog based on the identified sliding scale. On 8/01/24 at 2:30 PM, surveyor met with the Administrator and Director of Nursing (DON) and discussed the concern of staff failing to follow the medical provider orders for the administration of Novolog. At 3:10 PM, the DON returned to the surveyor and acknowledged the errors and stated they will develop a plan of action to address the concern. No further information regarding this concern was presented to the surveyor prior to the exit conference on 8/01/24. 2. For Resident #4, the facility staff failed to follow the medical provider order for the administration of Insulin Lispro, a fast-acting insulin used to lower blood sugar levels. Resident #4's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Heart Failure, and Hemiplegia and Hemiparesis following Cerebral Infarction. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 5/31/24 assigned the resident a brief interview for mental status (BIMS) summary score of 13 out of 15 indicating the resident was cognitively intact. Resident #4's current comprehensive person-centered care plan included a focus area stating [Resident #4] has Diabetes Mellitus with an intervention for Diabetes medication as ordered by doctor . Resident #4's current provider orders included an order dated 5/30/24 for Insulin Lispro 5 units subcutaneously before meals and hold for a blood sugar less than 300. A review of Resident #4's July 2024 Medication Administration Record (MAR) revealed Insulin Lispro 5 units was administered on 7/26/24 at 11:30 AM with a documented blood sugar reading of 140. On 8/01/24 at 2:30 PM, surveyor met with the Administrator and Director of Nursing (DON) and discussed the concern of staff failing to follow the medical provider order for the administration of Insulin Lispro. At 3:10 PM, the DON returned to the surveyor and acknowledged the error and stated they will develop a plan of action to address the concern. No further information regarding this concern was presented to the surveyor prior to the exit conference on 8/01/24.

Based on staff interview and facility document review, the facility staff failed to complete reviews of nurse aides at least every 12 months and failed to provide in-service education based on the outcome of these reviews. The findings were: The facility administration failed to complete performance reviews for nurse aides at least every 12 months and therefore failed to provide in-service education which was based on the outcome of the performance reviews. After completing the sufficient and competent nurse staff task, the surveyor asked the human resource manager about nurse aide performance reviews. The nurse aides had received in-service education during their employment however, the education was not based on the outcome of these reviews. On 12/13/23 at the end of day meeting with the administrator and director of nursing (DON), the concern about not having evidence of nurse aide performance reviews was discussed. The administrator said the facility had not provided performance reviews in years and he was unsure why. A policy and procedure with the subject titled, Employee j [sic]=Job Performance Evaluations with the document name: HR-405 and an effective date of 11/30/2014 was provided and reviewed. The policy read in part, It is the policy of The Company to evaluate each employee's job performance on a continual and ongoing basis. Employees will receive an evaluation of their performance prior to the completion of their introductory Period [sic] and annually thereafter. The procedure read in part, General Provisions Applicable to All Evaluations: Performance evaluations are to be conducted before the completion of the introductory period and annually thereafter. Written performance evaluations are to be prepared by the employee's immediate supervisor in conjunction with the department head, or in the absence of a supervisory, by the department head. No further information was provided prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to follow the providers order for 1 of 24 current residents, Residents #267. The findings included: For Resident #267, the facility nursing staff failed to administer the medications Gabapentin and Risperdal per the providers orders. Resident #267's diagnoses included, but were not limited to, diabetes, bipolar disorder, peripheral vascular disease, and orthopedic aftercare. There was no completed minimum data set assessment for Resident #267. This resident was alert and orientated to self and place. Resident #267's care plan included the intervention give all medications as ordered. Resident #267's clinical record included provider orders for Gabapentin 600 mg give 0.5 tablet by mouth every 12 hours for neuropathy and Risperdal 2 mg by mouth every 12 hours related to bipolar disorder the order dates were documented as 12/05/23. A review of the clinical record revealed that on 12/05/23 at 9:00 p.m. and 12/06/23 at 9:00 a.m. the facility nursing staff documented a 9 for the medications Risperdal and Gabapentin. Per the preprinted code on the medication administration record (MAR) a 9=other/see nurses note. Further review of the clinical record revealed that on 12/05/23 and 12/06/23 the nursing staff documented medication not arrived from pharmacy, medication on order, and/or awaiting arrival from pharmacy. A review of the Omnicell list (back up drug list) revealed these medications were available for administration. The facility staff provided the survey team with a copy of a policy titled, Medication Shortages/Unavailable Medications. This policy read in part, .Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy. If the medication shortage is discovered at the time of medication administration, Facility staff should immediately take action to notify the Pharmacy .If the next available delivery causes delay or a missed dose in the resident's medication schedule, Facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose . On 12/13/23 at 10:00 a.m., the Director of Nursing (DON) was made aware of the issue regarding Resident #267's medications Gabapentin and Risperdal not being administered per the provider orders when they were available in the Omnicell. The DON stated the nurses should have obtained the medications from the Omnicell and they would re-educate the nursing staff. On 12/13/23 at 3:30 p.m., during an end of the day meeting with the Administrator and DON the issue regarding Resident #267's medications not being administered per the providers orders was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to ensure the resident environment was free of accident hazards for 1 of 24 current residents, Resident #96. The findings were: Resident #96 possessed both cigarettes and lighter in his room which was against facility policy. The smoking assessment coded Resident #96 as an unsafe smoker prior to the surveyors asking about the facility's smoking policy. Resident #96's admission record contained a list of diagnoses which included but were not limited to chronic kidney disease, major depressive disorder, generalized anxiety disorder, unsteadiness on feet, malignant neoplasm of prostate, secondary malignant neoplasm of bone, disorientation, and psychophysiologic insomnia. The minimum data set with an assessment reference date of 11/24/23 coded the resident's brief interview for mental status a 12 out of 15 in Section C (cognitive patterns). The care plan included but was not limited to a focus area that read the resident was a smoker with interventions which included but were not limited to, instruct resident about the facility policy on smoking: locations, times, safety concerns, and notify charge nurse immediately if it is suspected resident has violated facility smoking policy. On 12/11/23 between 3:30 p.m. and 4:00 p.m., while meeting residents, two surveyors observed a pack of cigarettes on Resident #96's bed. The resident was sitting next to the bed, in a wheelchair. Resident #96 reported being a smoker and acknowledged the cigarettes on the bed belonged to him. When asked how he got his cigarettes lit, he stated he kept his lighter in his pocket and tapped his shirt pocket with his hand. The resident reported staff did accompany him outside during scheduled smoking times. Resident #96's clinical record contained a smoking evaluation dated 11/29/2023. Under Observations, number three read in part, the resident was not able to light cigarette safely with a lighter. The summary of evaluation noted the resident was an Unsafe Smoker and needed constant supervision while smoking. The concern about Resident #96 having cigarettes and lighter in his room was discussed with the administrator, the director of nursing (DON), and regional nurse consultant at the end of day meeting on 12/12/23 at 3:35 p.m. The DON reported the facility policy prohibited residents from keeping cigarettes and/or lighters in their room. The policy and procedure with Subject: Smoking - Supervised, Document Name: S-406 with an effective date of 11/30/2014 and revision date of 2/07/2020 was reviewed. Under the Procedure, it read in part, 5. The Center will retain and store matches, lighters, etc. for all residents. On 12/13/23, the DON provided the surveyor with a new smoking evaluation for Resident #96 and reported facility staff had performed an audit for all smoking residents. Resident #96's new smoking evaluation dated 12/13/23 determined the resident was a safe smoker with the observation portion reading that the resident was able to light cigarette safely with a lighter. On 12/14/23 at approximately 1:30 p.m., the DON acknowledged that regardless of whether Resident #96 was determined a safe or unsafe smoker, no resident was allowed to maintain their cigarettes and/or lighter in their room. No further information was provided prior to the exit conference.

