Every finding on record at Heritage Hall Blacksburg

Based on observation, resident and staff interview, clinical record review, and facility document review, the facility staff failed to ensure electronic cigarettes (vapes) and/or illicit substances were stored in a manner to prevent misuse from other vulnerable residents and/or a fire hazard for four (4) of four (4) sampled residents, Resident #1, Resident #2, Resident #3, and Resident #4. The findings included:1. For Resident #1, the facility staff failed to ensure an electronic cigarette (vape) was securely stored. A facility policy titled, Resident Smoking, dated 2/21/24 specified, Smoking and/or vaping is not allowed inside the facility under any circumstances. The policy also specified, All smoking paraphernalia cigarettes, cigars, e cigs, vapes, etc. will not be left in the possession of any resident at any time. These items must be kept at the nurse's station or locked inside the med room or additional locked safe area designated by the facility.An admission Record indicated the facility admitted Resident #1 on 5/22/23. According to the admission Record, Resident #1 had a medical history that included, but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, generalized muscle weakness, and chronic kidney disease stage 3. A quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/26/25, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated the resident had intact cognition. Resident #1's comprehensive person-centered care plan included a focus area revised on 11/19/24, that indicated Resident #1 was an active smoker with a history of non-compliance with the smoking policy and had lost smoking privileges in the past due to non-compliance. Interventions included Ensure smoking items are stored correctly per policy.Resident #1's Safe Smoking Assessment completed 2/18/26 did not address the use of an electronic cigarette or vape. During an interview on 2/23/26 at 3:10 PM, Resident #1 stated he vaped and kept his vape in his room and charged it without staff assistance. On 2/23/26 at 6:00 PM, the administrator was informed that Resident #1 reported having a vape in his room and charged it without staff assistance. The administrator provided a copy of a facility letter issued to and signed by Resident #1 dated 4/2/24 which indicated The intent of this letter is to reiterate the smoking policy. Residents are not allowed to keep any smoke materials (vapes, cigarettes, lighters, etc.). You have, again, been found with smoke materials on your person. Smoking is a privilege in this facility. Please know that if you are found to have any further smoke materials on your person or in your room your privilege to smoke at our facility will be rescinded. The letter also included a handwritten note dated 4/11/2024 indicating Found with another vape [no] smoking privileges now. On 2/24/26 at 8:58 AM, the administrator stated all vapes and chargers were to be kept secure by the activities department. The facility Activities Director (AD) was interviewed on 2/24/26 at 9:53 AM. The AD stated vapes are to be used at smoking times only and are kept in the activities department and locked. AD stated vapes were charged in the activities office while staff were working. AD stated they had heard residents have vapes, but she had never witnessed it, and they preached about the smoking policy. AD stated Resident #1 attended smoke breaks and usually smoked one cigarette, but she had never seen him with a vape. The facility Social Worker (SW) was interviewed on 2/24/26 at 10:09 AM. The SW stated she had taken multiple marijuana, and nicotine vapes from Resident #1's room in the past that were out in plain sight. SW stated this most recently occurred in November 2025. SW stated Resident #1 had received warnings and write-ups and had lost smoking privileges in the past but got them back. On 2/24/26 at 2:10 PM, the administrator and Director of Nursing were informed of the concern of Resident #1 having a vape and charging it in their room without staff assistance. No further information was provided prior to the exit conference on 2/24/26. 2. For Resident #2, the facility staff failed to ensure an electronic cigarette (vape) was securely stored. A facility policy titled, Resident Smoking, dated 2/21/24 specified, Smoking and/or vaping is not allowed inside the facility under any circumstances. The policy also specified, All smoking paraphernalia cigarettes, cigars, e cigs, vapes, etc. will not be left in the possession of any resident at any time. These items must be kept at the nurse's station or locked inside the med room or additional locked safe area designated by the facility.An admission Record indicated the facility admitted Resident #2 on 7/28/25. According to the admission Record, Resident #2 had a medical history that included, but not limited to dislocation of C6/C7 cervical vertebrae, chronic pain syndrome, generalized muscle weakness, and adult failure to thrive. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/09/25, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated the resident had intact cognition. Resident #2's comprehensive person-centered care plan included a focus area initiated on 7/29/25, which indicated the resident had a history of smoking with a goal that the resident will not smoke without supervision. Interventions included administering medications as ordered for smoking and notify charge nurse immediately if it is suspected that resident has violated facility smoking policy. Resident #2's Safe Smoking Assessment dated 12/09/25 indicated the resident was a non-smoker. During an interview on 2/23/26 at 3:13 PM, Resident #2 stated he had a vape in a tote bag on his bed and the facility lets him vape while in bed, but he hardly uses it. When asked if staff helped him charge the vape, he stated no he uses his phone charger. The resident's phone charger was on the bed beside the resident. On 2/23/26 at 6:00 PM, the administrator was informed that Resident #2 reported having a vape in his room and charged it without staff assistance. On 2/24/26 at 8:58 AM, the administrator stated Resident #2 gave her his vape last evening. The administrator further stated all vapes and chargers were to be kept secure by the activities department. The facility Activities Director (AD) was interviewed on 2/24/26 at 9:53 AM. The AD stated vapes are to be used at smoking times only and are kept in the activities department and locked. AD stated vapes were charged in the activities office while staff were working. AD stated they had heard residents have vapes, but she had never witnessed it, and they preached about the smoking policy. On 2/24/26 at 2:10 PM, the administrator and Director of Nursing were informed of the concern of Resident #2 having a vape and charging it in their room without staff assistance. 3. For Resident #3, the facility staff failed to ensure a drug substance was safely secured. A facility policy titled, Resident Smoking, dated 2/21/24 specified, Smoking and/or vaping is not allowed inside the facility under any circumstances. The policy also specified, All smoking paraphernalia cigarettes, cigars, e cigs, vapes, etc. will not be left in the possession of any resident at any time. These items must be kept at the nurse's station or locked inside the med room or additional locked safe area designated by the facility.The Resident admission Agreement labeled VII: 01-01 2025 specified Facility will not permit the use or possession of, without Facility's permission and a physician's order, cannabis or marijuana products, or any controlled substance (except as prescribed) in violation of any law. Any resident who, while on Facility premises, engages in the sale and/or unauthorized possession of cannabis or marijuana products, or any controlled substance may be subject to discharge and may be referred to local law enforcement. Upon suspicion of possession of cannabis or marijuana products, or a controlled substances violating this section and with consent of Resident, Facility may search the resident's room, personal locker, personal effects, and other personal spaces.An admission Record indicated the facility admitted Resident #3 on 3/28/25. According to the admission Record, Resident #3 had a medical history that included, but not limited to type 2 diabetes mellitus with diabetic neuropathy, need for continuous supervision, and generalized muscle weakness. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/25, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) summary score of 14 out of 15, which indicated the resident had intact cognition. Resident #3's comprehensive person-centered care plan included a focus area revised on 9/30/25, that indicated the resident was a smoker with a history of noncompliance with smoking policy despite education. Interventions included the resident requires a smoking apron while smoking and notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Resident #3's Safe Smoking Assessment completed 2/10/26 indicated the resident was a smoker and used a vape. On 2/23/26 at 5:53 PM, while walking by Resident #3's room, the door opened and another resident entered the room and quickly closed the door. An odor resembling marijuana was noted coming from inside the room. Surveyor knocked on Resident #3's door and was welcomed in, the odor was stronger in the room but there was no substance, vaping or smoking device visible in Resident #3's room. The administrator was notified of the observation on 2/23/26 at 5:55 PM. The administrator entered the room briefly, exited the room and agreed to noting an odor resembling marijuana. She stated a marijuana smell had previously been reported coming from Resident #3's room but this was the first time she had observed the odor herself. During an interview with the administrator and Regional Nurse Consultant (RNC) on 2/24/25 at 8:58 AM, the administrator stated they spoke with Resident #3 last evening and the resident admitted to having marijuana in his room and turned over a small baggie with a pinch size amount and a lighter but stated he did not smoke it in his room. Administrator stated Resident #3 was re-educated on the facility smoking policy. Resident #3's current medical provider orders did not include an order for marijuana products. The long-term care social worker (SW) was interviewed on 2/24/26 at 10:09 AM. SW denied having witnessed a resident using marijuana but stated it had been reported to her and each time she received a report she met with the resident and asked to search their room. SW stated Resident #3 was the main one that she had received reports concerning the smell of marijuana from their room. SW stated Resident #3 had never consented to a search. A review of Resident #3's clinical record failed to reveal any conversations regarding marijuana or facility requests to search the resident's room. During an interview with the SW on 2/24/26 at 1:41 PM, SW stated she failed to document the conversations. Throughout the course of the survey, during interviews with Licensed Practical Nurse (LPN) #1, LPN #4, Certified Nursing Assistant (CNA) #1, CNA #4, Housekeeper #1, Housekeeper #2, Unit Manager (UM) #2, each reported noting the smell of marijuana in or near the vicinity of Resident #3's room. On 2/24/26 at 2:13 PM, the administrator and Director of Nursing were notified of the concern regarding Resident #3 having an unsecured drug substance in their room with an odor resembling marijuana and failing to provide documentation of having addressed staff reports of marijuana use in the facility. No further information was provided prior to the exit conference on 2/24/26. 