Every finding on record at Gretna Health and Rehabilitation Center

Based on staff interview, clinical record review, and facility document review, the facility staff failed to follow the provider orders for wound care and failed to obtain provider orders for a fracture for 1 of 5 closed record reviews, Resident #94. Findings included:1. The facility staff failed to complete provider ordered treatments for a hematoma on Resident #94's left calf. Resident #94 experienced a fall prior to admission to the facility. A hematoma is a localized collection of blood outside blood vessels, usually caused by injury or trauma, which can lead to swelling, pain, and discoloration. Resident #94's diagnoses included contusion of lower leg, Parkinson's disease, and muscle weakness. Section C (cognitive patterns) of Resident #94's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/28/2024 included a Brief Interview for Mental Status (BIMS) score of 9, indicating Resident #94 was moderately impaired in cognitive skills for daily decision making. The Comprehensive Care Plan (CCP), initiated on 05/22/2024, identified impaired skin integrity of the left lower leg related to hematoma and included the intervention treatment as ordered. The clinical record included provider orders dated 05/22/2024 to cleanse the outer left calf with dermal wound cleanser, cover with Xeroform, ABD gauze pad, and Kerlix every day. The order was revised on 05/26/2024 with no changes other than documentation of a vascular diagnosis. Further review of the clinical record revealed that on 05/23/2024 and 05/30/2024, the facility staff documented a 9 (other/see progress notes) in the administration blocks on the Treatment Administration Record (TAR) for the left calf treatment. On 05/25/2024, staff documented a 14 (resident unavailable), the administration block for 05/26/2024 was left blank. Documentation on 05/23/2024, 05/25/2024, and 05/30/2024 indicated that Resident #94 was out of the facility for an appointment. No documentation was found for 05/26/2024. On 04/29/2026 at 5:00 PM, during an end of the day meeting with the Interim Administrator, Interim DON, Regional Nurse Consultant #1, and Regional [NAME] President of Operations, the issue with the missed provider ordered treatments for Resident #94 was reviewed. On 04/30/2026 at 8:56 AM, during an interview with the current wound care nurse Registered Nurse (RN) # 1, this staff stated if a resident had a scheduled appointment, wound care would typically be completed either before the appointment or upon the resident's return, unless the resident refused. This nurse confirmed they would have completed the treatment upon the resident's return to the facility. On 04/30/2026 at 9:15 AM, during an interview, the Interim Director of Nursing (DON) stated they probably would have waited until this resident returned from their appointment to complete the dressing change unless it was soiled but the treatment would have been completed. On 04/30/2026 at 9:29 AM, the surveyor attempted to contact Licensed Practical Nurse (LPN) #3 regarding the missed treatments. The call went to voicemail, and a message was left, no return call was received prior to completion of the survey. On 04/30/2026 at 1:15 PM, the Interim Administrator provided the survey team with a copy of their policy titled, Wound/Skin Impairments (effective 07/17/2024). This policy read in part, .Provide treatments as ordered . No additional information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #94, the facility staff failed to obtain a medical provider orders to address the care and/or treatment of a right pinky finger fracture. Resident #94's diagnosis list indicated a fracture of unspecified phalanx of unspecified finger, subsequent encounter for fracture with routine healing. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 5/28/24, assigned the resident a brief interview for mental status (BIMS) summary score of 9 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. Section I (Active Diagnoses) was coded (I4000) at Other Fracture. A review of a medical provider orders did not disclose any treatment, care, and/or follow-up appointment orders for Resident #94's right pinky finger fracture. A review of the September 2024 TAR (treatment administration record) did not disclose any treatment and/or plan for care of Resident #94's right pinky finger fracture. A review of Resident #94's clinical record disclosed the following documentation: A hospital progress note dated 5/19/24, which read in part, .Fracture of finger on right hand.Now on a splint, appreciate orthopedics.Follow-up in 1 to 2 weeks after discharge. A medical provider progress note dated 5/22/24 read in part, .ASSESSMENT AND PLAN.Fracture of finger of right hand - proximal phalanx of 5th digit (pinky finger); continue supportive care. A skilled nursing progress note dated 5/29/24 read in part, .Splint to right pinky finger is in place. A review of the comprehensive person-centered care plan did not disclose a focus area, goal, and/or interventions related to Resident #94's fracture of the right pinky finger. On 4/29/26 at 10:44 AM, the Medical Provider (MP) was interviewed via phone conversation and stated he never saw that ortho (orthopedics) saw Resident #94 in the hospital about the fracture of the right pinky finger. The MP recalled he saw Resident #94's bandaged finger at the facility and it was splinted. On 4/30/26 at 8:56 AM, the Wound Care Nurse (WCN) was interviewed and stated she was not employed at the time of Resident #94's admission. When asked the process if there was no order for care/treatment of a fractured finger, the WCN stated she would ask the medical provider for orders about a splint and/or treatment of a fractured finger. On 4/30/26 at 9:14 AM, the Interim Director of Nursing (IDON) was interviewed and stated she did not recall a splint being on Resident #94's fractured right pinky finger. A nursing progress note dated 5/29/26 written by the IDON was reviewed and the IDON stated she did not recall documenting the information. When asked what the protocol is for an admission with a fractured finger, the IDON stated the protocol would be to notify the medical provider to make them aware and to wait for an order. On 4/30/26 at 10:34 AM, the TCU (transitional care unit) UM (Unit Manager) was interviewed and stated she looked at Resident #94's picture in the clinical record but could not recall the resident. When asked what the protocol was if a new admission entered the facility with a fractured finger, the UM stated she would review the admission paperwork and look for any recommendations from ortho and would look for any follow-up ortho appointments related to the fracture. The UM stated she would call ortho if it was not clear for a treatment plan to make sure the fracture was treated/cared for appropriately. Four other nurses who were identified that cared for Resident #94 were no longer employed at the facility and were not available for interviews. This concern was discussed at the end of day meeting on 04/29/26 at 5:00 PM with the Interim Administrator, Assistant Administrator, Interim Director of Nursing, Regional Director of Clinical Services, and the Regional [NAME] President of Operations. Requested and received a facility policy titled, Physician's Orders with an effective date of 1/29/24 which read in part, .admission Physician's Orders must be provided for every patient at the time of admission.to activate a medical plan of care.1. Upon every patient's admission.a licensed nurse will notify the physician requesting.physician's orders.2.b. admission orders should include.10. Other orders as indicated by patient's condition with specific directions. No further information was provided prior to exit on 4/30/26.