Based on staff interview, facility document review and clinical record review the facility staff failed to ensure medications were available for administration for one of 24 residents, Resident #93. The findings include: For Resident #93, the facility staff failed to ensure the medication Zyprexa was available for administration. Resident #93's face sheet listed diagnoses which included but not limited to dementia, bipolar disorder, depression, and unspecified mood disorder. Resident #93's most recent minimum data set with an assessment reference data of 11/07/23 coded the resident as having both long- and short-term memory loss with severely impaired cognitive skills for daily decision making. Resident #93's comprehensive care plan was reviewed and contained care plans for . has potential to be physically aggressive & have increased sexual behaviors r/t Dementia and . uses psychotropic medications r/t dementia with behaviors, BIPOLAR d/o (disorder), depression, insomnia. Resident #93's clinical record was reviewed and contained a physician's order summary which read in part, Zyprexa Oral Tablet (Olanzapine). Give 2.5 mg by mouth one time a day for Mood related to BIPOLAR DISORDER, UNSPECIFIED. Resident #93's electronic medication administration (eMAR) record for the months of September and October 2023 were reviewed and contained an entry which read in part, Zyprexa Oral Tablet (Olanzapine). Give 2.5 mg by mouth one time a day for Mood related to BIPOLAR DISORDER, UNSPECIFIED. This entry was coded 9 on 09/23/23 and 10/26/23. Chart code 9 is equivalent to other/see nurse's notes. Resident #93's nurse's progress notes were reviewed and contained notes which read in part, Effective Date: 09/23/23 Note Text: On order from pharmacy and Effective Date: 10/26/2023 Note Text: on order. Surveyor requested and was provided with a facility policy entitled Medication Shortages/Unavailable Medications which read in part Procedure: 1. Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy. If the medication shortage is discovered at the time of medication administration, Facility staff should immediately take action to notify the Pharmacy. 2. If a medication is unavailable during normal Pharmacy hours: 2.1 A Facility Nurse should call Pharmacy to determine the status of the order, which may be found on Omniview under Pharmacy Connection menu. If the medication has not been ordered, the licensed Facility nurse should place the order or reorder for the next scheduled delivery. 2.2 If the next available delivery causes delay or missed dose in the resident's medication schedule, Facility nurse should obtain the medication from Emergency Medication Supply to administer the dose. 2.3 If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for an emergency delivery, if medically necessary. 3. If a medication is unavailable is discovered after normal Pharmacy hours: 3.2 If the ordered medication is not available in the Emergency Medication Supply, the licensed Facility nurse should call Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: 3.2.1 Emergency delivery; or 3.2.2 Use of an emergency (back-up) Third Party Pharmacy. 4. If an emergency delivery is unavailable, Facility nurse should contact the attending physician to obtain orders or directions. 9. When a missed dose is unavoidable, Facility nurse should document the missed dose and the explanation for such missed dose on the MAR (medication administration record) or TAR (treatment administration record) and in the nurse's notes per Facility policy. 9.1 A description of the circumstances of the medication shortage; 9.2 A description of Pharmacy's response upon notification; and 9.3 Action(s) taken. Surveyor requested and was provided with a copy of medications available in the facility's emergency medication supply. This list did not contain the medication Zyprexa 2.5 mg. Surveyor spoke with the director of nursing (DON) on 12/12/23 at 3:30 pm. DON stated that staff should follow the policy for obtaining the medication. DON provided the surveyor with a copy of an Education In-service Attendance Record form dated 12/12/23 which read in part If a medication was not available be sure to check Omnicell (emergency supply) and notify MD. The concern of not ensuring medications were available for administration for Resident #93 was discussed with the administrator and DON on 12/14/23 at 1:30 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility staff review the facility staff failed to ensure three of 24 residents was free of significant medication errors, Resident #82, Resident #215 and #267. The findings included: 1. For Resident #82 the facility staff failed to administer the anticoagulant medication, Xarelto. Resident #82's face sheet listed diagnoses which included but not limited to Alzheimer's disease, atrial fibrillation, and hypertension. Resident #82's most recent minimum data set with an assessment reference date of 09/07/23 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #82's comprehensive care plan was reviewed and contained a care plan for . is on anticoagulant therapy r/t (related to) Atrial fibrillation. Interventions for this care plan include Administer ANTICOAGULANT medications as ordered by physician. Resident #82's clinical record was reviewed and contained a physician's order summary which read in part, Xarelto Tablet 15 mg (Rivaroxaban). Give 1 tablet by mouth at bedtime related to unspecified atrial fibrillation (I48.91). Resident #82's electronic medication administration record (eMAR) for the month of November 2023 was reviewed and contained and entry which read in part, Xarelto Tablet 15 mg (Rivaroxaban). Give 1 tablet by mouth at bedtime related to unspecified atrial fibrillation (I48.91). This entry was coded 9 on 11/26/23. Chart code 9 is equivalent to other/see nurses notes. Resident #82's nurse's progress notes were reviewed and contained a note, which read in part 11/26/2023 20:14 Note Text: awaiting pharmacy. Surveyor requested and was provided with a facility policy entitled Medication Shortages/Unavailable Medications which read in part Procedure: 1. Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy. If the medication shortage is discovered at the time of medication administration, Facility staff should immediately take action to notify the Pharmacy. 3. If a medication is unavailable is discovered after normal Pharmacy hours: 3.1 A Facility nurse should obtain the ordered medication from the Emergency Medication Supply. Surveyor requested and was provided with a copy of medications available in the facility's emergency medication supply. This list contained the medication, Xarelto 15 mg tablet. Surveyor spoke with the director of nursing (DON) on 12/12/23 at 3:30 pm. DON stated that medication should have been removed from the emergency supply, if available there. DON provided the surveyor with a copy of an Education In-service Attendance Record form dated 12/12/23 which read in part If a medication was not available be sure to check Omnicell (emergency supply) and notify MD. The concern of not ensuring Resident #82 was free of significant medication error was discussed with the administrator and DON on 12/14/23 at 1:30 pm. No further information provided prior to exit. 28169 2. For Resident #215, facility staff failed to administer an antibiotic, Ceftriaxone, as ordered by the provider. Resident #215's face sheet listed diagnoses which included but were not limited to heart failure, cellulitis of right and left lower limbs (bacterial skin infection), sepsis, ST elevation myocardial infarction (heart attack), pasteurellosis (bacterial infection), and