4. For Resident #4, the facility staff failed to ensure an electronic cigarette (vape) was securely stored. A facility policy titled, Resident Smoking, dated 2/21/24 specified, Smoking and/or vaping is not allowed inside the facility under any circumstances. The policy also specified, All smoking paraphernalia cigarettes, cigars, e cigs, vapes, etc. will not be left in the possession of any resident at any time. These items must be kept at the nurse's station or locked inside the med room or additional locked safe area designated by the facility.An admission Record indicated the facility admitted Resident #4 on 9/17/25. According to the admission Record, Resident #4 had a medical history that included, but not limited to Alzheimer's Disease, major depressive disorder, generalized arthritis, and generalized muscle weakness. A significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/09/26, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) summary score of 14 out of 15, which indicated the resident had intact cognition. Resident #4's comprehensive person-centered care plan did not address their smoking status. Resident #4's Safe Smoking Assessment completed 12/18/25 indicated the resident was a nonsmoker. Resident #4's clinical record included a physician's progress note dated 1/06/26 which revealed Patient reports THC (the main active ingredient of cannabis) vape use which is helping with pain management. During an interview in their room on 2/23/26 at 3:23 PM, Resident #4 stated she did not smoke cigarettes but did have a vape in her room but did not use it. Resident #4 stated she was able to charge the vape without staff assistance. No odor of cigarette smoke, marijuana, or vape use noted in Resident #4's room during the interview. On 2/23/26 at 5:35 PM, Certified Nursing Assistant (CNA) #2 stated they had noticed the smell of marijuana in the facility before. CNA #2 pointed down the hall to the general vicinity of Resident #4's room and stated it started down there just a week or two ago. CNA #2 stated residents are not supposed to have vapes in their room and when staff see them, they take them and then the resident will have another one. On 2/23/26 at 6:00 PM, the administrator was informed that Resident #4 reported having a vape in her room and charged it without staff assistance. On 2/24/26 at 8:58 AM, the administrator stated they met with Resident #4 last evening and she admitted to having a tobacco vape but declined to turn it in but did surrender a lighter. Administrator stated she had received the first report of a marijuana smell coming from Resident #4's room on 2/23/26. The facility Activities Director (AD) was interviewed on 2/24/26 at 9:53 AM. The AD stated vapes are to be used at smoking times only and are kept in the activities department and locked. AD stated vapes were charged in the activities office while staff were working. AD stated they had heard residents had vapes, but she had never witnessed it, and they preached about the smoking policy. During an interview on 2/24/26 at 11:11 AM, CNA #4 stated she had noticed the smell of marijuana in the hall near Resident #4's door but did not report it because she did not know exactly where it was coming from. During an interview on 2/24/26 at 11:26 AM, Housekeeper #2 stated she smells marijuana in the facility probably twice a week. She stated had never seen Resident #4 using it but had noticed the smell from that particular room. Housekeeper #2 stated she had never reported the smell of marijuana to administration because she did not know. On 2/24/26 at 12:33 PM, Resident #4's physician (MD) stated the resident reported using THC for pain control and he did not know she was using it in the facility. MD further stated he had no knowledge the resident was using THC in the facility. On 2/24/26 at 2:13 PM, the Administrator and Director of Nursing were informed of the concern regarding Resident #4 having a vape in her room. No further information was provided prior to the exit conference on 2/24/26.

Based on staff interviews, clinical record reviews, and facility document review, the facility staff failed to maintain complete and/or accurate clinical documentation for one (1) of 30 sampled residents, resident # 44. The findings included: The facility staff failed to document baths in the electronic medical record for resident # 44. Resident # 44's diagnoses included but were not limited to anxiety disorder, muscle weakness, need for assistance with personal care, unspecified dementia with psychotic disturbance and major depressive disorder. Resident # 44's minimum data set (MDS) assessment with an assessment reference date of 7/31/24 assigned the resident a brief interview for mental status (BIMS) score of 03 out of 15 indicating severe cognitive impairment. The electronic medical record for resident # 44 was reviewed. This surveyor was unable to locate documentation that resident # 44 had been bathed in the month of August. On 8/28/24 at 5:27 PM the survey team met with the Administrator, Assistant Administrator, Director of Nursing (DON) and Regional Director of Clinical Services. Surveyor asked for documentation of baths for resident # 44 for June, July and August. On 8/29/24 this surveyor was provided with worksheets that had pictures of the human body, one from the front, one from the back, one from the left side and one from the right side. The worksheet had the name of the facility at the top with a line to write in a resident name, and at the bottom a line for a signature and a line for the date. The worksheets had no mention of any type of bath on them. There were at least eight provided for each of the three months. The DON stated, Those are bath sheets. The DON also provided the Documentation Survey Report from the electronic medical record for the three months. The Documentation Survey Report had a section that read, Bathing/Showers on Tuesday and Friday. There were spaces for the staff to document on Mondays and Thursdays and each space was blank except for the occasional NA for not applicable. This surveyor asked the DON how they knew that resident # 44 was being bathed. They stated, Those are our bath sheets, they fill them out when they bathe the resident. Surveyor asked if they would expect the staff to document the baths in the electronic medical record and they stated, Well that would be double documentation. This surveyor did point out that no where on the work sheet does it say the resident was bathed, it only documents if they had a skin concern. The DON stated, Well those are scanned into the record, or should be. The worksheets were not found in the clinical record for # 44. The policy entitled, Charting and Documentation with a revised date of July 2017 read in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. No further information was provided to the survey team prior to the exit conference.

Based on observations, resident interviews, staff interviews, and facility document review, the facility staff failed to follow the infection prevention and control program guidelines to provide a sanitary environment for 2 of 30 sampled residents, Resident #38 and Resident #55. The findings were: 1. For Resident #38, facility staff failed to return urine collection containers (urinal and urine collection bag) to the resident's bedside after use. The containers were left in the bathroom which was shared between two semi-private resident rooms. Resident #38's minimum data set assessment with an assessment reference date of 08/12/24 noted the resident was rarely/never understood and therefore a brief interview for mental status was not conducted. Resident #38 had one roommate in a semi-private room which shared a bathroom with another semi-private room occupied by two (2) residents. The total of four (4) residents shared one bathroom which contained only a commode. In an interview with one of the four residents' family members on 08/27/24 at 2:39 p.m., the family member reported having observed dirty items left in the bathroom. Specifically, a urine bag was left hanging on the grab bar beside the commode and anyone using the commode had no choice but to hold onto that grab bar. On 08/27/24 at approximately 3:15 p.m., this surveyor observed the bathroom in Resident #38's room. The bathroom had a strong odor of urine and an empty urinal hanging on the grab bar beside the commode. The commode was empty and there were no items noted or matter visible on the floor. LPN#3 was interviewed and reported the urinal was used to empty Resident #38's urine collection bag. On 08/28/24 at 12:16 p.m., this surveyor observed Resident #38's bathroom. A slight urine odor was detected. A urine collection bag with urine remaining in the bag was hanging on the grab bar beside the commode. At 12:20 p.m., LPN #1 was asked to observe the bathroom. LPN #1 acknowledged the urine bag with urine in it should not be hanging on the grab bar. The nurse stated the urine bag should be emptied, wrapped in a bag, and left at Resident #38's personal area. When asked who uses that bathroom, LPN#1 stated the two residents in the room next door use that bathroom. At an end of day meeting with the administrator, assistant administrator, director of nursing (DON), nurse consultant, and regional director of clinical services on 08/28/24 at 5:40 p.m., this surveyor described the infection control observations in Resident #38's shared bathroom. The DON acknowledged the urine collection bag should not have been left hanging in the bathroom and stated her expectation was the urinal/urine collection bag be emptied and cleaned, placed in a bag and placed near the bedside table, in this case Resident #38's bedside table. The infection preventionist (IP) was interviewed on 08/29/24 at 11:48 a.m. The IP reported her expectation was for urine collection containers to be stored in a bag at the bedside of the resident to whom it belongs. . The policy provided by the administrator on 08/29/24 titled, Bedpan/Urinal, Offering/Removing did not address emptying urine collection bags or urinals used to empty a urine collection bag specifically. The policy read in part, After Assisting the Resident: . 8. Clean the bedpan or urinal. Wipe dry with a clean paper towel. Discard paper towel into designated container. Store the bedpan or urinal per facility policy. Do not leave it in the bathroom or on the floor. No other policy was provided. On 08/29/24 at 4:22 p.m. during a team meeting with the DON, nurse consultant, administrator, and assistant administrator, the infection control concern was discussed. No further information was provided prior to the exit conference. 42353 2. For Resident #55, the facility staff placed soiled linens on the resident's floor. Resident #55's diagnosis list indicated diagnoses, which included, but not limited to Dementia, Chronic Kidney Disease, Congestive Heart Failure, and Chronic Obstructive Pulmonary Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/24/24 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. During initial facility rounding on 8/27/24, a facility resident who requested to remain anonymous stated staff were throwing soiled briefs, pads, and linen on the floor prior to removing from the room. On 8/28/24 at 9:49 AM, Certified Nursing Assistant (CNA) #2 opened Resident #55's door and surveyor observed a pile of soiled linens on the floor beside the resident's bed. When the surveyor spoke with CNA #2 at approximately 2:55 PM regarding the observation, CNA #2 apologized and stated this was not their usual practice and their usual practice was to place soiled linens in a bag and not on the floor. On 8/29/24 at 12:05 PM, surveyor spoke with the facility Infection Preventionist who stated the CNA should have placed the soiled linens in a bag and not in the floor. Surveyor requested and received the undated facility policy titled Soiled Laundry and Bedding which read in part, .All used laundry is handled as potentially contaminated using standard precautions .Contaminated laundry is bagged or contained at the point of collection (i.e., location where it was used) . On 8/28/24 at 5:30 PM during a team meeting with the Administrator, Assistant Administrator, Director of Nursing, Regional Nurse Consultant, and Regional Director of Clinical Services, surveyor discussed the concern of staff placing soiled linen in the floor. No further information regarding this concern was presented to the survey team prior to the exit conference on 8/29/24.