Based on observation, staff interview, and facility document review, the facility staff failed to utilize appropriate personal protective equipment (PPE) prior to entrance into a resident room identified for contact precautions. The findings included:On 3/11/26 at 1:01 PM during an initial tour of the facility, Resident #2's room was observed to have a sign outside of the room which read in part, Contact Precautions.gown and gloves.prior to entering room. Other staff #1 (OS#1) was observed in the room with a KN95 mask visible covering their face. No gown or gloves were visible on OS#1. On 3/4/26 at 1:04 PM, unit manager #1 (UM#1) was interviewed and stated the expectation for staff entering the room is for gown and gloves to be worn. On 3/4/26 at 1:05 PM, OS#1 was interviewed and stated education on proper PPE for a contact precaution room had been received and stated a gown and gloves should be worn when entering the room. OS#1 was then observed to don a gown and gloves and then re-entered the resident room. This concern was discussed at the pre-exit meeting on 3/12/26 at 11:07 AM with the administrator, director of nursing, and regional director of clinical services. Requested and received a facility policy titled, Transmission Based Precautions-General Practice with an effective date of 12/1/21, which read in part, .The Center initiates transmission-based precautions (TBPs) to protect other patients, employees and visitors from the spread of confirmed or suspected infection or contagious disease.19. If protective attire is determined necessary.1. A gown must be worn when indicated by the type of isolation in order to protect clothing from coming in contact with contaminated materials.e. Put on gloves. No further information was provided prior to exit on 3/12/26.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure resident treatment and care in accordance with professional standards of practice for (1) one of (4) four sampled residents, Resident #1. The findings included:For Resident #1, the facility staff failed to follow a medical provider order to discontinue the medication polyethylene glycol powder (MiraLAX) after a bowel movement. Resident #1's diagnosis list indicated diagnoses, which included, but not limited to, chronic kidney disease, vascular dementia-mild with agitation, left femur fracture, and difficulty walking. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 2/19/26, assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 for cognitive abilities, indicating Resident #1 was moderately impaired in cognition. A review of a medical provider progress note dated 2/16/26 read in part, .flagged for constipation greater than 3 days. Polyethylene glycol 1 (one) capful every evening has been added until [Resident #1] has a bowel movement. A review of a medical provider orders with a start date of 2/16/26 read in part, .Polyethylene Glycol 3350 Powder Give 17 gram by mouth at bedtime for Osmotic laxative (a type of medication, available over-the-counter and by prescription, that relieve constipation by drawing water from surrounding body tissues into the colon). A review of Resident #1's bowel elimination record for February 2026 disclosed the resident had a bowel movement on 2/17/26. A review of the February 2026 medication administration record (MAR) disclosed Resident #1 received polyethylene glycol at bedtime from 2/16/26 through 2/24/26. A review of the comprehensive person-centered care plan disclosed a focus and intervention which read in part, .the resident is at risk for constipation related to reduced physical mobility. An intervention related to the focus read in part, .administer medications as ordered. Requested clarification of the medical provider order to discontinue polyethylene glycol after Resident #1 had a bowel movement. On 3/12/26 at 9:48 AM, the director of nursing (DON) provided a MD (medical doctor) Communication Form dated 2/16/26, which read in part, .Diagnosis.Constipation.Orders.Polyethylene Glycol 1 (one) capful.until BM (bowel movement). The DON agreed that the MiraLAX should have been discontinued after Resident #1 had a bowel movement on 2/17/26. This concern was discussed at the pre-exit meeting on 3/12/26 at 11:07 AM with the administrator, director of nursing, and regional director of clinical services. Requested and received a facility policy titled, Non-Controlled Medication Orders with an effective date of 9/2018, which read in part, .1. Medication orders specify the following.f. Quantity or duration (length) of therapy. No further information was provided prior to exit on 3/12/26.

Based on observations, interviews, and facility document review, the facility staff failed to ensure 1. the resident communication system relayed calls directly to a staff person or to a centralized staff work area from all residents' rooms and 2 of 2 bathing areas, and 2. call light pull cords were in working order in 2 of 2 bathing areas. The findings were: 1. The residents' call button/bell communication system was not connected to any centralized staff work area or directly to any staff person. During a resident council meeting discussion regarding staff call bell response times, the residents reported their call buttons triggered a visual light above their door to illuminate in the hallway but there was nothing audible when they pressed the button; a handbell had been provided for an audible call bell. Following the resident council meeting which took place on 07/26/23 at 3:00 p.m., the administrator acknowledged the call button communication system was visual, not audible, and residents had been provided a hand bell for audible notifications. At approximately 4:15 p.m. on 7/26/23, an anonymous facility staff member reported to one surveyor that it had been over a year since the call system stopped working properly and the notification boxes were removed from the nurses' stations. Call bell lights were not observed visually or audibly at any centralized location, only lighting above resident doors. The survey team tested resident room call buttons on each unit. When the call button was pushed, the light over the resident room door illuminated but that notification was not sent to any centralized system or to any direct staff member. The nurses' stations did not contain any communication system (neither visual nor audible) which showed there was a resident room call button pushed; staff must look down each hall to see whether any lights illuminated over a resident's door. There was no sound heard when the residents' call buttons were pushed. While assessing the call button system, the survey team observed all residents' rooms (both A & B beds) for the presence of hand bells and found 39 of 87 residents did not have a hand bell. The call buttons/cords in the two shower rooms did not send a notification directly to a staff member or centralized staff work area when pushed. On the morning of 07/27/23, the 39 residents who did not have a handbell the day before were re-assessed by the survey team. Two (2) residents did not have a handbell. One of the two, reportedly did not want one and the other resident was said to probably have it in his pocket. That resident was rarely in his room. On 07/27/23, the administrator provided communication documents regarding the call bell system. A business' letter dated 08/05/21 indicated the repair parts for the existing system were no longer available and recommended replacement. A replacement estimate document dated 08/10/21 was provided. An email from the administrator to a corporate employee dated 03/15/23 read the call bell system needed to be addressed and described the concern. The administrator, director of nursing and regional nurse were informed of the concern again on 07/27/23 at 11:29 a.m. No other information was provided prior to the exit conference. 42353 2. Six (6) of six (6) call light pull cords present in the TCU Spa (bathing area) and one (1) of three (3) call light pull cords in the PCU Spa (bathing area) did not activate the facility call light system. On 7/26/23 at 5:09 pm, surveyor and registered nurse (RN) #1 entered the TCU Spa room to test the call light system. The Spa room included six (6) call light pull cords located in a bathroom, two (2) separate shower stalls, an area containing a roll-on scale, and in a storage area. Each of the six (6) pull cords failed to activate the visual call light located in the hall outside of the TCU Spa. The TCU Spa was located behind a coded locked door. On 7/26/23 at 5:16 pm, surveyor tested the call light system in the PCU Spa (bathing area), and the call light pull cord located in the back left shower stall did not activate the visual call light located in the hall outside of the PCU Spa. The PCU Spa was located behind a coded locked door. On 7/26/23 at 5:18 pm, surveyor notified the regional nurse consultant of the call light observations in the TCU and PCU Spa rooms. On 7/27/23 at 9:47 am, surveyor spoke with certified nursing assistant (CNA) #1 and asked what they would do if they were alone in the bathing area with a resident and needed assistance. CNA #1 stated they would use the call light or stick their head out of the door and ask for help. On 7/27/23 at 11:30 am the survey team met with the administrator, director of nursing, and the regional nurse consultant and discussed the concern of the call light pull cords located in the TCU and PCU Spa rooms failing to activate the facility call light system. No further information regarding this concern was presented to the survey team prior to the exit conference on 7/27/23.

Based on staff interview, clinical record review and facility document review the facility staff failed to act upon pharmacist recommendations for 1 of 18 residents, Resident #40. The findings included: For Resident #40 the facility staff failed to act upon a pharmacist recommendation. Resident #40's face sheet listed diagnoses which included but not limited to anemia, depression, and psychosis. Resident #40's most recent minimum data set with an assessment reference date of 05/12/23 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 #40's clinical record was reviewed and contained a Consultant Pharmacist Medication Regimen Review form dated 06/17/23 which read in part See report for any noted irregularities and/or recommendations. Surveyor could not locate a report in the clinical record. This surveyor requested and was provided with a copy of a Consultation Pharmacist Recommendation to Physician report dated, which read in part MRR (medication regimen review) Date: 6/17/2023 Federal guidelines state sedative hypnotic drugs should have an attempt at a gradual dose reduction (GDR) quarterly (approximately every 3 months), when used routinely and beyond the manufacturer's recommendations for duration of use. This resident had been taking Melatonin 3 mg since 1/12/2023 without a GDR in last 3 months. Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? If not, please indicate response below: Response: () Reduce the dose of Melatonin to: D/C (discontinue) Melatonin. This form was signed and dated by the facility family nurse practitioner on 07/26/23. The director of nursing stated that the form was just reviewed and acted upon on this day. This surveyor requested and was provided with a facility policy entitled Medication Regimen Review which read in part 6. Resident-specific irregularities and/or clinically significant risks resulting from or associated with medication are documented in the resident's active record and reported to the Director of Nursing, Medical Director, and/or prescriber as appropriate. 7. Recommendations are acted upon and documented by the facility staff and/or prescriber. a. The prescriber accepts and acts upon recommendation or rejects provides an explanation for disagreeing. The concern of not acting upon a pharmacist recommendation was discussed with the administrator, director of nursing and regional nurse consultant on 07/27/23 at 11:30 am. No further information provided prior to exit.