acute respiratory failure with hypoxia. Resident #215's minimum data set with an assessment reference date of 12/05/23 coded the resident's brief interview for mental status a 13 out of 15 in Section C (cognitive patterns). The care plan included a focus area for the resident having pasteurella bacteremia with bilateral lower extremities cellulitis with sepsis. Interventions included but were not limited to Administer antibiotic as per MD orders. The electronic clinical record contained a provider order for Ceftriaxone Sodium Intravenous Solution Reconstituted 2 GM. Use 2 gram intravenously at bedtime for covid PNX for 14 days to start on 11/30/23 and end of 12/14/23. The Medication Administration Record (MAR) was reviewed. For the 9:00 p.m. dose on 12/09/23, the nurse documented a 9, the code meaning Other/See Nurse Notes. The eMAR - Medication Administration Note dated 12/10/23 at 12:04 a.m. and written by a licensed practical nurse read, medication not available pharmacy was contacted and made aware. On 12/14/23 at approximately noon, the director of nursing (DON) was notified of the concern regarding Resident #215 not receiving the ordered Ceftriaxone dose for 12/09/23 9:00 p.m. The DON stated the pharmacy had not sent that dose of the antibiotic and stated it was common for the pharmacy to send medication doses in batches instead of the complete order's doses. On 12/14/23 at 1:18 p.m. the nurse practitioner (NP) and DON reported to the survey team that Resident #215 did not receive the Ceftriaxone because the pharmacy had not delivered the medication. The NP reported that she and the medical director were both aware of the missed dose and were communicating with the pharmacy; the pharmacy insisted the order was complete. Both the NP and DON acknowledged the resident did miss a dose of the antibiotic and acknowledged their emergency box did not contain the ordered medication (Ceftriaxone 2GM). The DON stated that although the facility does have a backup pharmacy, staff had gotten out of the habit of using it but we have a good plan to correct that, with education and everything. The DON acknowledged the medication was not available in their emergency medication box. The concern of not ensuring Resident #215 received an antibiotic as ordered was discussed with the administrator and DON on 12/14/23 at 1:30 p.m. No further information was provided prior to the exit conference. 28567 3. For Resident #267, the facility nursing staff failed to administer the antibiotic Vancomycin per the providers orders. Resident #267's diagnoses included, but were not limited to, diabetes, bipolar disorder, peripheral vascular disease, and orthopedic aftercare. There was no completed minimum data set assessment for this resident. Resident #267 was alert and orientated to self and place. Resident #267's care plan included the intervention give all medications as ordered. Resident #267's clinical record included provider orders for Vancomycin 125 mg give 1 capsule by mouth every 6 hours for wound for 8 days. The order date was documented as 12/05/23 with a start date of 12/06/23. A review of the clinical record revealed that on 12/06/23 at midnight, 6:00 a.m., and 12:00 p.m., the facility nursing staff documented a 9 for the medication on the medication administration record (MAR). Per the preprinted code on the MAR a 9=other/see nurses note. On 12/06/23 the nursing staff documented in the clinical record medication not arrived from pharmacy, medication on order, and/or awaiting arrival from pharmacy. The facility staff provided the survey team with a copy of a policy titled, Medication Shortages/Unavailable Medications. This policy read in part, .Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy. If the medication shortage is discovered at the time of medication administration, Facility staff should immediately take action to notify the Pharmacy .If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for an emergency delivery, if medically necessary .If an emergency delivery is unavailable, Facility nurse should contact the attending physician to obtain orders or directions . On 12/14/23 at 1:30 p.m., during a meeting with the Administrator and Director of Nursing the issue with Resident #267's antibiotic Vancomycin was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation and staff interview, the facility staff failed to dispose of expired laboratory (blood) tubes in 1 of 4 medication rooms. The 100-hall medication room. The findings included: The medication room on 100-hall contained 6 expired laboratory tubes. On [DATE] at 9:10 a.m., the surveyor and Licensed Practical Nurse (LPN) #4 completed an observation of the medication room on 100-hall. This medication room was observed to contain 6 yellow top laboratory tubes with an expiration date of [DATE]. The expired laboratory tubes were mixed in with laboratory tubes that were not expired. LPN #4 acknowledged the laboratory tubes were out of date and placed the expired blood tubes in the sharps box for disposable. On [DATE] at 1:30 p.m., the Administrator and Director of Nursing were made aware of the issue regarding the expired laboratory tubes. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to consult with the physician the need to review current treatment due to possible adverse medication interactions for 2 of 23 residents in the survey sample, Residents #29 and #359. For Resident #29, the facility staff failed to consult the physician regarding drug protocol alerts for possible drug interactions between [MEDICATION(S)] (a benzodiazepine used to treat anxiety) and [MEDICATION(S)] (a narcotic used to treat pain), [MEDICATION(S)] and [MEDICATION(S)] Shampoo (a topical antifungal), and [MEDICATION(S)] and [MEDICATION(S)] Sprinkles (an antiepileptic used to treat seizures). For Resident #359, the facility staff failed to consult the physician regarding drug protocol alerts for possible drug interactions between [MEDICATION(S)] (a serotonin modulator used to treat depression) and [MEDICATION(S)] (an anxiolytic used to treat anxiety), and [MEDICATION(S)] (an antidepressant used to treat depression) and [MEDICATION(S)]. The findings included: 1. Resident #29's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 2/07/22 assigned the resident a BIMS (brief interview for mental status) summary score of 0 out of 15 indicating the resident was severely cognitively impaired. Resident #29's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #29's clinical record included an Orders Progress Note dated 1/21/22 4:25 pm stating in part the system has identified a possible moderate drug interaction between [MEDICATION(S)] and [MEDICATION(S)], a possible severe interaction between [MEDICATION(S)] and [MEDICATION(S)] Shampoo 2%, and a possible moderate interaction between [MEDICATION(S)] and [MEDICATION(S)] Sprinkles. Surveyor was unable to locate documentation of physician notification of these possible drug interactions. On 4/06/22 at 3:02 pm, surveyor spoke with the DON (director of nursing) regarding system identified possible drug interaction alerts. DON stated the nurse should make a list of the interactions and notify the doctor. On 4/06/22 at 3:08 pm, surveyor spoke with UM (unit manager) #1 regarding system identified possible drug interaction alerts and the UM stated if there is an interaction the pharmacy notifies them and they do not have to do anything for the auto-generated system identified interactions. On 4/06/22 at 4:05 pm, surveyor met with the administrator and DON and discussed the concern of Resident #29's physician not being notified of the system identified possible drug interactions. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/07/22. 2. Resident #359's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 3/08/22 did not assess the resident's BIMS (brief interview for mental status) summary score. Resident #359 was coded as usually makes self understood and sometimes understands others. Resident #359's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's clinical record included an Orders Progress note dated 3/11/22 7:06 pm stating in part the system has identified a possible severe drug interaction between [MEDICATION(S)] and [MEDICATION(S)] in which the additive serotonergic effects may occur during co-administration and the risk of developing serotonin syndrome may be increased. Additional Orders Progress notes dated 3/17/22 10:24 am and 3/19/22 5:23 pm again identified a possible severe drug interaction between [MEDICATION(S)] and [MEDICATION(S)]. Surveyor reviewed Resident #359's clinical record and was unable to locate documentation of physician notification of the possible severe interaction between [MEDICATION(S)] and [MEDICATION(S)]. Orders Progress Notes dated 3/17/22 10:24 am and 3/19/22 5:23 pm also documented the system has identified a possible severe drug interaction [MEDICATION(S)] and [MEDICATION(S)] in which the additive serotonergic effects may occur during co-administration and the risk of developing serotonin syndrome may be increased. Surveyor reviewed Resident #359's clinical record and was unable to locate documentation of physician notification of the possible severe interaction between [MEDICATION(S)] and [MEDICATION(S)]. On 4/06/22 at 3:02 pm, surveyor spoke with the DON (director of nursing) regarding system identified possible drug interaction alerts. DON stated the nurse should make a list of the interactions and notify the doctor. On 4/06/22 at 3:08 pm, surveyor spoke with UM (unit manager) #1 regarding system identified possible drug interaction alerts and the UM stated if there is an interaction the pharmacy notifies them and they do not have to do anything for the auto-generated system identified interactions. On 4/06/22 at 4:05 pm, surveyor met with the administrator and DON and discussed the concern of Resident #359's physician not being notified of the system identified possible drug interactions. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/07/22.

Based on observations, staff interviews, clinical record review, and facility document review, the facility staff failed to complete a Significant Change Minimum Data (MDS) assessment for 1 of 23 sampled residents, Resident #160. The findings include: Resident #160's comprehensive minimum data set (MDS) assessment, with an assessment reference date of 2/23/22, was dated as completed on 3/1/22. Resident #160 was assessed as able to make self understood and as able to understand others. Resident #160's Brief Interview for Mental Status (BIMS) summary score was documented as an eight (8) out of 15; this indicated moderate cognitive impairment. Resident #160 was documented as requiring assistance with bed mobility, transfers, toilet use, and personal hygiene. Resident #160's diagnose included, but were not limited to: high blood pressure, [CONDITION(S)] disease, arthritis, and Alzheimer's disease. Resident #160 was assessed as not having unhealed pressure ulcers. Resident #160 was assessed as not having an indwelling urinary catheter. Resident #160's clinical documentation indicated, on 2/25/22, the resident was ordered an indwelling urinary catheter. The indwelling urinary catheter was noted to be in use on 4/5/22. Resident #160's treatment administration records (TARs) indicated the indwelling urinary catheter had been in place since ordered on 2/25/22. Resident #160's clinical documentation indicated, on 2/28/22, a stage two pressure wound was noted to the resident's left heel and a stage one pressure wound was noted to the left calf. On 4/6/22 at 1:50 p.m., Resident #160 was observed to receive wound care: (a) for a left heel pressure wound documented as a stage II wound and (b) for a left calf pressure wound that had been documented as progressing to an unstageable wound on 3/28/22). Suspected deep tissue injuries were documented to the left medial foot on 3/7/22 and to the lower spine on 3/16/22. Resident #160's clinical documentation did not include a significant change MDS assessment to address the changes in skin condition and the addition of an indwelling urinary catheter. The following information was found in a facility policy titled MDS (with a revision date of 9/25/17): The center conducts initial and periodic standardized, comprehensive and reproducible assessments no less than every three months for each resident including, but not limited to, the collection of data regarding functional status, strengths, weaknesses and preferences using the federal and/or state required RAI. On 4/07/22 at 11:25 a.m., the facility's MDS nurse reported a significant change MDS assessment should have been completed for an ARD date of 3/4/22 instead of the Interim Payment MDS assessment that was completed with an ARD date of 3/4/22. A survey team meeting was conducted with the facility's Administrator and Director of Nursing on 4/07/22 at 12:52 p.m. The failure of the facility staff to complete a significant change MDS assessment to address Resident #160's indwelling urinary catheter and skin condition changes was discussed.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to review and revise the comprehensive person-centered plan of care for 1 of 23 residents in the survey sample, Resident #29. Resident #29's comprehensive person-centered plan of care was not revised following discovery of the resident inappropriately touching another resident. The findings included: Resident #29's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 2/07/22 assigned the resident a BIMS (brief interview for mental status) summary score of 0 out of 15 indicating the resident was severely cognitively impaired. A review of Resident #29's clinical record revealed a physician's progress note dated 11/30/21 stating in part On rounds 11-23-21 for eval (evaluation) of dementia and sexual behaviors. (He/she) recently had an incident of inappropriate touching another impaired residents [sp]. They were discovered quickly by staff and easily redirected. (He/she) has no recall of the event . On 4/05/22, the DON (director of nursing) provided the surveyor with a copy of a FRI (facility reported incident) dated 11/18/21 and follow-up investigation dated 11/22/21 regarding the aforementioned incident. Upon review on 4/06/22, Resident #29's current comprehensive person-centered plan of care did not address the incident of inappropriate touching occurring on 11/18/21. On 4/06/22 at 1:54 pm, surveyor spoke with the MDS Nurse regarding revision of Resident #29's care plan following the incident of inappropriate touching. The MDS Nurse reviewed the resident's care plan and stated it was not listed under the behaviors care plan and this was the first time knowing of the incident. Surveyor requested and received the facility policy entitled Plans of Care which read in part Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA MDS assessment (except discharge assessments), and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental and psychosocial well-being. On 4/06/22 at 4:05 pm, surveyor met with the administrator and director of nursing and discussed the concern of Resident #29's care plan not being revised following an incident of inappropriately touching another resident. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/07/22.