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents are free of significant medication errors for 3 of 30 sampled residents (Resident #5, Resident #93, and Resident #108). The findings included: 1. For Resident #5, the facility staff failed to administer Lantus, Humalog, and Bactrim DS as ordered by the provider. Resident #5's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Chronic Kidney Disease, Heart Failure, and Chronic Obstructive Pulmonary Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/18/24 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. Resident #5's current comprehensive person-centered care plan included a focus area stating the resident had a diagnosis of Type 2 Diabetes with an intervention to administer medications and insulin per orders. Resident #5's current provider orders included the following insulin orders: Lantus 30 units in the morning and 50 units at bedtime; Humalog 3 units before meals and at bedtime and additional Humalog per sliding scale before meals and at bedtime. A review of Resident #5's August 2024 Medication Administration Record (MAR) indicated Lantus 30 units was not administered at 6:00 AM as ordered on 8/05/24, 8/10/24, 8/13/24, and 8/20/24. Lantus 50 units was not administered on 8/06/24 at 8:00 PM. The MAR was coded with a 13 on 8/05/24, 8/13/24, and 8/20/24 indicating no insulin required, however the Humalog order did not include hold parameters and the clinical record did not include provider directions to hold the Lantus. Resident #5's 6:00 AM blood sugar readings were as follows: 8/05/24 92, 8/13/24 99, 8/20/24 82. The MAR was left blank for Lantus administration on 8/06/24 at 8:00 PM and 8/10/24 at 6:00 AM. Resident #5's MAR was also left blank for the administration of Humalog 3 units on 8/06/24 at 8:00 PM and 8/10/24 at 6:00 AM. The 6:00 AM doses of Humalog 3 units were also not administered as ordered on 8/05/24, 8/10/24, 8/13/24, and 8/20/24. An 8/14/24 1:30 PM progress note stated in part U/A [urinalysis], C&S [culture and sensitivity] report called to MD with the following order noted, Bactrim DS - one tablet by mouth twice daily x 7 days for UTI/ESBL [urinary tract infection/extended-spectrum beta-lactamase], contact precautions noted . According to the August 2024 MAR, the first scheduled dose of Bactrim DS on 8/14/24 at 5:00 PM was not administered. An 8/14/24 4:16 PM progress note read in part Bactrim DS .med not available. The MAR indicated the resident received 13 out of the 14 ordered doses of Bactrim DS. Surveyor requested and received the facility inventory list of medications available upon demand in the facility. This list indicated a supply of Bactrim DS 800/160 mg tablets was maintained on site and available for administration. On 8/28/24 at 5:27 PM, the survey team met with the Administrator, Assistant Administrator, Director of Nursing (DON), Regional Nurse Consultant, and Regional Director of Clinical Services and discussed the concern of Resident #5 not receiving Lantus, Humalog, and Bactrim DS as ordered by the provider. On 8/29/24 at 4:22 PM, surveyor spoke with the DON who stated they had no additional information regarding Resident #5's Lantus, Humalog, and Bactrim DS. No further information regarding this concern was presented to the survey team prior to the exit conference on 8/29/24. 2. For Resident #93, the facility staff failed to administer Lagevrio, an oral antiviral used to treat COVID-19, as ordered by the provider. Resident #93's diagnosis list indicated diagnoses, which included, but not limited to Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Type 2 Diabetes Mellitus, and Heart Failure. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/19/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. A review of Resident #93's clinical record revealed the resident tested positive for COVID-19 on 7/18/24. A provider order for Lagevrio 200 mg 4 capsules by mouth two times a day through 7/24/24 was entered on 7/20/24. Resident #93's July 2024 Medication Administration Record (MAR) indicated Lagevrio was not administered on 7/20/24 at 5:00 PM and 7/24/24 at 9:00 AM. A 7/20/24 4:57 PM progress note stated in part Lagevrio .hold medication ti [sic] received from pharmacy. A 7/24/24 2:50 PM progress note stated in part Lagevrio .awaiting arrival from pharmacy . On 8/28/24 at 3:58 PM, surveyor spoke with the pharmacy representative who stated a box containing 40 tablets of Lagevrio (a 5-day supply) was delivered to the facility and electronically signed for on 7/19/24 at 3:33 PM for Resident #93. On 8/28/24 at 5:27 PM, the survey team met with the Administrator, Assistant Administrator, Director of Nursing (DON), Regional Nurse Consultant, and Regional Director of Clinical Services and discussed the concern of Resident #93 not receiving Lagevrio as ordered on two occasions. Surveyor spoke with the DON on 8/29/24 at 4:22 PM and they stated they had no additional information regarding Resident #93's Lagevrio. No further information regarding this concern was presented to the survey team prior to the exit conference on 8/29/24. 34307 3. For Resident #108 the facility staff administered insulin outside the physician ordered parameters on six separate occasions. Resident #108's face sheet listed diagnoses which included but not limited to type 2 diabetes mellitus, generalized anxiety disorder, and dementia. Resident #108's most recent minimum data set with an assessment reference date of 07/29/24 assigned the resident a brief interview for mental status score of 6 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #108's comprehensive care plan was reviewed and contained a plan for Diabetes: The resident has Diabetes Mellitus. Interventions for this care plan included Diabetes medication as ordered by doctor . Resident #108's clinical record was reviewed and contained a physician's order summary which read in part, Novolin N FlexPen Subcutaneous Pen-injector 100 unit/ml (Insulin NPH (Human) (isophane)). Inject 8 unit subcutaneously one time a day for DM (diabetes mellitus) II FOR BLOOD GLUCOSE GREATER THEN (sic) 180. Resident #108's electronic medication administration record for the month of August 2024 was reviewed and contained an entry as above. This entry was initialed as administered on 08/18/24 with a blood sugar (BS) of 174, on 08/20/24-BS 164, 08/24/24-BS 110, 08/25/24-BS 115, 08/27/24-BS 122, and 08/28/24-BS 96. Surveyor spoke with the director of nursing on 08/28/24 at 3:30 pm regarding Resident #108's insulin order. Director of nursing stated that insulin should not have been administered on the days that blood sugar was lower than physician ordered parameters. Surveyor requested and was provided with a facility policy entitled Administering Medications which read in part, Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required timeframe. The concern of not ensuring Resident #108 was free from significant medication error was discussed with the administrator, assistant administrator, director of nursing, assistant director of nursing, regional nurse consultant, and regional director of clinical services on 08/28/24 at 5:30 pm No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure 1 of 30 sampled residents was free of unnecessary medication, Resident #54. The findings include: For Resident #54 the facility staff failed to ensure the resident was free of an unnecessary medication, Hydralazine. (Hydralazine is a medication used to treat hypertension (high blood pressure)) Resident #54's diagnosis list indicated diagnoses that included, but were not limited to, Muscle Weakness, Cognitive Communication Deficit, Dementia, Atrial Fibrillation, Congestive Heart Failure, Hypertension (HTN), Peripheral Vascular Disease, and Cerebral Infarction (stroke). The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/12/24, assigned the resident a brief interview for mental status (BIMS) summary score of 10 out of 15 for cognitive abilities, indicating Resident #54 was moderately impaired in cognition. An active medical provider order dated 5/22/24 read in part, .Hydralazine 25 MG (milligrams) tablet orally two times a day for HTN Hold if Systolic (the pressure in your arteries when your heart beats and pumps blood out into the body. It's the first number in a blood pressure reading) is <120 . (less than 120) A review of the June 2024 MAR (medication administration record) revealed Resident #54 received the medication, Hydralazine, on the following dates with Systolic BP (blood pressure) documented as follows: 6/15/24 with a documented Systolic BP of 91 6/16/24 with a documented Systolic BP of 79 A review of the July 2024 MAR revealed Resident #54 received the medication, Hydralazine, on the following dates with Systolic BP documented as follows: 7/13/24 with a documented Systolic BP of 118 7/14/24 with a documented Systolic BP of 108 7/17/24 with no Systolic BP recorded A review of the August 2024 MAR revealed Resident #54 received the medication, Hydralazine, on the following dates with Systolic BP documented as follows: 8/21/24 with a documented Systolic BP of 103 8/23/24 with a documented Systolic BP of 118 This concern was discussed at the end of day meeting with the administrator, director of nursing, assistant administrator, corporate nurse consultant, and regional director of clinical services on 8/28/24 at 5:27 PM and again at the pre-exit meeting on 8/29/24 at 4:22 PM. Surveyor requested and received a facility policy titled, Administering Medications, that read in part, .Medications are administered .as prescribed .4. Medications are administered in accordance with prescriber orders .6. Medication errors are documented, reported and reviewed .10. The individual administering the medication checks the label THREE (3) times to verify .the right dosage .of administration before giving the medication. 11. The following information is checked/verified for each resident prior to administering medications .b. Vital signs, if necessary . No further information regarding this concern was presented to the survey team prior to the exit conference on 8/29/24.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure a medication was available for administration for 1 of 30 sampled residents (Resident #10). The findings included: For Resident #10, the facility staff failed to ensure Zofran, a medication used to treat nausea and vomiting, was available for administration. Resident #10's diagnosis list indicated diagnoses, which included, but not limited to Nausea and Vomiting, Generalized Abdominal Pain, Gastro-Esophageal Reflux Disease (GERD), Alzheimer's Disease, Guillain-Barre Syndrome, Chronic Obstructive Pulmonary Disease, and Chronic Ischemic Heart Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/11/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #10's current comprehensive person-centered care plan included a focus area stating the resident had a history of GERD with an intervention to administer medications per orders. Resident #10's current provider orders included an order dated 10/28/23 for Zofran 4 mg by mouth every six hours as needed for nausea/vomiting. On 8/29/24 at 9:02 AM, during a medication administration observation, Resident #10 requested medication for an upset stomach. Licensed Practical Nurse (LPN) #6 was unable to locate the resident's Zofran in the medication cart. LPN #6 stated they would have to call the pharmacy to obtain the medication. On 8/29/24 at 1:06 PM, surveyor spoke with the pharmacy representative who stated 12 tablets of Zofran was delivered to the facility on [DATE] for Resident #10. According to the resident's July 2024 and August 2024 Medication Administration Records (MARs), since the delivery of the 12 tablets of Zofran on 7/23/24, only one dose had been administered which was on 8/11/24. On 8/29/24 at 4:22 PM, the survey team met with the Administrator, Assistant Administrator, Director of Nursing (DON), and the Regional Nurse and discussed the concern of the Zofran being unavailable when requested. The DON stated they believed the Zofran was removed from the medication cart during a MAR to cart check and the medication has now been received via a STAT delivery from the pharmacy. No further information regarding this concern was presented to the survey team prior to the exit conference on 8/29/24.