Based on observation, staff interview, clinical record review, facility document review and during a medication pass and pour observation the facility staff failed to ensure a medication error rate of less than 5 %. There were two errors in 28 opportunities for a medication error rate of 7.14%. These errors affected Resident #60. The findings included: For Resident #60, the facility staff failed to administer the medication, amlodipine and failed to follow the physician's order for the administration of the medication, Vitamin D3. Resident #60's face sheet listed diagnoses which included but not limited to hypertension and vitamin D deficiency. Resident #60's most recent minimum data set with an assessment reference date of 06/30/23 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #60's comprehensive care plan was reviewed and contained a care plan for the resident is at risk for cardiac complications secondary to chronic kidney disease, congestive heart failure, history of myocardial infarction, hyperlipidemia, hypertension, cardiomyopathy, CKD3 (chronic kidney disease 3) Interventions for this care plan include administer medications as ordered. This surveyor observed licensed practical nurse ((LPN) #1 administer medications to Resident #60 on 07/26/2023 at 8:20 am. LPN #1 removed a bottle of Vitamin D3 5000 IU (international units) and placed 2 tablets in the medicine cup. LPN #1 administered the Vitamin D3, along with other medications to Resident #60. Surveyor did not observe LPN #1 administer amlodipine to the resident. This surveyor reconciled Resident #60's medication on 07/26/2023. Resident #60's physician's order summary contained an order which read in part, Vitamin D3 capsule 125 mcg (5000 UT [units]). Give 5000 unit by mouth one time a day for vit d def (deficiency) and amlodipine besylate tablet 10 mg. Give 1 tablet by mouth one time a day related to essential (primary) hypertension. This surveyor spoke with LPN #1 on 07/26/2023 at 9:30 am regarding Resident #60's medications. Surveyor asked LPN #1 if they had administered Resident #60's amlodipine and LPN #1 stated they had and proceeded to remove Resident #60's medications from the cart. Resident #60's amlodipine was not among the medications in the cart. LPN #1 stated, I thought I gave it, but I guess not. I'll have to pull it from the Omnicell. LPN #1 removed the amlodipine from the Omnicell and administered it to the resident. Surveyor asked LPN #1 how many Vitamin D3 tablets they had administered to Resident #60, and LPN #1 stated they had administered two, and that's what the order called for. Surveyor asked LPN #1 to review the Vitamin D3 order, and after reviewing the order, LPN #1 stated that the order read to administer one tablet. This surveyor requested and was provided with a facility policy entitled General Guidelines for Medication Administration, which read in part Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer. I. Preparation 6. At a minimum, the 5 Rights-right resident, right drug, right dose, right route, and right time-should be applied to all medication administration and reviewed at three steps in the process of preparation: (1) when medication is selected, (2) when the dose is removed from the container, and (3) after the dose is prepared and the medication is put away. The concern of not ensuring a medication error rate of less than 5% was discussed with the administrator, director of nursing, and regional nurse consultant on 07/26/23 at 4:30 pm. No further information was provided prior to exit.

Based on staff interview and clinical record review, facility staff failed to administer a diuretic medication per physician orders for 1 of 18 residents in the survey sample (Resident #20). Resident #20 was admitted to the facility with diagnoses including atherosclerotic heart disease, congestive heart failure, presence of implanted defibrillator, pulmonary hypertension, long-term use of insulin and anticoagulants, Parkinson's disease, type 2 diabetes mellitus, chronic respiratory failure, and essential hypertension. On the Minimum Data Set assessment with assessment reference date 6/5/2023, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. Clinical record review on 7/25/23 revealed an order dated 7/13/23 for metolazone oral tablet 2.5 mg (milligrams) Give 1 tablet by mouth one time only for fluid overload 1 day to be given 30 minutes prior to torsemide. The order was entered for administration on 7/14, 7/24, and 7/31. The surveyor asked LPN #3 to check the clinical record software for administration times for torsemide and metolazone administered on 7/14 and 7/24. The record indicated metolazone administered on 7/14 at 9:29 AM and torsemide administered at 9:50 AM, allowing 21 minutes between administrations. On 7/24/23 the record indicated the resident received metolazone at 8:46 AM and torsemide at 8:49 AM. During a summary meeting on 7/25/23 the surveyor notified the administrator and director of nursing of the concern with timing of medication administration. On 7/26/23 the director of nursing informed the surveyor that the nurse practitioner reviewed the metolazone order, which was written by the cardiologist, and changed the scheduled times of the medications to 6 AM for metolazone and 8 AM for torsemide, therefore ensuring that there would be a sufficient gap between administrations to ensure effectiveness of the torsemide in the future.