Based on observation, staff interview, and clinical record review the facility staff failed to provide ADL (activities of daily living) care for a dependent resident for 1 of 23 residents, Residents #69. The facility staff failed to provide nail care. The findings included: Resident #69's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C (cognitive patterns) of Resident #69's quarterly MDS assessment with an ARD (assessment reference date) of 02/15/22 included a BIMS (brief interview for mental status) summary score of 00. Section G (functional status) was coded 3/2 for personal hygiene to indicate the resident required extensive assistance of one person for this task. Resident #69's comprehensive care plan included the focus area-Has ADL self-care performance deficit related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 04/05/22 11:39 a.m., toenails observed to be long, thick, and jagged. 04/06/22 10:40 a.m., checked toenails with MDS coordinator, toenails remain long, thick, and jagged in appearance. 04/06/22 1:50 p.m., CNA (certified nursing assistant) #1 stated they were responsible for cutting the residents nails unless the person is a diabetic. 04/06/22 4:05 p.m., the issue with Resident #69's nails was discussed during an end of the day meeting with the administrator and DON (director of nursing). 04/07/22 12:51 p.m., during a meeting with the survey team the DON stated Resident #69 had been placed on the podiatrist list. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to follow physician's orders for 2 of 23 residents in the survey sample, Resident #7 and #110. For Resident #7, the facility staff failed to perform weekly skin assessments as ordered by the physician. For Resident #110, the facility staff failed to transcribe a physician's order from the hospital discharge summary for wound care. The findings included: 1. Resident #7's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 1/07/22 assigned the resident a BIMS (brief interview for mental status) summary score of 2 out of 15 indicating the resident was severely cognitively impaired. Resident #7 was coded as requiring extensive assistance with bed mobility, transfers, toilet use, and personal hygiene. The resident was coded as being at risk of developing pressure ulcers. Resident #7 had a current physician's order dated 12/31/21 stating Weekly Skin Checks. Surveyor reviewed the resident's clinical record and was unable to locate documentation of any weekly skin checks. On 4/06/22 at 10:22 am, surveyor spoke with the UM (unit manager) regarding Resident #7's weekly skin assessments. UM reviewed the resident's clinical record and acknowledged the lack of documented weekly skin assessments and stated I am going to fix that. Surveyor requested and received the facility policy entitled Skin Evaluation which read in part A Licensed Nurse will complete a total body evaluation on each resident weekly and document the observation on the Skin Evaluation form. On 4/06/22 at 4:05 pm, surveyor met with the administrator and director of nursing and discussed the concern of Resident #7's lack of weekly skin assessments as ordered by the physician. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/07/22. 2. Resident #110's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS (minimum data set) with an ARD (assessment reference date) of 5/18/21 assigned the resident a BIMS (brief interview for mental status) summary score of 14 out of 15 indicating the resident was cognitively intact. Resident #110 was coded as requiring extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and being totally dependent on staff for bathing. The resident was coded for the presence of an unstageable pressure ulcer due to coverage of the wound bed by slough and/or eschar and another unstageable pressure ulcer presenting as a deep tissue injury. Each pressure ulcer was coded as being present on admission to the facility. Resident #110 was also coded for the presence of four (4) venous and arterial ulcers and surgical wounds. Resident #110's comprehensive person-centered plan of care included venous/stasis ulcers to the left lateral foot, top of left foot, left medial knee, left lateral knee; surgical wounds to the left medial calf and left groin; and a DTI (deep tissue injury) to the left heel. Resident #110 was discharged from (hospital name omitted) and admitted to (facility name omitted) on 5/11/21 following a coronary artery bypass graft x four and a left femoral popliteal artery bypass with intraoperative angiogram and left femoral endarterectomy. Follow-up instructions included keep wounds clean with [MEDICATION(S)] daily. Resident #110's Admission/Readmission Data Collection-CHC - V3 dated 5/11/21 documented in part that resident had the following skin areas present on the lower extremities: groin rash and incision from procedure, wound to front of left knee, abrasion to front of left lower leg, DTI (deep tissue injury) to left heel, large darken area to left heal, and ? Excoriation to left toe(s). Surveyor reviewed Resident #110's 5/11/21 admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 5/12/21 stated skin prep to areas on left foot and heel and leg every day shift. On 4/06/22 at 9:09 am, surveyor spoke with the DON (director of nursing) regarding the reason for the [MEDICATION(S)] on the hospital discharge summary not being ordered upon admission to the facility. DON stated they would look into it. On 4/07/22 at 9:42 am, DON stated they did not know why the [MEDICATION(S)] treatment was not ordered on admission. Surveyor asked if it should have been and the DON stated it was on the discharge summary. On 4/07/22 at 12:52 pm, surveyor met with the administrator and DON and discussed the concern of the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] #110's wounds as documented on the discharge summary. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/07/22.

Based on staff interview, clinical record review and facility document review the facility staff failed to follow up on monthly drug regimen reviews for 2 of 23 residents, Resident #72 and Resident #74. For Resident #72, the facility staff failed to follow up on pharmacist recommendations for the months of September 2021 and December 2021. For Resident #74, the facility staff failed to follow up on a pharmacist recommendation for the month of September 2021. The findings included: 1. Resident #72's face sheet included diagnoses which included but not limited to Alzheimer's disease, dementia, Type 2 diabetes mellitus, depression, hypertension, and gastroesophageal reflux disease. Resident #72's most recent annual MDS (minimum data set) with an ARD (assessment reference date) of 02/21/22 assigned the resident a BIMS (brief interview for mental status) score of 2 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #72's clinical record was reviewed and contained monthly MRR's (medication regimen review) dated 09/24/21 and 12/29/21, which read in part See report for any noted irregularities and/or recommendations. This resident's medical record including electronic documentation was reviewed on this date. These reviews were signed by the consultant pharmacist. The surveyor could not locate the recommendations in the resident's clinical record. Surveyor spoke with the DON (director on nursing) on 04/06/22 at 3pm regarding the missing pharmacy recommendations. DON informed surveyor on 04/07/22 at 10:30 am that the recommendations had not been located. Surveyor requested and was provided with a facility policy entitled Medication Regimen Review, which read in part 1. The Consultant Pharmacist will conduct MRR's if required under a Pharmacy Consultation Agreement and will make recommendation based on the information available in the resident's health record. 6. The pharmacist will address copies of residents' MRRs to the Director of Nursing and /or the attending physician and to the Medical Director. Facility staff should ensure that the attending physician, Medical Director, and Director of Nursing are provided with copies of the MRR's. 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon recommendations contained in the MRR. 7.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been take to address it. 8. Facility should alert the Medical Director where the MRR's are not addressed by the attending physician in a timely manner. The concern of the missing pharmacy recommendations was discussed with the administrative team during a meeting on 04/07/22 at 12:50 pm. No further information was provided prior to exit. 2. Resident #74's face sheet listed diagnoses which included but not limited to heart failure, acute kidney failure, [CONDITION(S)], type 2 diabetes mellitus, hypertension, anxiety, depression and [CONDITION(S)] disorder. Resident #74's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 02/22/22 assigned the resident a BIMS (brief interview for mental status) score of 13 out of 15 in Section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #74's clinical record was reviewed and contained a monthly MRR (medication regimen review) dated 09/24/21, which read in part See report for any noted irregularities and/or recommendations. This resident's medical record including electronic documentation was reviewed on this date. This review was signed by the consultant pharmacist. The surveyor could not locate the recommendation in the resident's clinical record. Surveyor spoke with the DON (director on nursing) on 04/06/22 at 3pm regarding the missing pharmacy recommendation. DON informed surveyor on 04/07/22 at 10:30 am that the recommendation had not been located. Surveyor requested and was provided with a facility policy entitled Medication Regimen Review, which read in part 1. The Consultant Pharmacist will conduct MRR's if required under a Pharmacy Consultation Agreement and will make recommendation based on the information available in the resident's health record. 6. The pharmacist will address copies of residents' MRRs to the Director of Nursing and /or the attending physician and to the Medical Director. Facility staff should ensure that the attending physician, Medical Director, and Director of Nursing are provided with copies of the MRR's. 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon recommendations contained in the MRR. 7.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been take to address it. 8. Facility should alert the Medical Director where the MRR's are not addressed by the attending physician in a timely manner. The concern of the missing pharmacy recommendation was discussed with the administrative team during a meeting on 04/07/22 at 12:50 pm. No further information provided prior to exit.