Based on staff interview, clinical record review and facility document review the facility staff failed to ensure an accurate minimum data set assessment for 2 of 3 closed record reviews, Resident #125 and Resident #127. The findings included: 1. For Resident #125 the facility staff incorrectly coded the resident's discharge status. Resident #125's face sheet listed diagnoses which included but not limited to obesity, encephalopathy, and anemia. Section A of Resident #125's discharge minimum data set (MDS) with an assessment reference date of 06/01/24 coded the resident as being discharged home. Resident #125's clinical record was reviewed and contained a nurse's progress note which read in part, 6/1/2024 17:50 Spoke with . (name omitted) at . (hospital name omitted) ED (emergency department) who stated rsd (resident) was being admitted and transferred to . (hospital name omitted) for CHF (congestive heart failure) per wife request to transfer. MD aware. RP (responsible party) aware. Surveyor spoke with MDS coordinator on 08/28/24 at 5:10 pm regarding Resident #125's MDS assessment. MDS coordinator stated that resident discharged to the hospital instead of home, and the MDS was incorrectly coded. MDS coordinator stated, It's just an error, and I will do a correction. The concern of the incorrectly coded MDS assessment was discussed with the administrator, assistant administrator, director of nursing, assistant director of nursing, regional nurse consultant, and regional director of clinical services on 08/28/24 at 5:30 pm. No further information was provided prior to exit. 2. For Resident #127 the facility staff incorrectly coded the resident's discharge status. Resident #127's face sheet listed diagnoses which included but not limited to hypothyroidism, dementia, and hypertension. Section A of Resident #127's discharge minimum data set (MDS) with an assessment reference date of 06/19/24 coded the resident as discharging to acute hospital. Resident #127's clinical record was reviewed and contained a nurse's progress note which read in part, 6/19/2024 22:05 discharged home. Surveyor spoke with MDS coordinator on 08/28/24 at 5:10 pm regarding Resident #125's MDS assessment. MDS coordinator stated that resident discharged to the hospital instead of home, and the MDS was incorrectly coded. MDS coordinator stated, It's just an error, and I will do a correction. The concern of the incorrectly coded MDS assessment was discussed with the administrator, assistant administrator, director of nursing, assistant director of nursing, regional nurse consultant, and regional director of clinical services on 08/28/24 at 5:30 pm. No further information was provided prior to exit.

Based on staff interview, record review and facility document review, the facility staff failed to notify the physician and/or responsible party of a significant change in the resident's physical, mental, or psychosocial status for one of 30 residents in the survey sample, resident #44. The findings included: The facility staff failed to notify resident # 44's responsible party of a significant weight loss. Resident # 44's diagnoses included but were not limited to gastroesophageal reflux disease (GERD), unspecified dementia with psychotic disturbance, major depressive disorder and anxiety disorder. The minimum data set (MDS) assessment with an assessment reference date (ARD) of 7/31/24 assigned the resident a brief interview for mental status (BIMS) score of 03 out of 15 indicating significant cognitive impairment. During a review of the clinical record surveyor noted a 11.50 % weight loss in 5 months. Resident # 44 weighed 127 pounds (lbs.) in March and on 8/22/24 their weight was recorded at 112.4 lbs. and on 8/29/24 was recorded at 111 lbs. The progress notes for resident # 44 were reviewed. There were notes from the Registered Dietician (RD) at least monthly since March, regarding ongoing weight loss. On 3/14/24 % weight loss in 90 days and 10.6% in 180 days the note went on to give a recommendation, add house supplement 90 ml (milliliters) TID (three times daily) for addition 540 calories and will follow weights. Consult RD as needed. An RD noted dated 4/4/24 read in part, CBW (current body weight) 122.8# weight loss 13.5% in 90 days and 14% in 180 days which has been addressed with the addition of house supplement 90 ml TID. She had a UTI (urinary tract infection) in February which affected her weight and has DX (diagnosis) of dementia and depression. Diet is regular with 50% po (by mouth) intake which has declined. Observed at lunch meal and she is easily distracted and seems to do better with handheld items . RDS (resident's) profile updated with sandwich at lunch/dinner and I spoke with the therapy director about restorative dining. Consult RD as needed. On 5/23/24 another RD note read, CBW 116# weight loss 6# in 3 weeks and continues to trigger for weight loss 7.2% in 30 days, 8.7% in 90 days, 18.3% in 180 days. Restorative dining initiated to help increase po intake. House supplement 90 ml TID in place for nutritional supplementation. Note went on to recommend adding a nutritional shake at lunch and dinner. The most recent RD note was dated 8/22/24 and discussed a meeting with speech therapy and a recommendation to downgrade the diet order to mechanical soft with chopped meats. This surveyor was unable to locate a note in the clinical record that indicated resident # 44's responsible party (RP) had ever been notified of their ongoing significant weight loss. On 8/28/24 at 5:27 PM the survey team met with the Administrator, Assistant Administrator, Director of Nursing (DON), Nurse Consultant, and Regional Director of Clinical Services. This concern was discussed. Surveyor asked for evidence the RP had been notified of the weight loss. On 8/29/24 at 4:24 PM the DON stated that they were unable to verify the RP for resident # 44 had ever been notified of the weight loss. This surveyor confirmed with the nurse consultant if they would expect the RP to be notified of a significant weight loss and they stated that they would. The policy entitled, Change in a Resident's Condition or Status with a revised date of February 2021 was reviewed and read in part, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). Under the heading, Policy Interpretation and Implementation the policy read in part, 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting); b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when; b. there is a significant change in the resident's physical, mental, or psychosocial status. No further information was provided to the survey team prior to the exit conference.

Based on observation and staff interview, the facility staff failed to prepare, distribute, and serve food in a manner that would prevent foodborne illnesses. The Bistro refrigerator and 2 of 3 pantry refrigerators (Center and Villa) contained out of date milk. The findings included: The Bistro refrigerator and the pantry refrigerators on the Center and Villa units were observed to contain out of date milk. [DATE], during the initial tour of the facility, the surveyor observed a tray of milk in the Bistro refrigerator with an expiration date of [DATE]. The Assistant Dietary Manager (ADM) removed the tray of milk from the refrigerator and stated they would dispose of the milk. [DATE] 3:39 p.m., the pantry refrigerator on the Center unit was observed by the surveyor to contain one carton of frozen milk with an expiration date of [DATE]. The Villa unit pantry refrigerator contained two cartons of milk with an expiration date of [DATE]. [DATE] 3:40 p.m., the Director of Nursing (DON) was shown the outdated milk from the pantry refrigerators. [DATE] 3:41 p.m., rechecked the Bistro refrigerator with the ADM. No out-of-date milk was observed, and the ADM stated if there was outdated milk in the pantry refrigerators the staff were not rotating the milk. [DATE] 4:33 p.m., the Nurse Consultant, DON, Administrator, and Assistant Administrator, were notified of the expired milk. No further information was provided to the survey team prior to the exit conference.