Based on staff interview and clinical record review, the facility staff failed to consistently document the results of COVID-19 tests in the (EHR) electronic health record for 23 of 26 residents. Resident's #6, #11, #16, #18, #19, #22, #24, #28, #34, #37, #42, #44, #45, #46, #51, #54, #61, #67, #71, #73, #75, #77, and #79. The findings included: The facility staff failed to consistently document the result of COVID-19 testing in the resident's EHR's. During the record reviews, the surveyors were unable to locate all of the results of recent COVID-19 tests in the resident's EHR's. 10/19/21 1:34 p.m., the (DON) Director of Nursing stated the results of the rapid COVID-19 tests were documented on the residents individual (eMARs) electronic medication administration records and the results of the (PCR) polymerase chain reaction COVID-19 laboratory tests were in a folder in a plastic tote in the conference room and were not placed in the residents EHR's. The nurse consultant stated they called the physician right away if they received a positive test result. Prior to the exit conference the facility staff began documenting the results of the COVID-19 tests in the residents individual records. 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 provide routine drugs by not ensuring medications were available for administration for 5 of 26 Residents, #44, #54, #22, #28, and #73. A facility document entitled Unavailable Medications was reviewed and read in part, Policy: The facility must make every effort to ensure that medications are available to meet the needs of each resident. The findings included: 1. For Resident # 44 the facility staff failed to ensure that the supplement Prostat was available for administration. Resident #44's face sheet listed diagnoses which included but not limited to urinary tract infection, non-pressure chronic ulcer, pressure ulcer of left hip, pressure ulcer of sacral region, [CONDITION(S)], hypertension, type II diabetes mellitus, and [CONDITION(S)]. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 09/22/21 assigned the resident a BIMS (brief interview for mental status) score of 14 out 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #44's comprehensive care plan was reviewed and contained a care plan for admitted with skin impairment r/t (related to) decreased mobility, weakness, PVD ([CONDITION(S)]), scattered bruising noted to bilateral up and lower extremities, hx (history) [CONDITION(S)], hx [CONDITION(S)] . Interventions for this care plan included Tx (treatment) as ordered. Resident #44's clinical record contained a physician's order summary for the month of October 2021, which read in part Prostat SF(sugar free) AWC (advanced wound care) three times a day for To Promote Wound Healing Give 30 ml via PO (by mouth) TID (three times a day). Resident #44's eMAR (electronic medication administration record) for the month of October 2021 was reviewed and contained an entry as above. This entry was coded 9 on 10/14-10/17/21 at 0900 and 10/14-10/16/21 at 1400. Chart code 9 is the equivalent of other/see nurses notes. Resident #44's nurses' progress notes were reviewed and contained notes which read in part, 10/14/2021 08:16 Prostat SF AWC three times a day for To Promote Wound Healing Give 30 ml via PO TID out of stock, 10/14/2021 13:50 Prostat SF AWC three times a day for To Promote Wound Healing Give 30 ml via PO TID out of stock, 10/15/2021 08:51 Prostat SF AWC three times a day for To Promote Wound Healing Give 30 ml via PO TID not in stock, 10/15/ 021 13:36 Prostat SF AWC three times a day for To Promote Wound Healing Give 30 ml via PO TID awaiting order, 10/16/ 9:15 Prostat SF AWC three times a day for To Promote Wound Healing Give 30 ml via PO TID on order, 10/16/2021 14:47 Prostat SF AWC three times a day for To Promote Wound Healing Give 30 ml via PO TID on order, and 10/17/2021 08:13 Prostat SF AWC three times a day for To Promote Wound Healing Give 30 ml via PO TID on order The concern of the medication not being available was discussed with the administrator, director of nursing, regional nurse consultant and unit manager during a meeting on 10/20/21 at 2:45 pm. No further information was provided prior to exit. 2. For Resident #54 the facility staff failed to ensure the medication labatelol was available for administration. Resident #54's face sheet listed diagnoses which included but not limited to generalized [CONDITION(S)], anxiety, acute kidney failure, depression, hypertension and chronic kidney disease. The most recent MDS (minimum data set) with an ARD (assessment reference date) 09/30/31 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #54's clinical record contained a physician's order summary for the month of October 2021 which read in part, [MEDICATION(S)] Tablet 100 mg Give 1 tablet by mouth tow times a day related to ESSENTIAL (PRIMARY) HYPERTENSION. Resident #54's eMAR (electronic medication administration record) for the month of October 2021 was reviewed and contained an entry as above. This entry was coded 5 on 10/15/21 at 5 pm. Chart code 5 is the equivalent of Hold/See progress note. The entry was coded 9 on 10/16, 10/17, 10/18 for both administration times and 10/19 at 9 am. Chart coded 9 is the equivalent of Other/See progress note. Resident #54's progress notes were reviewed and contained notes which read in part, 10/15/2021 17:50 [MEDICATION(S)] Tablet 100 mg Give 1 tablet by mouth two times a day related ESSENTIAL (PRIMARY) HYPERTENSION on order, 10/16/2021 09:30 [MEDICATION(S)] Tablet 100 mg Give 1 tablet by mouth two times a day related ESSENTIAL (PRIMARY) HYPERTENSION Medication unavailable in Omnicell. Awaiting from pharmacy. MD made aware, 10/17/2021 08:07 [MEDICATION(S)] Tablet 100 mg Give 1 tablet by mouth two times a day related ESSENTIAL (PRIMARY) HYPERTENSION Medication unavailable in Omnicell. Awaiting from pharmacy. MD made aware, 10/18/2021 08:05 [MEDICATION(S)] Tablet 100 mg Give 1 tablet by mouth two times a day related ESSENTIAL (PRIMARY) HYPERTENSION Medication unavailable in Omnicell. Awaiting from pharmacy. MD made aware, and 10/18/ 9:42 [MEDICATION(S)] Tablet 100 mg Give 1 tablet by mouth two times a day related ESSENTIAL (PRIMARY) HYPERTENSION Medication unavailable in Omnicell. Awaiting from pharmacy. MD made aware The concern of the medication not being available was discussed with the administrator, director of nursing, regional nurse consultant and unit manager during a meeting on 10/20/21 at 2:45 pm. No further information was provided prior to exit. 3. For Resident #22, facility staff failed to ensure a physician ordered supplement was available for administration. Resident #22 was admitted to the facility with diagnoses including [CONDITION(S)] heart disease, traumatic amputation of right lower leg, [CONDITION(S)], diabetes mellitus, hypertension, heart failure, gastroesophageal reflux disease, and dysphagia. On the Minimum Data Set Assessment with Assessment Reference Date 8/25/21, the resident scored 10/15 on the Brief Interview for Mental Status and was assessed as without signs of [CONDITION(S)] or [CONDITION(S)]. The resident exhibited physical behaviors directed toward others 1-3 days of the week prior to the assessment. Clinical record review revealed a physician order dated 6/9/2021 for Prostat SF 30 ml one time a day for wound healing and skin integrity. The October 2021 Medication Administration Record (MAR) documented 9 (Other/ See Progress Notes) on 10/15,16, and 19 and 45 ml (instead of 30) administered on 10/18/21. Notes on 10/15, 10/16, and 10/19 documented Prostat on order, will administer next dose. No mention of administering larger dose on 10/18. Surveyors discussed medication availability issues with the administrator, director of nursing, and other members of the management team during meetings on 10/20 and 10/21/21. The director of nursing reported that mediation availability was an ongoing concern with the facility's current pharmacy. 4. For Resident #28, the facility staff failed to ensure the medication [MEDICATION(S)] ([MEDICATION(S)]) (a diuretic used to treat fluid retention) was available for administration. Resident #28's diagnosis list indicated diagnoses, which included, but not limited to Unspecified Convulsions, Hypo-osmolality and [CONDITION(S)], Essential (Primary) Hypertension, [CONDITION(S)] Unspecified, and Unspecified Lack of Expected Normal Physiological Development in Childhood. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 9/03/21 assigned the resident a BIMS (brief interview for mental status) score of 3 out of 15 in section C, Cognitive Patterns. Resident #28's current physician's orders included an active order dated 5/26/21 for [MEDICATION(S)] 0.5 mg give 1 tablet by mouth one time a day related to [CONDITION(S)]. A review of the resident's September 2021 MAR (medication administration record) revealed [MEDICATION(S)] was not administered on 9/18/21, 9/19/21, 9/20/21, 9/21/21, and 9/22/21. According to Resident #28's nursing progress notes, [MEDICATION(S)] was not administered for the following documented reasons: 9/18/21 11:28 am - awaiting pharmacy 9/19/21 11:13 am - awaiting pharmacy 9/20/21 9:33 am - med not in facility 9/21/21 9:24 am - medication not available in stat box pharmacy will be sending on next run will administer on next scheduled dose 9/22/21 9:35 am - waiting for delivery from pharmacy Resident #28 was seen by the NP (nurse practitioner) on 9/22/21 and the progress note states in part The patient is being evaluated today at nursing request for reports of [CONDITION(S)]. The patient is on sodium tablets and [MEDICATION(S)] ([MEDICATION(S)]) to prevent [CONDITION(S)]. As per nursing, (he/she) has not had (his/her) [MEDICATION(S)] for approximately five days as it has not been coming from the pharmacy. The documented plan states in part as (he/she) has not had (his/her) regular medications, we will obtain a BMP (basic metabolic panel) to evaluate for worsening [CONDITION(S)]. Resident #28's 9/23/21 BMP results revealed a sodium level of 130. Resident #28's prior sodium level on 9/15/21 was also 130 indicating no change. On 10/20/21 at 8:40 am, surveyor spoke with the DON (director of nursing) who stated the facility changed pharmacies on 9/01/21 and there was an issue obtaining Resident #28's [MEDICATION(S)] ([MEDICATION(S)]). DON stated they contacted the pharmacy through the provided app and made daily phone calls attempting to obtain the medication. Surveyor met with the administrator, DON, regional nurse consultant, and the Unit Manager on 10/20/21 at 2:39 pm and discussed the concern of Resident #28 not receiving [MEDICATION(S)] as ordered. No further information regarding this issue was presented to the survey team prior to the exit conference on 10/21/21. 5. For Resident #73, the facility staff failed to ensure the physician ordered medication [MEDICATION(S)] ([MEDICATION(S)]) was available for administration. Resident #73's medical diagnosis included, but was not limited to, malignant neoplasm of colon, metabolic [CONDITION(S)], chronic kidney disease, and [CONDITION(S)]. Section C (cognitive patterns) of Resident #73's quarterly (MDS) minimum data set assessment with an (ARD) assessment reference date of 10/12/2021 included a (BIMS) brief interview for mental status summary score of 2 out of a possible 15 points. The residents (EHR) electronic health record included a physicians order for [MEDICATION(S)] 5 mg tablet every 12 hours. 10/20/21 8:32 a.m., during a medication pass and pour observation with (RN) registered nurse #1 the medication was not available in the medication cart or in the backup supply (omnicell) for administration. RN #1 stated they would call the pharmacy and order the medication and stated they had recently changed pharmacies and were having issues with obtaining some medications. 10/20/2021 a review of the residents (eMARs) electronic medication administration records and progress notes revealed that this medication was not available for administration on 10/18/2021 and 10/19/2021 at 9:00 a.m. For the evening dose at 9:00 p.m., two different nurses documented that the medication had been administered. 10/20/21 2:42 p.m., the administrator, (DON) Director of Nursing, nurse consultant, and unit manager were made aware of the issue regarding the residents [MEDICATION(S)]. 10/21/21 09:14 a.m., during a meeting with the administrator and DON. The DON stated the [MEDICATION(S)] was signed in error and was not available for administration. No further information regarding this issue was provide to the survey team prior to the exit conference.