Based on staff interview, clinical record review, facility document review, and during a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5% there were 3 errors in 30 opportunities for a medication error rate of 10%. These errors effected Residents #12 and #42. The findings included: 1. Section C (cognitive patterns) of Resident #12's annual MDS (minimum data set) assessment with an ARD (assessment reference date) 01/05/22 included a BIMS (brief interview for mental status) summary score of 3 out of a possible 15 points. The clinical record included the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 04/06/22 7:48 a.m., LPN (licensed practical nurse) #1 prepared Resident #12's morning medications to include Senna 8.6 mg 2 tablets. Resident #12's clinical record included a physicians order for Senna 8.6 mg give 1 tablet by mouth two times a day for constipation. 04/06/22 9:34 a.m., LPN #1 stated they administered Senna 2 tablets. LPN #1 reviewed the clinical record and stated the order read 1 tablet and they were going to contact the doctor as the resident could use 2 tablets. 04/06/22 10:30 a.m., the DON (director of nursing) provided the survey team with a copy of a policy titled, General Dose Preparation and Medication Administration. This policy read in part, .Facility staff should verify that the medication name and dose are correct when compared to the medication order on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 4/06/22 4:05 p.m., during an end of the day meeting the medication error rate was discussed with the administrator and DON (director of nursing). No further information regarding this issue was provided to the survey team prior to the exit conference. 2. Section C (cognitive patterns) of Resident #42's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/09/22 included a BIMS (brief interview for mental status) summary score of 3 out of a possible 15 points. The clinical record included the diagnoses, Alzheimer's and major depressive disorder. 04/06/22 8:28 a.m., the surveyor observed LPN (licensed practical nurse) #2 prepare Resident #42's morning medications to include the medication [MEDICATION(S)] ([MEDICATION(S)]) 10 mg. Resident #42's clinical record included a physicians order for [MEDICATION(S)] give 15 mg by mouth one time a day for major depressive disorder. The clinical record also included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor did not observe any eye drops being administered. 04/06/22 9:40 a.m., the surveyor and LPN #2 checked the medication cart for the [MEDICATION(S)]. The medication card read [MEDICATION(S)] 10 mg give with 5 mg. LPN #2 stated they did not have a 5 mg card of this medication and they had not administered the residents eye drops. LPN #2 later stated they had found the 5 mg card of [MEDICATION(S)] in the medication drawer but it was turned backwards. 04/06/22 10:30 a.m., the DON (director of nursing) provided the survey team with a copy of a policy titled, General Dose Preparation and Medication Administration. This policy read in part, .Facility staff should verify that the medication name and dose are correct when compared to the medication order on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 4/06/22 4:05 p.m., during an end of the day meeting the medication error rate was discussed with the administrator and DON (director of nursing). No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observations, interviews, and facility document reviews, the facility staff failed to correctly implement contingency plans for staff who were not fully vaccinated for COVID-19. The findings include: Two (2) staff members (SMs), with COVID-19 vaccine exemptions, were reviewed as part of the COVID-19 immunization review (SM #21 and SM #22). On 4/6/22 at 9:30 a.m., SM #21 was observed to have a KN95 mask. SM #21 reported, as part of the facility's exemption contingency plan, they had to wear the mask when not eating or drinking. SM #21 also reported they had to have weekly COVID-19 test completed. On 4/6/22 at 9:40, SM #21 was asked about wearing a N95 mask verses a KN95 mask; SM #21 indicated their understand was the KN95 was okay to wear. On 4/6/22 at 9:35 a.m., SM #22 was observed to be wearing a KN95 mask. SM #22 reported, as part of the facility's exemption contingency plan, they had to wear the mask. SM #22 also reported they had to have weekly COVID-19 test completed. SM #22 was asked if the mask should be a N95 mask instead of a KN95; SM #22 indicated they believed the mask they were wearing was appropriate. The following information was found in a facility policy titled Employee COVID-19 Vaccinations (with a revised date of 3/23/22): Exempted Employees and Reasonable Accommodation: . Current guidance, which is subject to change, requires the use of Universal Source Control depending on Community Transmission rates and regular testing for all unvaccinated personnel working in Care Centers . Staff will use Respirators [sic] as source control . A survey team meeting was conducted with the facility's Administrator and Director of Nursing on 4/6/22 at 4:05 p.m. The facility's policy requiring staff members with COVID-19 vaccine exemptions to use respirators for source control and the observations of SM #21 and SM #22 to be using KN95 mask was discussed. The administrative team reported that the expectation was that the staff with COVID-19 vaccine exemptions would wear N95 masks not KN95 masks. The Administrator reported the facility provided its staff with N95 masks.