Based on observations, staff interviews, and documentation review, the facility staff failed to consistently perform hand hygiene during wound care for one (1) of 26 sampled current residents, Resident #11. The findings include: Licensed Practical Nurse (LPN) #3 failed to change gloves and perform hand hygiene after cleaning an open wound and prior to applying a new dressing/bandage to one of Resident #11's pressure wounds/areas. Resident #11's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/31/22, was dated as completed on 1/3/23. Resident #11 was assessed as able to make self understood and as able to understand others. Resident #11's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15 (this indicated intact and/or borderline cognition). Resident #11 was assessed as requiring assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #11 was assessed as having Stage 2 pressure ulcers present on admission to the facility. The facility's policy titled Handwashing/Hand Hygiene (with a revised date of August 2015) included the following situations which would indicate the need for hand hygiene/hand washing: - Before handling clean or soiled dressings, gauze pads, etc. and - Before moving from a contaminated body site to a clean body site during resident care. On the afternoon of 1/17/23 at approximately 3:00 p.m., a surveyor observed LPN #3 providing wound care to Resident #11's stage 2 pressure ulcer/wound. LPN #3 was observed to clean the open wound/ulcer with gauze and wound cleaner; LPN #3 preceded to apply a new bandage/dressing to the open wound/ulcer. LPN #3 did not change gloves or perform hand hygiene between cleaning the wound/ulcer and applying the new dressing bandage. During an interview on 1/19/23 at 9:36 a.m., LPN #3 reported they should have changed gloves and performed hand hygiene between cleaning Resident #11's open ulcer/wound and applying the new dressing/bandage. On 1/19/23 at 2:08 p.m., the survey team met with the facility's Administrator, Assistant Administrator, Regional Director of Clinical Services, and the Director of Nursing. The observation of LPN #3 failing to change gloves and perform hand hygiene after cleaning an open wound but prior to applying a new dressing/bandage was discussed. The Regional Director of Clinical Services acknowledged that a glove change and hand hygiene should have occurred between cleaning an open wound and applying a new bandage/dressing.

Based on staff interview, clinical record review, facility document review, and during the course of a facility reported incident investigation, facility staff failed to ensure the resident environment remains as free of accident hazards as is possible and failed to provide adequate supervision to prevent accidents for 1 of 11 residents in the survey sample, Resident #5. The findings included: For Resident #5, the facility staff failed to turn off the resident's portable oxygen cylinder prior to assisting the resident to smoke a cigarette resulting in a fire causing second degree burns to the resident's cheek, upper lip, and nose. Resident #5's diagnosis list indicated diagnoses, which included, but not limited to, Chronic Obstructive Pulmonary Disease, Heart Failure Unspecified, Anxiety Disorder Unspecified, Major Depressive Disorder Single Episode Unspecified, and Nonalcoholic Steatohepatitis. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 3/22/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, Cognitive Patterns. In section G, Functional Status, Resident #5 was coded as receiving extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, locomotion on unit and off of the unit, and supervision only for eating. A FRI (facility reported incident) dated 3/14/21 for the incident date of 3/13/21 states in part, At approximately 9:15 pm, resident, (name omitted), was in the facility courtyard on a scheduled smoke break. Resident reports (he/she) forgot to turn (his/her) oxygen off and it ignited. (Resident name omitted) reports (he/she) immediately removed (his/her) nasal canula [sp] and called for CNA (certified nursing assistant), (name omitted), to assist (him/her) in cutting the oxygen off. A body assessment of (name omitted) revealed a .5 x .5 x .1cm burn to (his/her) left cheek, a .3 x .3 x < 1cm burn to (his/her) upper lip and burns to (his/her) bilateral interior nostrils. (Name omitted) is self-responsible and MD has been notified. (Name omitted) initially refused to be sent to the ER stating (he/she) 'felt fine' but eventually did agree to be sent out for evaluation. All nursing staff on shift has been in-serviced regarding appropriate safety on smoke breaks to ensuring oxygen is not in use during smoke breaks. The facility will conduct a full investigation and report back within 5 days. The 3/19/21 final FRI submitted by the facility states in part, The facility has concluded its investigation. (Name omitted) returned from the ER a few hours after being sent out. (His/her) burns were classified by the hospital as 2nd degree and did not require any surgical intervention. (Name omitted) has been evaluated by and is under the care of the Certified Wound Care Nurse. The Wound Care Nurse reports that (name omitted) no longer complains of pain on palpation of (his/her) nose and (his/her) burns are almost completely healed. (Name omitted) reports that (he/she) feels 'ok, just a little sore'. The facility has in-serviced all Clinical, Activities, and Admin staff on the facility Resident Smoking Policy. The facility will continue to monitor closely. A nursing progress note dated 3/13/21 10:26 pm states, At approx. 2130 (9:30 pm) rsd (resident) came in from (his/her) smoke break and informed nurse (he/she) forgot to turn (his/her) O2 (oxygen) off while smoking and it 'blew up in my face', rsd stated 'I threw the cannula off as soon as I felt and saw fire', rsd assessed by this nurse and another nurse with rsd noted to have redness with slight blistering to left cheek, upper lip is noted to be reddened as well without blistering, bilateral nares with skin peeling and redness, rsd c/o burning and stinging in nostrils, nostrils appear to be charred with nose hair missing, rsd kept stating 'please don't send me to the hospital, please don't take away my smoking', VS - 152/88, 89, 19, 98.1, 91% with O2 on at 3 lpm (liters per minute) via NC (nasal cannula), MD notified, MD ordered to send rsd to ED for further eval, rsd initially refused to be sent to ED and then agreed after speaking with (spouse) and other staff, 911 phoned at approx. 2215 (10:15 pm) with arrival at 2230 (10:30 pm), report phoned to (hospital name omitted), transfer summary sent with rsd, RP (responsible party) (name omitted) notified and aware. A 3/13/21 10:52 pm nurse's note states, 911 arrived at the facility at 2230 (10:30 pm) with an officer. The officer talked with staff regarding the incident. Nasal canal [sp] placed in clear bag and EMS took the canal [sp] with them when they transported the resident to ER for evaluation. An addendum to the previous note dated 3/13/21 11:13 pm states, Thia [sp] nurse and another nurse applied cold compresses to smoked areas-chin; Lt (left) cheek; upper lip and underneath nasal passage. A nurse's note dated 3/14/21 at 3:08 am states in part, Resident arrived back to the facility via ambulance at 0100 (1:00 am). Received report from the nurse at (name omitted) and paperwork. Per discharge summary (he/she) was noted to have Second-Degree Burns (Partial-Thickness Burns) to the face. New orders: Apply antibiotic ointment to cheeks, upper lip and nose 3x a day. Continue oxygen at 3 lpm via nasal cannula orally. Follow up with (name omitted) within 4-6 Days. Nurse from (name omitted) states that resident received Percocet at 2445. A 3/14/21 12:23 pm nurse's note states, This WCC (wound care certified) nurse in to assess resident. Resident has superficial partial thickness burns to (his/her) nares, lateral to the philtrum, and (his/her) left cheek. Unable to measure surface area of nares. Lateral to the philtrum measures approximately 0.3 x 0.3 x < 0.1 cm. Left cheek measures approximately 0.5 x 0.5 x < 0.1 cm. Erythema is present. Tenderness reported on palpation. No weeping or blistering noted upon inspection. Orders verified with MD. Silvasorb gel TID (three times a day) initiated as it is hydrogel based, provides antibacterial protection, and does not contain petroleum. Resident is resting comfortably with O2 in place as ordered. Tubing protectors in place for protection. New orders received to assess pain and assess tissue to nares, upper lip and left cheek QS (every shift). MD and RP aware of new orders. On 3/31/21 at 3:39 pm, surveyor spoke with Resident #5 regarding the incident on 3/13/21. Resident #5 stated that another resident had cigarettes hidden under their shirt and (CNA #5) was trying to get them, Resident #5 stated (he/she) was also trying to talk to the other resident to calm them down. Resident stated they were in the courtyard and the CNA got the other resident straightened out and then passed everything out. Resident stated (CNA #5) was going to turn off the oxygen but got distracted by the other resident and (he/she) did not remember to turn it off either. Resident #5 stated they had smoked one cigarette and part of another and then went to take another puff and poof, resident stated (he/she) then grabbed the nasal cannula and threw it to the ground and (CNA #5) was trying to stomp out the fire. Surveyor asked the resident who normally turned off their oxygen prior to smoking and resident stated one of the CNAs or nurses. When asked about pain from the burn, Resident #5 stated it was never that bad and they are still putting cream in (his/her) nostrils and it does itch. When surveyor asked Resident #5 if they feel safe smoking, they stated yes. Resident #5 stated staff take off the oxygen tank from the wheelchair and place it in a holder before going out to smoke. Surveyor observed an empty rolling oxygen holder present in the resident's room. On 4/01/21 at 10:15 am, surveyor spoke with LPN (licensed practical nurse) #4 who stated they saw Resident #5 following the incident and their face was black and another nurse put a cool compress on the resident's face and tried to get some of the black off of their face. LPN #4 stated that in the beginning, the resident was refusing to go to the ER but the doctor wanted them to go. LPN #4 stated an officer arrived when EMS arrived and spoke to them and the other nurse present and asked what had happened. LPN #4 stated that when they called the administrator, they instructed them to in-service staff present to take oxygen tanks completely off of the wheelchairs and leave them in the residents' rooms before going out to smoke. LPN #4 stated there are no other smokers that use oxygen except for one that only uses it in their room. Surveyor asked who normally turns off the resident's oxygen prior to smoking and LPN #4 stated normally whoever takes them out turns it off. On 4/01/21 at 10:22 am, surveyor spoke with CNA #5 who was present with Resident #5 during the fire and asked them to describe the incident. CNA #5 stated the resident forgot to turn the tank off and I didn't check it either and when it caught on fire they put it out with their feet. CNA #5 stated that now the oxygen tank is turned off and left in the room during smoke breaks. The facility provided a copy of the ED report dated 3/13/21 which states in part, second-degree burn (partial-thickness burn) with instructions to apply antibiotic ointment to cheeks, upper lip, and nose 3 times a day and discontinue when healed, continue oxygen at 3-4 liters/minute orally with the nasal cannula, and follow up with (name omitted), an ENT (ear nose and throat physician) in 4-6 days. Resident #5 was seen by the ENT on 3/19/21 with new orders for Silvadene creme intranasal, apply with q-tip 2 times daily for 14 days with a return visit in 3-4 weeks. On 4/01/21 at 12:20 pm, surveyor contacted the (Name omitted) Police Department and requested the police report for the incident on 3/13/21. Department stated there is record of the officer's visit but there is no report. Resident #5's clinical record included a Safe Smoking assessment dated [DATE] in which the resident scored a 7 indicating the resident required supervision while smoking and recommended protective devices to promote safe smoking including a smoking apron or protector for clothing and a cigarette holder. Surveyor requested and received a copy of the facility policy entitled, Smoking Policy - Residents which states in part: 3. Oxygen use is prohibited in smoking areas. 8. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. On 3/31/21 at approximately 4:00 pm, surveyor spoke with the administrator concerning Resident #5's FRI and was provided with a copy of a completed Past Noncompliance Plan of Correction with an Allegation of Compliance Date of 3/15/21 which states: Corrective Action: The staff member monitoring the smoking activity has received one on one education regarding monitoring residents during smoking activities and their use of oxygen The resident's attending physician has been notified of the incident The resident has been reassessed using the Safe Smoking Assessment tool and (his/her) comprehensive plan of care has been updated to meet (his/her) current needs Physician's orders for care of the injury have been implemented Signature and Date Completed: 3/15/21, signed by the administrator and director of nursing Identification of Deficient Practice(s) and Corrective Action(s): All other residents who smoke may have potentially been affected All residents who smoke have been reassessed using the Safe Smoking Assessment tool and their comprehensive plans of care have been updated accordingly to ensure that each resident's current safety needs during smoking sessions are met An Incident and Accident form will be completed for each negative finding Signature and Date Completed: 3/15/21, signed by the director of nursing Systemic Change(s): The facility's smoking policy and procedure has been reviewed no changes are warranted at this time All facility administrative, nursing, and activities staff have been inserviced on Safe Smoking Assessments, the facility smoking policy, procedures for conducting resident smoking activities, and resident use of oxygen during smoking (staff will not be allowed to work after 3/15/21 until they have completed the related inservices) All nurses and the MDS department will be inserviced on the requirement that the resident smoking assessment be completed upon admission and at least quarterly thereafter Signature and Date Completed: 3/15/21, signed by the director of nursing Monitoring: The Administrator is responsible for maintaining compliance. The Administrator +/designee will observe resident smoking period activities twice weekly to monitor for compliance; and confirm that resident smoking assessments are completed timely upon admission and with the MDS calendar. Any negative findings will be addressed at the time of discovery and appropriate disciplinary action taken. Detailed findings of these results will be reported to the Quality Assurance Committee for review, analysis, and recommendations for changes in facility policy, procedure, and/or practice. Signature and Date Completed: 3/15/21, signed by the administrator Completion Date: 3/15/21 Signature and Date Completed: 3/15/21, signed by the administrator and director of nursing. Copies of the inservice sign in sheets were reviewed and multiple staff members were interviewed about the education provided by this surveyor. No further issues were noted. On 4/01/21 at approximately 3:40 pm, surveyor notified the administrative team consisting of the administrator, assistant administrator, administrator in training, director of nursing, and the regional director of clinical services of the concern of Resident #5 receiving burns while smoking with oxygen in use. No further information regarding this issue was presented to the surveyor prior to the exit conference on 4/01/21. This is a past non-compliance deficiency.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to assess the resident for risk of entrapment from bed rails and failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to use of the bedrails for 54 out of 139 beds, including Resident #135. The scope and severity was originally cited at Immediate Jeopardy, Level IV Widespread and was reduced to a Level II Widespread after the facility was cleared of Immediate Jeopardy. The administrator, assistant administrator, director of nursing, assistant director of nursing, and the regional nurse consultant were notified on 2/07/20 that the extended survey process had begun at 11:50 am, as the survey team had identified Immediate Jeopardy and Substandard Quality of Care in the area of Quality of Care. Upon Office of Licensure and Certification supervisory review of the interviews and documentation, the Scope and Severity was adjusted to Immediate Jeopardy, Level IV, Pattern and was reduced to a Level II Pattern. The findings included: The facility staff failed to assess residents utilizing bed rails for the risk of entrapment and review the risk and benefits of bed rail use with residents and/or resident representatives prior to implementing bed rails, thus creating the potential for a serious adverse outcome. On 2/06/20 while reviewing Resident #135's clinical record, the surveyor observed a progress note dated 11/28/19 9:24 pm stating if resident's right arm is bruised, they got it stuck in rail climbing out of bed. The subsequent progress note dated 11/29/19 1:35 am states in part, redness remains to right arm. A progress note dated 12/04/19 6:14 pm stated in part, resident's right arm is still red and resident acts as if moving it is tender to touch. Upon further investigation, surveyor located a physician's orders [REDACTED].½ rails at HOB (head of bed) to aid in turning/positioning. Surveyor was unable to locate a side rail assessment or documentation of consent for bed rail use in Resident #135's clinical record. Surveyor requested the facility investigation into incident on 11/28/19; the administrator stated they did not have an investigation. The surveyor then requested the most recent side rail assessment by nursing and bed safety assessment completed by maintenance. On 2/06/20 at 10:39 am, surveyor spoke with the ADON (assistant director of nursing) who stated maintenance does a side rail safety assessment when rails are added to a bed and when residents are moved to a new bed. ADON also stated most residents have ½ side rails when admitted . On 2/06/20 at 10:40 am, surveyor spoke with the regional nurse consultant who stated that the facility does not use a formal side rail assessment, but restraint assessments are done if the side rails are used as a restraint. On 2/06/20 at 11:12 am, the administrator provided copies of a form entitled, Bed Entrapment Inspection for Resident #135 completed on 6/20/19 and 2/06/20 indicating the resident's bed passed inspection. The surveyor requested and received the policy Bed Safety which stated in part: 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. 8. Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternative can be identified. 9. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails. For Resident #135, the facility staff failed to assess for the safe use of side rails and risk of entrapment. Following an incident when the resident's arm became trapped in the side rail, the resident's arm was described as still red and acted as if moving it was tender to touch seven days later. On 2/07/20 at 12:56 pm, the survey team notified the administrator, assistant administrator, director of nursing, assistant director of nursing, and the regional nurse consultant of the findings as stated above and that a Level IV Immediate Jeopardy deficiency had been cited as of 2/07/20 at 11:50 am. On 2/07/20 at approximately 1:30 pm, the administrator stated the facility did not have resident specific assessments for side rails or notification of risks and benefits for side rails. During the course of the survey, bedrails were observed on 139 beds. Out of the 139 beds, the facility was observed to be employing the use of either ½ or full side rails on 54 beds. On 2/07/20 at 3:13 pm, the facility presented the survey team with the facility's abatement plan. The immediate jeopardy abatement plan was signed by the administrator and documented as follows: Resident (#135) has been assessed for safe use of side rails Resident's RP (#135) has been notified of the risk and benefits of using side rails Consent for side rail use has been obtained (Resident #135) 100% assessment of all residents who use side rails by 0800 hrs on 2/10/20 100% notification of all resident and/or responsible parties of potential risks and benefits of using side rails by 0800 on 2/10/20 Consent obtained from resident and/or responsible party of all residents verbally either in person or by phone utilizing two person verification in the nursing note, who use side rails by 0800 hrs on 2/10/20 Staff will be educated prior to their next shift at work on the assessment of all residents for safe use of side rails; the potential risks and benefits of side rail use and the need to obtain consent prior to the use of side rails All new admissions will be assessed upon arrival and consent if needed will be obtained. Upon further investigation on 2/10/20, surveyor observed a progress note dated 11/13/18 9:29 pm stating in part, at 6:20 pm, resident is noted to be sitting on the side of the bed with lower abdomen and upper right thigh wedged between the rail and the mattress. Resident was assisted by several staff members and removed from rails/bed. Resident is noted to have some redness along lower abdomen and upper thigh. On 2/10/20 at approximately 10:00 am, the facility provided the survey team with a tabbed binder containing bed rail assessments and signed informed consent forms, identifying the potential risks and benefits of bed rail usage, for all residents of the facility as credible evidence. The survey team verified that all residents were assessed and all consents were obtained from the resident and/or resident representative on 2/10/20 at approximately 11:30 am. The administrator provided the survey team with staff inservice sign-in sheets for education regarding the assessment, risks and benefits and need to obtain consent for the use of side rails, beginning with all staff working on the evening shift on 2/07/20 and continuing through all shifts until 2/10/20 day shift. The survey team verified that all staff have been trained on 2/10/20 at approximately 5:00 pm. The risks and benefits of side rail usage has been added to the facility admission packet that is given to residents and/or families prior to or upon admission to the facility. Side rail assessments and consent forms have been added to the admission process. The survey team verified that these items had been added to the admission process on 2/10/20 at approximately 4:30 pm. The facility QAPI (Quality Assurance and Performance Improvement) team will review side rail usage, assessments, and consents at each quarterly QA (Quality Assurance) meeting and update as needed. On 2/10/20 at 5:16 pm, the administrator and director of nursing were made aware that the Level IV Widespread Immediate Jeopardy citation had been reduced to a Level II Widespread deficiency. No further information regarding this issue was presented to the survey team prior to the exit conference on 2/10/20.