Based on staff interview, employee record review, and facility document review, the facility staff failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of resident and misappropriation of resident property as evidenced by failure to pre-screen 2 of 25 new hire employees, #16 and #19. The findings included: The facility staff failed to obtain reference checks for Employee #16 and failed to obtain a criminal background check and reference checks for Employee #19. A review of the employee records for Employee #16 and #19 revealed the following documentation: Employee #16 was employed by the facility in housekeeping on 9/20/21. Employee #16's employee record did not contain documentation of a reference check review. Employee #19 was employed by the facility in human resources on 2/17/20. Employee #19's employee record did not contain documentation of a Virginia State Police criminal background check or a reference check review. On 10/20/21 at 3:36 pm, surveyor spoke with HR (human resources) staff member #1 concerning the missing documentation for Employee #16 and #19, they stated they did not have the missing documentation. Surveyor requested and received the facility policy entitled Prevention/Screening/Training which states in part Criminal background and reference checks are performed on all employees. On 10/21/21 at 10:45 am, surveyor met with the administrator, director of nursing, regional nurse consultant, and unit manager and discussed the concern of the missing employment screening documentation for Employee #16 and #19. No further information regarding these issues was presented to the survey team prior to the exit conference on 10/21/21.

Based on observation, staff interview, facility document review and clinical record review the facility staff failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, specifically COVID-19, for one of one COVID unit. The findings included: For the COVID unit of the facility, the facility staff failed to don proper PPE (personal protective equipment) prior to entering a room with a resident that was COVID positive, then exited the unit and back into the facility. On 10/19/21 at 4:00 pm, surveyor observed RN (registered nurse) #1 enter the COVID unit through a zippered barrier that separated the COVID unit from the observation unit. RN #2 was wearing an N95 mask, but no other PPE. RN #2 entered Resident #231's room, without donning any other PPE. When RN #2 exited the room, surveyor introduced herself and asked RN #2 if they had donned PPE prior to entering the room, and RN #2 stated I forgot my face shield, but I took everything else off in the room. Surveyor then informed RN #2 they had observed them entering the room, and RN #2 stated, Well, I guess you got me this time, I've been on the other side and it's about time for me to leave and I needed to ask her something. RN #2 then proceeded to unzip the barrier separating the units, and exit into the facility. Resident #231's clinical record was reviewed and contained a face sheet which listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor observed signage on the resident's door stating Enhanced Droplet-Contact Precautions and a list of steps to be taken, including Perform Hand Hygiene, N-95 or Surgical Mask when entering room, Eye Protection (goggles or face shield) when entering room, Gown when entering room, Gloves when entering room, Keep door closed and Remove PPE and Perform Hand Hygiene before exiting room. A cart containing PPE was located outside the resident's door. Surveyor spoke with DON (director of nursing) and RNC (regional nurse consultant) on 10/19/21 at 4:14 pm. RNC stated they will address the concern immediately. DON stated the nurse should have worn full PPE when entering the room and not went back into the facility after exiting room. Surveyor was provided with a copy of a facility policy entitled COVID-19 which read in part, 9. Containment/Management a. Identification of a positive case in a patient: Implement Enhanced Droplet-Contact Precautions until patient meets CDC (Centers for Disease Control) criteria for discontinuation of transmission-based precautions. 13. Education d. Review with all employees and visitors the core principles of COVID-19 of infection control: Employees will wear appropriate Personal Protective Equipment (PPE) when indicated. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to ensure that residents receive treatment and care by not following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: For Resident #11, the facility staff failed to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent annual MDS (minimum data set) with an ARD (assessment reference date) of 7/28/21 assigned the resident a BIMS (brief interview for mental status) score of 14 out of 15 in section C, Cognitive Patterns. Resident #11's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's October 2021 MAR (medication administration record) indicated [MEDICATION(S)] was administered daily at 9:00 am. The October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . However, surveyor was unable to determine if the resident's blood pressure was assessed prior to the administration of [MEDICATION(S)]. On 10/20/21 at 9:30 am, surveyor spoke with the DON (director of nursing) concerning the order to hold Resident #11's [MEDICATION(S)] if the SBP is less than 100. The DON stated the resident's blood pressure was taken twice a day but they do not correspond with the times the medication was given and it has been corrected. On 10/20/21 at 2:39 pm, surveyor met with the administrator, DON, regional nurse consultant, and unit manager and discussed the concern of the administration of [MEDICATION(S)] without prior assessment of Resident #11's blood pressure. No further information regarding this issue was presented to the survey team prior to the exit conference on 10/21/21.

Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to ensure an environment free of accident hazards for 1 of 21 Residents in the sample survey, Resident #82. For Resident #82 the facility staff failed to apply physician ordered Tubi Grips on the bilateral lower extremities. The Findings Included: Resident #82 was an [AGE] year old female who was originally admitted on [DATE] and readmitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was an Annual MDS assessment with an Assessment Reference Date (ARD) of 3/30/18. The facility staff coded that Resident #82 had a Cognitive Summary Score of 4. The facility staff also coded that Resident #82 required extensive (3/3) to total nursing care (4/3) with Activities of Daily Living (ADL's). On (MONTH) 18, (YEAR) at 10:05 a.m., the surveyor reviewed Resident #82's clinical record. Review of the clinical record produced signed physician orders [REDACTED]. (sic) The order originated on 5/29/17. Tubi grips are an elastic stocking that protects the legs and assists with reducing swelling. On (MONTH) 18, (YEAR) at 10:10 a.m., the surveyor observed an Activities Assist entering Resident #82's room. The surveyor asked the Activities Assistant if she, the Activities Assistant, could pull up Resident #82's pants legs. The Activities Assistant stated that she could assist the surveyor. The Activities Assistant and the surveyor stepped over to Resident #82, who was sitting up in her wheelchair. The surveyor asked Resident #82 if the surveyor could look at her legs and Resident #82 stated, Yes. The Activities Assistant raised Resident #82's pants legs up and exposed Resident #82's lower legs. Resident #82 had on white cotton socks that stopped just below the middle of the calf. On (MONTH) 18, (YEAR) at 10:25 a.m., the surveyor observed a Licensed Practical Nurse (LPN) walking down the hallway towards the surveyor. The surveyor asked the LPN for assistance. The LPN approached the surveyor and the surveyor informed the LPN that Resident #82 had a physician order [REDACTED].#82 did not have on the physician ordered Tubi grips. The surveyor reviewed Resident #82's clinical record with the LPN. The surveyor specifically pointed out the physician order [REDACTED].#82's room. The surveyor and LPN stepped over to Resident #82 who was still sitting in her wheelchair. The surveyor once again asked Resident #82 if she, the surveyor, could look at Resident #82's legs. Resident #82 stated, Yes. LPN reach down and pulled up Resident #82's pant legs exposing white cotton socks that stopped just below the mid-calf. The surveyor stated to the LPN, Those are not Tubi grips are they? LPN stated, No. The LPN stated that she was not assigned to provide care to Resident #82 and that she did not know why Resident #82 did not have on the Tubi grips. On (MONTH) 18, (YEAR) at 11 a.m., the surveyor observed the Director of Nursing (DON) and the Corporate Compliance Nurse (CCN) sitting in the DON's office. The surveyor stepped into the doorway of the DON's office and notified the DON and CCN that Resident #82 had a physician order [REDACTED].#82 did not have on the physician ordered Tubi grips. On (MONTH) 19, (YEAR) at 11:20 a.m., the survey team met with the Administrator (Adm), DON, CCN and the MDS Nurse. The surveyor notified the Administrative Team (AT) that Resident #82 had a physician order [REDACTED].#82 did not have on the Tubi grips on 4/18/18. No additional information was provided prior to exiting the facility as to why the facility staff failed to applied physician ordered safety interventions for Resident #82.