Based on staff interview, clinical record review, facility document review and in the course of a complaint investigation the facility failed to allow a resident to return to the facility for 1 of 4 residents, Resident #1 The findings included: For Resident #1, the facility failed to allow the resident to return after a hospital visit. Resident #1's face sheet listed diagnoses of but not limited to chronic obstructive pulmonary disease, hypertension, history of pulmonary embolism, alcohol dependence in remission, anxiety, and major depressive disorder. Resident #1's admission MDS (minimum data set) with an ARD (assessment reference date) of 07/30/2020 assigned the resident a BIMS (brief interview for mental status) score of 13 out of 15 in section C, cognitive patterns. Resident #1's clinical record was reviewed and contained an admission assessment dated [DATE], which read in part Section D: Mood/Behaviors/Psychosocial: Mood: Pleasant Behaviors: No obvious problems Section N: Safety: Elopement Risk Evaluation: Based on potential risk factors above, resident is determined to be AT RISK for elopement: NO. Resident #1's clinical record also contained an admission social services evaluation dated 07/30/2020, which read in part Resident anticipated discharge plan: LTC (long-term care) Resident's overall discharge goal: Expects to remain in this facility. Resident #1's clinical record contained a form, which read in part PLEASE POST ON CHART. THIS PERSON HAS A COURT-APPOINTED GUARDIAN and In the event of an emergency, particularly a medical or mental health emergency, involving the . (name omitted) Program's client, . (Resident #1), you are required to contact the Primary Case Manager immediately. The resident's clinical record also contained a form, which read in part ORDER APPOINTING GUARDIAN. IN CONSIDERATION WHEREOF, the Court makes the following findings, supported by clear and convincing evidence: . It is therefore ADJUDGED, ORDERED, and DECREED: 3. That the incapacities of the Respondent (Resident #1) are total and perpetual, and that the Respondent is relieved of all authority and power to manage and perform legal acts in respect to his person, such power and authority being vested in the guardian. Resident #1's clinical record contained nurse's progress notes, which read in part 9/28/2020 10:20 Social Services Progress Note. SW (social worker) notified Guardian of resident's determination to go to hospital. She said send him if he feels he need to go., 9/28/2020 10:21 Nursing Progress Note. Resident outside smoking with CNA (certified nursing assistant) supervision. Stated he needed to leave and go to the hospital. CNA, administrator and DON (director of nursing) attempted to talk resident into coming back inside the building so a nurse could assess him and resident refused. Resident stated he was leaving and was going to call a taxi to come get him and take him to the hospital. Explained that the nurse could assess him and he could go to the hospital via ambulance. Resident refused to come back inside the building and started walking away. Explained that he was leaving against medical advice and resident continued walking off the premises stating he did not want to stay here and would walk to the hospital. 911 called and resident was picked up by EMT's (emergency medical technician) and transported to the hospital. MD notified., 9/28/2020 14:29 Nursing Progress Note. ER discharged resident. Transport arranged for resident to return to this facility. Driver called facility and reported that while transporting resident back to this facility resident unlocked van door, took seatbelt off and jumped out of van at stop sign. Resident ran away and police were notified to look for resident., and 9/29/2020 8:21 Social Services Progress Note. Resident left facility on 09/28/2020-alert & oriented to self, stated he was going to the hospital in . (omitted)-ambulatory. Staff attempted to reason with resident for him to come back inside and be assessed. He declined. Law Enforcement notified. He was evaluated ER. ER notified facility he was ready to return to facility. Facility staff member went to pick him up to return to facility. Resident exited the van and left per report of staff member. Police notified. D/C (discharged ) from facility. APS (adult protective services) aware. Guardian aware. Surveyor spoke with DON on 01/12/21 at approximately 9:30 am. DON stated that resident was outside smoking with staff, when he stated he was leaving and began walking toward road. DON stated that staff attempted to talk resident into coming back, but he said he did not want to be at the facility. DON stated that resident began walking up the road, and that staff stayed with him. DON stated that EMS was called, and picked resident up and transported him to the hospital. DON stated that hospital called the facility and said resident was being discharged . Facility agreed to pick resident up from hospital. DON stated that when transport staff arrived at hospital, resident was again saying that he did not want to be at facility, and did not want to return. DON stated that transport staff reported that resident got out of vehicle at stop sign and ran. Transport staff returned to hospital and notified facility and police. Surveyor asked DON why the facility did not allow resident to return after he was located by the police and DON stated, We considered it an AMA (against medical advice). Surveyor spoke with the facility administrator on 01/12/21 at approximately 10:10 am. Administrator stated that there was not talking resident into coming back to facility and that staff had tried to talk to him for approximately 45 minutes outside facility before he left the premises. Administrator stated that when the resident left the facility, a facility staff went with him for safety purposes. Administrator stated that the police were notified and EMS picked the resident up and transported to the hospital. Administrator stated that they did not consider this as an elopement, but as a leaving AMA. Surveyor spoke with Resident #1's guardian on 01/12/21 at approximately 12:00 pm. Guardian stated that resident has a diagnosis of alcohol dementia. Guardian stated that resident had been doing well at the facility and had not had any problems. Guardian stated that resident had a history of elopement. Guardian stated that on 09/28/2020, the facility social worker had notified them that resident was requesting to go to the hospital and was attempting to leave the facility. Guardian stated that they told the social worker to go ahead and send resident to hospital to be evaluated due to his history and COVID positive status. Guardian stated that resident was seen at the ER and cleared to go back to facility. Guardian stated that while resident was being transported back to the facility, he jumped out of facility van and got onto a local transit bus. Guardian stated that police located the resident and returned him to the hospital and facility was notified, but refused to take resident back. Guardian stated that resident was literally stranded at the ER for close to 2 weeks, because no other facility would take him, because he was COVID positive. Surveyor asked the guardian if they wanted resident returned to the facility, and guardian stated that they did. Surveyor asked guardian if the facility had asked them to sign an AMA form, and guardian stated they had not. Surveyor spoke with facility transport staff on 01/3/21 at approximately 10:05 am. Transport staff stated that resident had ran from facility earlier in the day and that either EMS or police had picked him up and taken him to the hospital. Transport staff stated that he had been asked to go pick resident up from hospital. Transport stated that when he arrived at the hospital, Resident #1 was giving the staff a fit, and stating that he did not want to return to the facility. Transport staff stated that hospital staff talked Resident #1 into returning to the facility, and walked resident to the van and he got in. Transport staff stated they assisted resident with seatbelt and locked the van door. Transport staff stated he noticed the resident messing with the door lock and when they stopped at a stop sign, resident jumped out of van and ran off through the neighborhood. Transport driver stated that they immediately turned around and went back to hospital and notified facility and hospital staff notified the police. Surveyor asked the transport driver if they saw Resident #1 board a transit bus, and transport driver said they did not. Surveyor requested the facility policy on discharges and was given a policy entitled, Transfer/Discharge Notification & Right to Appeal. This policy read in part, PROCEDURE: Transfer/Discharge Requirements: The center must permit each resident to remain in the center, and not transfer or discharge the resident from the center unless: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the center; .Documentation: When the center transfers or discharges resident under any circumstance listed above the facility will ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. Documentation in the medical record to include: The basis for the transfer; In the case of inability to meet resident needs (as per (a) above); The specific resident's need that cannot be met, The facilities attempts to meet the resident needs, And the service available at the receiving facility to meet those needs. The documentation must be made by: The resident's physician when the transfer or discharge is necessary due to: The resident's welfare and the resident's needs cannot be met in the center. The concern of the facility not allowing the resident to return to the facility was discussed with the administrative team (administrator, DON) via telephone on 01/14/21 at approximately 3:15 pm. No further information was provided prior to exit. This is a complaint deficiency.