Based on staff interview, clinical record review and facility document review the facility staff failed to ensure an accident free environment for 1 of 31 residents, Resident #135. For Resident #135, the facility staff failed to assess for the safe use of bedrails and risk of entrapment prior to implementing side rails. Following an incident when the resident's arm became trapped in the bed rail, the resident's arm was described as still red and acted as if moving it was tender to touch seven days later. This is harm. The findings included: Resident #135's [DIAGNOSES REDACTED]. The most recent annual MDS with an ARD (assessment reference date) of 1/14/20 coded the resident as being severely impaired in cognitive skills for daily decision making with short term and long term memory loss in section C, Cognitive Patterns. Resident #135 is also coded as requiring the extensive assistance of two or more staff members for bed mobility and being totally dependent on two or more staff members for transfers in section G, Functional Status. A review of Resident #135's medical record revealed a progress note dated 11/28/19 9:24 pm stating if resident's right arm is bruised, they got it stuck in rail climbing out of bed. The subsequent progress note dated 11/29/19 1:35 am states in part, redness remains to right arm. A progress note dated 12/04/19 6:14 pm states in part, resident's right arm is still red and acts as if moving it is tender to touch. The medical record included an active physician's orders [REDACTED].½ rails at HOB (head of bed) to aid in turning/positioning. Surveyor was unable to locate a side rail assessment in Resident #135's medical record. Surveyor then requested the most recent side rail assessment by nursing and the bed safety assessment performed by maintenance. On 2/06/20 at 10:40 am, surveyor spoke with the regional nurse consultant who stated that the facility does not use a formal side rail assessment, but restraint assessments are done if the side rails are used as a restraint. On 2/06/20 at 11:12 am, the administrator provided copies of a form entitled, Bed Entrapment Inspection for Resident #135 completed on 6/20/19 and 2/06/20 indicating the resident's bed passed inspection. Surveyor requested the investigation into the incident on 11/28/19; the administrator stated the facility did not have an investigation. Surveyor was unable to locate documentation as to how the resident's right arm became trapped in the side rail or any changes to the resident's plan of care following the incident. The surveyor requested and received the policy Bed Safety which stated in part: 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. 8. Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternative can be identified. On 2/07/20 at 12:56 pm, the administrative team (administrator, assistant administrator, director of nursing, assistant director of nursing, and the regional nurse consultant) were made aware of Resident #135 not being assessed for the safe use of side rails and risk of entrapment prior to implementing side rails or following an incident in which the resident's right arm became trapped in the side rail. On 2/07/20 3:13 pm, the administrator presented documentation stating Resident #135 has now been assessed for the safe use of side rails and risk of entrapment. Upon further investigation on 2/10/20, surveyor observed a progress note dated 11/13/18 9:29 pm stating in part, at 6:20 pm, resident is noted to be sitting on the side of the bed with lower abdomen and upper right thigh wedged between the rail and the mattress. Resident was assisted by several staff members and removed from rails/bed. Resident is noted to have some redness along lower abdomen and upper thigh. On 2/10/20 at 1:15 pm, surveyor spoke with the administrator and asked for the investigation into the incident on 11/13/18. The administrator stated the facility has internal documents that they usually do not share. No further information regarding this issue was presented to the survey team prior to the exit conference on 2/10/20.

Based on staff interview, clinical record review, facility document review and in the course of a complaint investigation the facility staff failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each residents for 5 of 31 residents, #236, #34, #120, #101 and #66, and 2 out of 3 medication rooms in the facility. 1. While checking medication storage rooms for medication storage practices on [DATE], the surveyor discovered expired intravenous fluids in the medication storage room for the skilled therapy unit with room numbers in the 100s. One 1 liter [MEDICATION NAME] 5% expired [DATE] and two 1 liter [MEDICATION NAME] 5% expired [DATE]. On [DATE] at 10:12 AM, the surveyor talked with the unit manager about the expired IV fluids. The unit manager said they did not have anyone on IVs right now. The last person went home last week. When asked how often they clean the storage cabinets and remove expired items, the unit manager said they try to do it once a month. Asked about the disposal of medications at discharge, the unit manager said the resident's fluids should have been sent back to the pharmacy when the resident discharged . The unit manager took the expired items from the cabinet. While checking medication storage rooms for medication storage practices on [DATE], the surveyor discovered 8 cans of Glucerna 1.5 cal expired [DATE] in the medication storage room for the central hall. On [DATE] at 10:31 AM, the surveyor discussed the concern with the unit manager. The unit manager said none of the residents used Glucerna 1.5 bolus feed. The director of nursing was notified of the concerns during a meeting on [DATE]. 2. For Resident #34, facility staff and pharmacy services failed to ensure that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Resident #34 was admitted to the facility with [DIAGNOSES REDACTED]. On the most recent minimum data set assessment, the resident scored ,[DATE] on the Brief Interview for Mental Status and was assessed as without signs of [MEDICAL CONDITIONS], or behaviors affecting care. The resident was assessed as receiving scheduled pain medication ,[DATE] days in the look back period and as needed pain medication in the look back period and as being without pain. The surveyor was unable to interview the resident. A complaint filed with the office of licensure and certification indicated that Resident #34 was one of the residents whose pain medication had been diverted by a nurse. Clinical record review on [DATE] revealed staff documented administering the pain medication [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME] 7.5mg-325 mg every 6 hours for pain) more often than signed out of the ledger from [DATE] through February 2020. The medication was not available in the medication stat box.: [DATE] staff documented on the medication administration record four scheduled doses and an as needed dose at 7:25 AM; the narcotic sign out sheet documented the as needed dose was obtained at 9 AM [DATE] four doses documented as administered, but no 6 AM dose was signed out of the narcotic ledger [DATE] 6 AM dose signed out twice, one administration documented [DATE] 6 PM dose of [MEDICATION NAME] documented as administered but no 6 PM dose was signed out of the narcotic ledger [DATE] 12 AM dose of [MEDICATION NAME] documented as administered but no 12 AM dose was signed out of the narcotic ledger; the administration record indicated a dose or [MEDICATION NAME] was administered at 11:02 AM but the Individual Narcotic Record documented the dose was signed out of the narcotic ledger at 9 AM All doses of [MEDICATION NAME], whether documented as administered or not administered, were documented as effective in follow-up medication administration detail notes. No account sheet for narcotics from ,[DATE] through [DATE] was available. Sixteen doses were documented on the medication administration record (MAR) during that period. A. On [DATE], the resident's Individual Narcotic Record for [MEDICATION NAME]-[MEDICATION NAME] 7XXX,[DATE] received [DATE] was marked expired ,[DATE] has new card with 5 of 30 pills listed remaining. Under Disposition of Unused Drug, a RN had signed Date Discontinued [DATE], Amount Remaining 0. Method of Disposition was left blank. Neither nurse signature/title nor witness signature/title were signed. B. At approximately [DATE], the resident's Individual Narcotic Record for [MEDICATION NAME]-[MEDICATION NAME] 7XXX,[DATE] received [DATE] was marked wasted expired ,[DATE] with 20 of 30 pills listed remaining. Under Disposition of Unused Drug, a RN had signed Date Discontinued ,[DATE], Amount Remaining 0. Method of Disposition was left blank. Neither nurse signature/title nor witness signature/title were signed. C. On [DATE], the resident's Individual Narcotic Record for [MEDICATION NAME]-[MEDICATION NAME] 7XXX,[DATE] received [DATE] was marked expired [DATE] with 6 of 30 pills listed remaining. Under Disposition of Unused Drug, a RN had signed Date Discontinued [DATE], Amount Remaining 0. Method of Disposition was left blank. Neither nurse signature/title nor witness signature/title were signed. D. On [DATE], the resident's Individual Narcotic Record for [MEDICATION NAME]-[MEDICATION NAME] 7XXX,[DATE] received [DATE] was marked wasted expired ,[DATE] with 7 of 30 pills listed remaining. Under Disposition of Unused Drug, a RN had signed Date Discontinued [DATE], Amount Remaining 0. Method of Disposition was other: pill buster. Neither nurse signature/title nor witness signature/title were signed. The record contained no explanation for destroying the medication prior to the end of the expiration month. The surveyor brought the multiple concerns to the attention of the director of nursing (DON) on [DATE]. The DON said the documentation that the medication was effective was the result of an automatic prompt with limited choices for documentation. The pharmacy stated there was no way to know what the expiration dates of the medications were. There was no record. The DON had no explanation for the failure to properly document and witness the disposal of medications, other than a nurse had been terminated for failure to follow policy concerning wasting controlled medications. The nurse named had not signed any #34's questioned Individual Narcotic records. 