Based on resident interview , staff interview and clinical record review it was determined that the facility staff failed to ensure that the physician provided necessary orders for care and treatment of [REDACTED].#6. The Findings Included: Resident #6 was a [AGE] year old male who was originally admitted on [DATE] and readmitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was an Annual MDS assessment with an Assessment Reference Date of 1/10/18. The facility staff coded that Resident #6 had a Cognitive Summary Score of 15. The facility staff also coded that Resident #6 required extensive assistance (3/3) with Activities of Daily Living (ADL's). In Section H. Bladder and Bowel the facility staff coded that Resident #6 had an indwelling Foley catheter (including supra-pubic or nephrostomy tube). On (MONTH) 17, (YEAR) at 12:50 p.m., the surveyor observed Resident #6 sitting in high back wheelchair at the side of his bed. Resident #6 stated he has been at [MEDICAL TREATMENT]. Resident #6 informed the surveyor that he had a catheter. However, the surveyor did not observe a catheter drainage bag. On (MONTH) 18, (YEAR) at 2:58 p.m., the surveyor observed Resident #6 up in his wheelchair and self propelling himself down the hallway. The surveyor did not observe a urinary drainage bag. The surveyor observed Resident #6's Medication Nurse, who was a Registered Nurse (RN), walking down the hallway. The surveyor asked the RN if Resident #6 has a catheter. The RN informed the surveyor that Resident #6 has a supra-pubic catheter. On (MONTH) 18, (YEAR) at 3:15 p.m., the surveyor reviewed Resident #6's clinical record. Review of the clinical record produced signed physician orders dated 4/13/18. Signed physician orders did not include a physician order for [REDACTED]. On (MONTH) 18, (YEAR) at 3:30 p.m., the surveyor observed the Director of Nursing (DON) and the Corporate Compliance Nurse (CCN) sitting in the Director of Nursing's office. The surveyor requested for the DON and CCN to come into the conference room to speak with the surveyor. The DON and CCN came into the conference room and the surveyor notified the DON and CCN that Resident #6 had a Supra-pubic catheter. The surveyor also notified the DON and CCN that Resident #6's physician orders did not include an order for [REDACTED]. The DON and CCN were unable to locate physician orders for care and treatment of [REDACTED]. On (MONTH) 19, (YEAR) at 11:20 a.m. the survey team met with the Administrator (Adm), DON, Corporate Compliance Nurse (CCN) and the Minimum Data Set (MDS) Nurse. The surveyor notified the Administrative Team (AT) that the facility staff failed to ensure that Resident #6 had a physician order for [REDACTED]. No additional information was provided prior to exiting the facility as to why the facility staff failed to ensure that Resident #6 had a physician order for [REDACTED].

Based on observation, staff interview, and facility document review it was determined that the facility staff failed to ensure that a multi-dose vial of Insulin was dated when opened in 1 of 2 medication rooms. The facility staff failed to date a multi-dose vial of Insulin when the vial was opened on the PCU unit in cart #1. The Findings Included: On (MONTH) 17, (YEAR) at 2:15 p.m., the surveyor observed the PCU unit #1 medication care that was located in the PCU medication room. A Licensed Practical Nurse (LPN) unlocked the medication cart and the surveyor inspected the drawer of the medication cart that contained the opened vials of Insulin. The surveyor observed an open multi-dose vial of Humalog Insulin that was not dated when opened. The surveyor notified the LPN that the vial of Humalog Insulin was not dated when opened. The LPN inspected the open vial of Insulin and was not able to locate the date of when the Humalog Insulin vial was opened. The LPN stated that the vial of Humalog Insulin should have been dated when opened. The LPN stated to the surveyor, I'm sorry. On (MONTH) 17, (YEAR) at 3:25 p.m., the surveyor notified the Director of Nursing (DON) that an opened multi-dose vial of Humalog Insulin was observed in the PCU unit #1 medication cart. The surveyor requested the facility policy and procedure for storage and labeling and dating opened vials of insulin. On (MONTH) 17, (YEAR) at 3:35 p.m., the DON approached the surveyor and hand delivered a policy and procedure titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles. The policy and procedure read in part . 5. Once and medication of biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shorter expiration date once opened. On (MONTH) 19, (YEAR) at 11:20 a.m., the survey team met with the Administrator (Adm), DON, Corporate Compliance Nurse (CCN) and the Minimum Data Set (MDS) Nurse. The surveyor notified the Administrative Team (AT) that the facility staff failed had opened a multi-dose vial of Humalog Insulin and did not date the vial when opened. No additional information was provided prior to exiting the facility as to why the facility staff failed to label/date multi-dose vial of Humalog Insulin when opened.

Based on staff interview and clinical record review, the facility staff failed to ensure that 1 of 21 residents in the final survey sample received treatment and care in accordance with professional standards of practice, Resident # 58. The findings included The facility staff failed to obtain accu checks as ordered by the physician for Resident # 58. Resident # 58 is a [AGE] year-old-female who was originally admitted to the facility on [DATE], with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 58 was reviewed on 4/18/18 at 12:13 pm. The most recent MDS (minimum data set) assessment was an annual assessment with an ARD (assessment reference date) of 3/26/18. Section C assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 58 had a BIMS (brief interview for mental status) score of 15/15, which indicated that she was cognitively intact. The current plan of care for Resident # 58 was reviewed and revised on 4/4/18. In a focus area documented as The resident has diabetes mellitus, interventions included but were not limited to Labs as ordered by doctor, and diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. The physician signed the current physician's orders [REDACTED]. The current orders included but was not limited to Accu check one time a day every Monday, Wednesday, Friday for diabetes mellitus, Notify MD (medical doctor) of BS (blood sugar) < 60 or > 500. Upon further review of the clinical record, the surveyor could not locate any blood sugar results. On 4/19/18 at 9:05 am, the surveyor spoke with the DON (director of nursing) and asked if she could assist in locating the blood sugar results for Resident # 58. On 4/19/18 at 9:21 am, the DON reported to the survey team that the order for accu checks had been discontinued on 6/24/16. The DON also stated that the facility was no longer obtaining accu checks for Resident # 58 and that her blood sugars were being monitored by her A1C levels. The surveyor spoke with the director of nursing and stated that the current physician's orders [REDACTED]. The DON stated that she would look further into it. On 4/19/18 at 9:41 am, the DON provided the survey team with documentation from the clinical record that was dated 6/24/16 at 16:05. The documentation stated to discontinue accucheck before meals and at bedtime related to Type 2 diabetes mellitus without complications. The survey team spoke with the DON and pointed out that the start date for the order written as accu check one time a day every Monday, Wednesday, Friday for diabetes mellitus, Notify MD of BS < 60 or > 500 was 6/27/16, which was 3 days after the order was written to discontinue accuchecks before meals and at bedtime. The director of nursing voiced understanding and stated I can see how that would be an active order. On 4/19/18 at 11:35 am, the administrative team was made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 4/19/18.