Based on observation, staff interview and clinical record review, the facility staff failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #4) of nine (9) residents. The findings included: For Resident #4 (described by the physician as symptomatic and felt that the COVID result was a false negative), the facility staff failed to ensure the privacy curtain remained pulled separating Resident #4 from their COVID-19 positive roommate for the purpose of droplet precautions. Resident #4's [DIAGNOSES REDACTED]. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 8/18/20 assigned the resident a BIMS (brief interview for mental status) score of 13 out of 15 in section C, Cognitive Patterns. Resident #4 is also coded as requiring extensive assistance with bed mobility. A review of Resident #4's medical record revealed the following documentation: A final lab report dated 8/28/20 for Resident #4 indicated a COVID-19 nasopharyngeal specimen was collected on 8/25/20 and the results were released on 8/28/20 indicating 2019-n COV RNA (ribonucleic acid) Not Detected. Resident #5's, the roommate of Resident #4, medical record revealed a final lab report dated 8/28/20 which indicated the a COVID-19 nasopharyngeal specimen was collected on 8/25/20 and the results were released on 8/28/20 indicating Positive; 2019-nCoV RNA Detected. Resident #4's Orders Report dated 9/03/20 includes an order dated 8/28/20 for droplet precautions. Surveyors requested and received the policy Isolation - Categories of Transmission-Based Precautions which stated in part: Droplet Precautions 2. Residents on droplet precautions will be placed in a private room if possible. b. When a private room is not available and cohorting is not achievable, a curtain will be used and a distance of at least 3 feet of space will be maintained between the infected resident his or her roommate. On 9/03/20 at 2:15pm, the onsite surveyor, accompanied by LPN (licensed practical nurse) #4, noted the privacy curtain in Resident #4's room to be open, the curtain was not pulled between Resident #4 and their COVID-19 positive roommate. On 9/03/20 at 2:48pm, surveyors spoke with the IP (Infection Preventionist) and DON (Director of Nursing) who stated they looked at moving negative residents but felt it was more of a risk to move them. The DON stated when a positive and negative resident are in the same room, the curtain is pulled. On 9/03/20 at 4:59 pm, surveyors spoke with Resident #4's physician who stated they assessed Resident #4 on 8/28/20 and the resident was symptomatic and felt that the COVID result was a false negative. The 8/28/20 physician's progress note states in part, On rounds today due to [MEDICAL CONDITION] of 89-90% RA (room air) today and yesterday a temperature 100.0, 99.2, O2 (oxygen) sat (saturation) 90% and Rec (recommend) reswab for COVID when swabs available, remains high risk with a recent pos (positive) roommate and pos cases in facility . On 9/03/20 at 4:36 pm, the administrator and DON were made aware that the privacy curtain was not pulled separating Resident #4 from (Resident #5) their COVID-19 positive roommate. On 9/04/20 at 10:59am, the administrator and DON informed the surveyors that the results from the 9/01/20 PPS (point prevalence survey) testing returned last evening and Resident #4 is now positive. The administrator provided results from the 9/01/20 PPS testing indicating Resident #4 is positive for COVID-19. No further information regarding this issue was presented to the survey team prior to the exit conference on 9/04/20.

Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate DDNR (Durable Do Not Resuscitate) for 2 of 26 residents in the survey sample (Resident #99 and Resident #95). The findings included: 1. The facility staff failed to ensure a complete and accurate DDNR (Durable Do Not Resuscitate) for Resident #99. Resident #99 was admitted to the facility on [DATE] with the following diagnoses, but not limited to [MEDICAL CONDITION], high blood pressure, diabetes and dementia. On the 5 day admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/20/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 3 out of a possible score of 15. The resident was coded as requiring extensive assistance of 2 staff members for dressing and personal hygiene. Resident #99 was also coded as being totally dependent on 2 staff members for bathing. The surveyor conducted a clinical record review on Resident #99 on 1/30/19. During this review, it was noted by the surveyor that the DDNR dated for 12/18/18 was not filled out completely. Section 1 of the DDNR read in part, I further certify (must check 1 or 2): 1. The patient is CAPABLE of making an informed decision . 2. The patient is INCAPABLE of making an informed decision . The boxes beside #2 was checked. Section 2 read If you checked 2 above, check A, B, or C below: The three boxes below were blank. The surveyor notified the administrative team on 1/30/19 at 2 pm in the conference room of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 1/31/19. 2. The facility staff failed to ensure an accurate DDNR for Resident # 95. Resident # 95 was a [AGE] year-old-male who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 95 was reviewed on 1/29/19 at 1:26 pm. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 1/8/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 95 had a BIMS (brief interview for mental status) score of 3 out of 15, which indicated that Resident # 95's cognitive status was severely impaired. The plan of care for Resident # 95 was reviewed and revised on 1/15/19. The facility staff documented a focus area for Resident # 95 as Resident has advanced directives r/t (related to) DNR (do not recesutate) AEB (as evidenced by) DNR order. Interventions included but were not limited to, Discuss advanced directives with resident and or resident's representative. The physician signed the current orders for Resident # 95 on 1/1/19. Orders included but were not limited to, Do not resuscitate. On 1/29/19 at 1:26 pm, the surveyor observed a DDNR (durable do not resuscitate) form in the clinical record for Resident # 95. The surveyor observed a check mark on the DDNR form for Resident # 95 documented next to .B. While capable of making an informed decision, the patient has executed a written advanced directive which appoints a Person Authorized to Consent on the Patient's Behalf with authority to direct that life prolonging procedures be withheld or withdrawn. The surveyor further reviewed the clinical record for Resident # 95 and did not locate a written advance directive for Resident # 95. On 1/30/19 at 2:35 pm, the surveyor asked the administrative team to provide the advanced directive for Resident # 95. On 1/30/19 at 3:20 pm, the social services director informed the surveyor that Resident # 95 had a financial power of attorney, but did not have a written advance directive in his clinical record. The social services director stated, Resident # 95 came from (facility name withheld) with that DDNR. On 1/31/19 at 2:00 pm, the administrative team was made aware of the findings as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 1/31/19.