Based on staff stall interview and clinical record review, it was determined that the facility staff failed to follow physician ordered parameters on medications for 3 of 18 Residents in the sample survey, Resident #9, Resident #11 and Residents #4. The Findings Included: 1. For Resident #9 the facility staff failed to follow physician orders [REDACTED]. Resident #9 was a [AGE] year old male who was originally admitted on [DATE] and readmitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was a Significant Change MDS assessment with an Assessment Reference Date (ARD) of 2/7/17. The facility staff coded that Resident #9 had a Cognitive Summary Score of 13. The facility staff also coded that Resident #9 required extensive assistance (3/3) with Activities of Daily Living (ADL's). On March 8, 2017 at 11 a.m. the surveyor reviewed Resident #9's clinical record. Review of the clinical record produced a physician order [REDACTED].< (less than) 100; HR (heart rate) <60, [MEDICATION NAME] 50 mg Give 50 mg Give 1 tablet by mouth one time a day every Mon (Monday), Wed (Wednesday), Fri (Friday) related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for SBP <100; HR<60, [MEDICATION NAME] ER Tablet Extended Release 24 hours 60 MG Give 1 tablet by mouth one time a day for hypertension related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for SBP <100; HR<60, [MEDICATION NAME] Tablet 20 mg Give 20 mg by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for SBP <100; HR<60, [MEDICATION NAME] ER Tablet Extended Release 24 Hour Give 90 mg by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for SBP <100; HR<60, [MEDICATION NAME] Tablet 50 MG Give 1 tablet by mouth two times a day every Sun, Tue, Thu, Sat related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for SBP <100; HR<60. (sic) Further review of the clinical record produced the February and March 2017 Medication Administration Records (MAR's). Review of the March 2017 MAR's documented that on March 3, 2017 at 5 p.m. Resident #9's blood pressure was 115/69 and the pulse was 56 and the facility staff did not hold the [MEDICATION NAME]. March 6, 2017 at 9 a.m. Resident #9's blood pressure was 149/70 and the pulse was 59 and that the Hyralazine, [MEDICATION NAME] and [MEDICATION NAME] were not held. On March 7, 2017 at 5 p.m. Resident 9's blood pressure was 84/32 and the pulse was 48 and the facility staff did not hold the [MEDICATION NAME]. The February 2017 MAR's Documented on February 6, 2017 at 9 p.m. Resident #9's blood pressure was 151/72 and the pulse was 56 and the facility staff did not hold the [MEDICATION NAME] or the [MEDICATION NAME]. On February 7, 2017 at 9 p.m. Resident #9's blood pressure was 133/62 and the pulse was 52 and the facility staff did not hold the [MEDICATION NAME]. On February 8, 2017 at 9 p.m. Resident #9's blood pressure was 85/52 and the pulse was 49 and the facility staff did not hold the [MEDICATION NAME] or Hydrazine. On February 11, 2017 at 9 p.m. Resident #9's blood pressure was 102/59 and the pulse was 55 and the facility staff did not hold the [MEDICATION NAME] and [MEDICATION NAME]. On February 14, 2017 at 9 p.m. Resident #9's blood pressure was 116/56 and the pulse was 53 and the facility staff did not hold the [MEDICATION NAME] or the [MEDICATION NAME]. On February 18, 2017 at 9 p.m. Resident ##9's blood pressure was 125/56 and the pulse was 55 and the facility staff did not hold the [MEDICATION NAME] or the [MEDICATION NAME]. On March 8, 2017 at 2:40 p.m. the surveyor notified the Director of Nursing (DON) and Corporate Compliance Nurse (CCN) that Resident #9 had a physician orders [REDACTED]. The surveyor notified the DON and CCN that the facility staff had not followed the physician ordered blood pressure parameters in February and March of 2017. The surveyor reviewed Resident #9's clinical record with the DON and CCN. The surveyor specifically pointed out the physician orders [REDACTED]. The surveyor then reviewed the February and March 2017 MAR's with the DON and CCN. The surveyor pointed out the multiple times that Resident #9's blood pressure was less than 100 SBP or pulse was less than 60 and the facility staff administered the medications. On March 8, 2017 at 3:35 p.m. the survey team met with the Administrator (Adm), DON and CCN. The surveyor notified the Administrative Team (AT) that Resident #9 had a physician ordered medication parameters and that the facility staff had not followed the medication parameters. No additional information was provided prior to exiting the facility as to why the facility staff failed to follow physician ordered medication parameters for Resident #9. 2. For Resident #11 the facility staff failed to follow physician ordered medication, blood pressure and pulse, parameters. Resident #11 was an [AGE] year old female who was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was a Quarterly MDS assessment with an Assessment Reference Date (ARD) of 2/9/17. The facility staff coded that Resident #11 had a Cognitive Summary Score of 3. The facility staff also coded that Resident #11 required extensive (3/3) to total nursing care (4/2) with Activities of Daily Living (ADL's). On March 7, 2017 at 3:10 p.m. the surveyor reviewed Resident #11's clinical record. Review of the clinical record produced a physician order [REDACTED].< (less than) 100 HR (heart rate) < 70. (sic) Continued review of the clinical record produced the February and March 2017 Medication Administration Records (MAR's). Review of the March 2017 MAR's documented the following at 9 p.m.: March 2, 2017 Blood pressure 111/62 pulse 60 March 5, 2017 Blood pressure 101/51 pulse 57 March 7, 2017 blood pressure 118/60 pulse 61 February 1, 2017 blood pressure 101/54 pulse 56 February 2, 2017 blood pressure 130/57 pulse 57 February 3, 2017 blood pressure 136/54 pulse 60 February 4, 2017 blood pressure 136/54 pulse 60 February 5, 2016 blood pressure 116/62 pulse 58 February 6, 2017 blood pressure 95/48 pulse 51 February 10, 2017 blood pressure 95/49 pulse 64 February 11, 2017 blood pressure 105/40 pulse 58 February 13, 2017 blood pressure 112/50 pulse 49 February 15, 2017 blood pressure 84/49 pulse 58 February 16, 2017 blood pressure 98/56 pulse 59 February 19, 2017 blood pressure 101/45 pulse 52 February 20, 2017 blood pressure 109/61 pulse 63 February 21, 2017 blood pressure 110/82 pulse 67 February 23, 2017 blood pressure 92/42 February 24, 2017 blood pressure 92/42 pulse 53 February 25, 2017 blood pressure 120/48 pulse 56 February 26, 2017 blood pressure 94/35 pulse 62 February 28, 2017 blood pressure 126/53 pulse 55 The surveyor noted that the [MEDICATION NAME] should have been held on each of these occurrences and that the facility staff administered the medication. On March 7, 2017 at 3:20 p.m. the surveyor notified the Director of Nursing (DON) and Corporate Compliance Nurse (CCN) that Resident #11 had a physician order [REDACTED]. The surveyor reviewed the clinical record with the DON and CCN. The surveyor reviewed the physician orders [REDACTED]. On March 8, 2017 at 3:35 p.m. the survey team met with the Administrator (Adm), DON and CCN. The surveyor notified the Administrative Team (AT) that Resident #11 had a physician order [REDACTED]. No additional information was provided prior to exiting the facility as to why the facility staff failed to follow physician ordered medication, blood pressure and pulse, parameters for Resident #11. 3. The facility staff failed to follow the physician ordered parameters for administration of the medication, [MEDICATION NAME] (a heart medication), for Resident #4. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) with a reference date of 12/26/16 assessed the resident with a cognitive score of 6 of 15. The resident was assessed requiring extensive assistance of 2 persons for bed mobility, transfers, dressing, toileting, bathing, and hygiene. The clinical record was reviewed. The physician had written an order with a start date of 7//7/16 for, [MEDICATION NAME] 125 mcg by mouth one tine a day related to unspecified [MEDICAL CONDITION] Hole if HR (heart rate) < 60. The Medication Administration Record [REDACTED]. She failed to hold the medication as ordered for a pulse less than 60 and did not document any notification to the physician. The comprehensive care plan was reviewed. The care plan contained interventions to administer medications as ordered. The director of nursing was informed of the findings and also the unit manager (RN#2) on 3/8/17 at approximately 9:00 a.m. The administrator , director of nursing and corporate nurse consultant were informed of the findings during the end of the day meeting with survey team on 3/8/17 at 4:00 p.m.

Based on staff interview and clinical record review, it was determined that the facility staff failed to follow physician orders [REDACTED].#11. The Findings Included: For Resident #11 the facility staff failed to follow physician orders [REDACTED]. Resident #11 was an [AGE] year old female who was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was a Quarterly MDS assessment with an Assessment Reference Date (ARD) of 2/9/17. The facility staff coded that Resident #11 had a Cognitive Summary Score of 3. The facility staff also coded that Resident #11 required extensive (3/3) to total nursing care (4/2) with Activities of Daily Living (ADL's). On March 7, 2017 at 3:10 p.m. the surveyor reviewed Resident #11's clinical record. Review of the clinical record produced a physician order [REDACTED]. (sic) Continued review of the clinical record produced the Weights and Vitals Summary. Review of the document revealed the following: On 2/3/17 at 1:47 a.m. the facility staff obtained the blood pressure, respirations and temperature. The pulse was not obtained. On 2/4/17 at 6:08 p.m. the facility staff obtained the blood pressure, pulse, respirations and temperature. On 2/5/17 at 1:59 p.m. the facility staff obtained the blood pressure, pulse, respirations and temperature. On 2/5/17 at 9:19 p.m. the facility staff obtained the blood pressure and pulse. On 2/6/17 at 4:49 p.m. the facility staff obtained the blood pressure, pulse, respirations and temperature. On 2/8/17 at 11:41 a.m. the facility staff obtained the blood pressure, pulse, respirations and temperature. On 2/8/17 at 7:20 p.m. the facility staff obtained the blood pressure and pulse. On 2/9/17 at 11:50 a.m. the facility staff obtained the blood pressure, pulse, respirations and temperature. On 2/9/17 at 4:44 p.m. the facility staff obtained the blood pressure, pulse, respirations and temperature. On 2/9/17 at 9:25 p.m. the facility staff obtained the blood pressure, pulse, respirations and temperature. On 2/10/17 at 1:59 p.m. the facility staff obtained the blood pressure, pulse, respirations and temperature. On 2/10/17 at 3:27 p.m. the facility staff obtained the blood pressure, pulse, respirations and temperature. Continued review of the clinical record produced the Nursing Progress Notes, Medication Administration Records (MAR's) and Treatment Administration Records (TAR's). These documents did not produce any additional vital signs to include a full set of blood pressures, pulses, respirations and temperatures from 2/3/17 through 2/10/17. On March 7, 2017 at 3:20 p.m. the surveyor notified the Director of Nursing (DON) and Corporate Compliance Nurse (CCN) that Resident #11 had a physician order [REDACTED]. The surveyor notified the DON and CCN that review of the clinical record failed to produce the physician ordered vital signs every shift for 1 week. The surveyor reviewed the clinical record with the DON and CCN. The surveyor specifically pointed out the physician order [REDACTED]. The surveyor then reviewed the Weights and Vitals Summary, Nursing Progress Notes, MAR's and TAR's with the DON and CCN. The DON and CCN were unable to locate documentation of the vital signs every shift for 1 week from 2/3/17 through 2/10/17. On March 8, 2017 at 3:35 p.m. the survey team met with the Administrator (Adm), DON and CCN. The surveyor notified the Administrative Team (AT) that Resident #11 had a physician order [REDACTED]. The surveyor notified the AT that review of the clinical record failed to produce evidence that the facility staff obtained the physician ordered vital signs every shift for 1 week, from 2/3/17 through 2/10/17. No additional information was provided prior to exiting the facility as to why the facility staff failed to follow physician orders [REDACTED].#11.

Based on staff interview and clinical record review, it was determined that the facility staff failed to obtain a physician ordered [MEDICATION NAME] level for 1 of 18 Residents in the sample survey, Resident #10. The Findings Included: Resident #10 was an [AGE] year old female who was originally admitted on [DATE] and readmitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) located in the clinical record was a Quarterly MDS assessment with an Assessment Reference Date (ARD) of 11/29/16. The facility staff coded that Resident #10 had a Cognitive Summary Score of 10. The facility staff also coded that Resident #10 required limited (2/2) to extensive assistance (3/2) with Activities of Daily Living (ADL's). On March 8, 2017 at 8:30 a.m. the surveyor reviewed Resident #10's clinical record. Review of the clinical record produced physician orders [REDACTED]. Physician orders [REDACTED]. (sic) Continued review of the clinical record produced a physician's orders [REDACTED]. Further review of the clinical record produced a [MEDICATION NAME] level obtained on 1/13/17. Continued review did not produce a [MEDICATION NAME] level in October of 2016. On March 8, 2017 at 9 a.m. the surveyor notified the Director of Nursing (DON) and the Corporate Compliance Nurse (CCN) that Resident #10 was receiving [MEDICATION NAME] and was supposed to have a [MEDICATION NAME] level obtained every 3 months. The surveyor notified the DON and CCN that a [MEDICATION NAME] level for January 13, 2017 was in the clinical record, but that a [MEDICATION NAME] level 3 months prior to January 2017, October 2016, could not be located in the clinical record. The surveyor reviewed the clinical record with the DON and CCN. The surveyor pointed out the physician order [REDACTED]. The surveyor reviewed the [MEDICATION NAME] level obtained on 1/13/17. The DON and CCN were unable to locate the physician ordered [MEDICATION NAME] level in October 2016. On March 8, 2017 at 3:35 p.m. the survey team met with the Administrator (Adm), DON and CCN. The surveyor notified the Administrative Team (AT) that Resident #10 had a physician order [REDACTED]. The surveyor notified the AT that Resident #10 had a [MEDICATION NAME] level obtained on 1/13/17. The surveyor notified the AT that a [MEDICATION NAME] level should have been obtained in October 2016. The surveyor notified the AT that the facility staff were unable to locate the results of the physician ordered [MEDICATION NAME] level for October 2016. No additional information was provided prior to exiting the facility as to why the facility staff failed to obtain the physician ordered [MEDICATION NAME] level in October 2016 for Resident #10.

Based on staff interview and clinical record review it was determined that the facility staff failed to ensure a complete and accurate Care Area Assessment Summary (CAA's) for 1 of 18 Residents in the sample survey, Resident #2. The Findings Included: For Resident #2 the facility staff failed to ensure that the CAA for Vision on an Annual/5 Day Medicare Minimum Data Set (MDS) assessment with an Assessment reference Date (ARD) of 12/9/16 was complete and accurate. Resident #2 was an [AGE] year old male who was originally admitted on [DATE] and readmitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current MDS located in the clinical record was a 60 Day Medicare MDS assessment with an ARD of 1/28/17. The facility staff coded that Resident #2 had a Cognitive Summary Score of 10. The facility staff also coded that Resident #2 required extensive (3/3) to total nursing care (4/2) with Activities of Daily Living. On March 8, 2017 at 3 p.m. the surveyor reviewed Resident 32's clinical record. Review of the clinical record produced an Annual/5 Day Medicare MDS assessment with an ARD of 12/9/16. The facility staff coded that Resident #2 had a Cognitive Summary Score of 8. The facility staff also coded that Resident #2 required extensive (3/3) to total nursing care (4/3) with ADL's. In Section B1000. Vision the facility staff coded that Resident #2 was Moderately Impaired -limited vision: not able to see newspaper headlines but can identify objects. In Section B1200. Corrective Lenses the facility staff coded that Resident #2 did not have any corrective lenses. In Section V. Care Area Assessment Summary (CAA's) Resident #2 triggered for Vision. In the column titled, Location and Date of CAA documentation the facility staff documented CAA WS dated 12/15/2016. (CAA worksheet dated 12/15/16) (sic) No additional supporting information/documentation regarding the assessment or decision making process for Vision could be located. The surveyor reviewed the CAA worksheets and no additional supporting documentation/assessment could be located for the decision making regarding care planning of Vision. On March 9, 2017 at 8:35 a.m. the surveyor notified the Director of Nursing (DON) that Resident #2's CAA's on the Annual/5 Day Medicare MDS with the ARD of 12/9/16 were incomplete/incorrect. The surveyor reviewed the MDS and CAA worksheets with the DON. The surveyor pointed out that Resident #2 triggered for Vision. The surveyor also pointed out that the facility staff documented in Section V CAA WS dated 12/15/2016 for the location and date of supporting assessment/documentation for Resident #2. The surveyor then reviewed the CAA worksheets with the DON. The surveyor pointed out that the CAA worksheets did not document a location and date for the supporting documentation/assessment for the care plan decision making process for Vision for Resident #2. The surveyor requested a copy of the MDS and CAA worksheets. On March 9, 2017 at 9:10 a.m. the MDS Nurse hand delivered the copy of the Annual/5 Day Medicare MDS and the CAA worksheets. The MDS Nurse told the surveyor that, she; the MDS Nurse had missed the vision CAA. I didn't do it On March 9, 2017 at 2 p.m. the survey team met with the Administrator (Adm), DON and Corporate Compliance Nurse (CCN). The surveyor informed the Administrative Team (AT) that Resident #2's CAA's were incomplete/inaccurate. The surveyor informed the AT that the location and date of the supporting documentation/assessment for the care planning process/decision making for Vision hand not been documented in Section V or in the CAA worksheets. No additional information was provided prior to exiting the facility as to why the facility staff failed to ensure complete and accurate CAA's for Resident #2.