3. For Resident #120, facility staff and pharmacy services failed to ensure that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Resident #120 was admitted to the facility with [DIAGNOSES REDACTED]. On the most recent minimum data set assessment, the resident scored ,[DATE] on the Brief Interview for Mental Status and was assessed as without signs of [MEDICAL CONDITIONS], or behaviors affecting care. The resident was assessed as receiving scheduled pain medication ,[DATE] days in the look back period and as needed pain medication ,[DATE] days in the look back period and as being without pain. The surveyor was unable to interview the resident. Clinical record review on [DATE] revealed staff documented administering the pain medication [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME] 5mg-325 mg every 6 hours for pain) more often than signed out of the ledger on 8 days from [DATE] through [DATE]. The medication was not available in the medication stat box.: [DATE] three doses documented as administered, but only the 12 PM dose was signed out of the narcotic ledger [DATE] four doses documented as administered, but only the 6 PM dose was signed out of the narcotic ledger [DATE] three doses documented as administered, but only the 12 AM dose was signed out of the narcotic ledger [DATE] four doses documented as administered, but no medication was signed out of the narcotic ledger [DATE] four doses documented as administered, but only the 6 PM dose was signed out of the narcotic ledger [DATE] four doses documented as administered, but no 6 PM dose was signed out of the narcotic ledger [DATE] the 12 AM dose was documented as administered and effective, but no medication was signed out of the individual narcotic record. [DATE] the 12 AM dose was documented as administered and effective, but no medication was signed out of the individual narcotic record. All doses of [MEDICATION NAME], whether documented as administered or not administered, were documented as effective in follow-up medication administration detail notes. There was no Individual Narcotic Record sheet for [DATE]-[DATE]. The surveyor asked two times for that sheet on [DATE]. The other documents were provided to surveyor on [DATE]. A. After the [DATE] 6 AM dose, the resident's Individual Narcotic Record for [MEDICATION NAME]-[MEDICATION NAME] ,[DATE] received [DATE] was marked wasted expired ,[DATE] with 12 of 30 pills listed remaining. Under Disposition of Unused Drug, a RN had signed Date Discontinued ,[DATE], Amount Remaining 0 signature date [DATE]. Method of Disposition was left blank. Neither nurse signature/title nor witness signature/title were signed. B. After the [DATE] 02:55 dose, the resident's Individual Narcotic Record for [MEDICATION NAME] PRN received [DATE] was crossed out with 14.75milliliters of 16.25 milliliters listed remaining. No explanation was documented and the whole section under Disposition of Unused Drug was blank. The administrator and director of nursing were notified of the concern that nurses documented administering pain medications that were not given to the resident and there was no account of disposition of unused medications. 4. For Resident #236, facility staff and pharmacy services failed to ensure that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. [DATE] 09:22 AM On [DATE], staff marked the resident's [MEDICATION NAME] as expired and destroyed. On ,[DATE] through [DATE], the MAR documented not given- meds not available for 3 consecutive doses. Resident #236 was admitted to the facility with [DIAGNOSES REDACTED]. On the most recent minimum data set assessment, the resident scored ,[DATE] on the brief interview for mental status and was assessed as without signs of [MEDICAL CONDITIONS], or behaviors affecting care. The resident was noted to receive scheduled pain medication and to be assessed by staff as not exhibiting signs of pain. Clinical record review on [DATE] revealed staff documented administering the pain medication [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME] 5mg-325 mg every 6 hours for pain) more often than signed out of the ledger in [DATE] and that the medication was unavailable in [DATE]. The medication was not available in the medication stat box.: [DATE] three doses documented as administered, but 10 PM dose was not signed out of the narcotic ledger. A dose was signed out with a remainder of 4 pills on ,[DATE] at 21:00, then marked through as an error. The ,[DATE] 21:00 dose was signed out on the first entry on a new ledger sheet. [DATE] two doses documented as administered, but only the 2 PM dose was signed out of the narcotic ledger [DATE] the remainder of the resident's [MEDICATION NAME] medication wasted by staff claiming it was expired. The medication was unavailable until delivered to the facility. The Individual narcotic ledger documented the medication was delivered on [DATE]. The first dose was signed out on ,[DATE] at 13:00. The medication administration record documented the medication was unavailable on ,[DATE] at 6 AM and 10 PM and on ,[DATE] at 6 AM. The medication administration documented administration of the medication on ,[DATE] at 14:00. ( The medication was not available in the stat box.) A. On [DATE], the resident's Individual Narcotic Record for [MEDICATION NAME]-[MEDICATION NAME] ,[DATE] received [DATE] was marked expired 4 with 4 of 30 pills listed remaining. Under Disposition of Unused Drug, a RN had signed Date Discontinued [DATE], Amount Remaining 0. Method of Disposition was pill buster. Neither nurse signature/title nor witness signature/title were signed. B. On [DATE], the resident's Individual Narcotic Record for [MEDICATION NAME]-[MEDICATION NAME] ,[DATE] received [DATE] was marked wasted order changed with 21 of 30 pills listed remaining. Under Disposition of Unused Drug, a RN had signed Date Discontinued [DATE], Amount Remaining 0. Method of Disposition was left blank. Neither nurse signature/title nor witness signature/title were signed. C. On [DATE], the resident's Individual Narcotic Record for [MEDICATION NAME]-[MEDICATION NAME] ,[DATE] received [DATE] was marked expired ,[DATE] wasted with 18 of 30 pills listed remaining. Under Disposition of Unused Drug, Date Discontinued [DATE], Amount Remaining 0, no Method of Disposition. Neither nurse signature/title nor witness signature/title were signed. The director of nursing stated that B above occurred because the physician had changed the order from as needed to scheduled three times per day so the instructions did not match. The surveyor was unable to locate administration instructions on the Individual Narcotic Record. There was only a sticker with name, drug identification, date, and quantity sent. The surveyor had noted Resident #34 (above) had both scheduled and as needed orders and staff pulled the doses from the same Individual Narcotic Record sheet. During a meeting on [DATE], the administrator and director of nursing were notified of the concerns with availability, documentation of medications administered while not in the building , inability to account for method of disposal with signatures and counter signatures, and large number of medications documented as expired within a month of delivery from the pharmacy. 4. For Resident #101 the facility staff failed to ensure the pain medication, [MEDICATION NAME] was available for administration. Resident #101's face sheet listed diagnoses, which included but not limited to dysphagia, gastro-[MEDICAL CONDITION] reflux disease, anxiety, [MEDICAL CONDITION], and cognitive communication deficit. Resident #101's most recent annual MDS (minimum data set) with an ARD (assessment reference date) of [DATE] assigned the resident a BIMS (brief interview for mental status) score of 14 out of 15 in section C, cognitive patterns. Section J, health conditions, coded the resident as receiving scheduled pain medication. Resident #101's comprehensive care plan was reviewed and contained a care plan for Rsd (resident) states -- has frequent c/o (complaint of) pain to -- legs. -- receives scheduled pain medications per orders. Approaches for this care plan include Provide medications per orders. Resident #101's clinical record was reviewed on [DATE]. It contained a signed physician's orders [REDACTED]. Resident #101's eMAR's (electronic medication administration record) for the months of June and [DATE] were reviewed and contained entries, which read in part [MEDICATION NAME] 7XXX,[DATE] mg tablet one tablet by mouth four time a day. The eMAR for June was coded with N on [DATE] at 1:00 pm. The administration notes section of the eMAR contained a note dated [DATE], which read in part 2:48PM, [DATE] (Scheduled: 1:00PM, [DATE]; [MEDICATION NAME] 7XXX,[DATE] TABLET) [MEDICATION NAME] 7XXX,[DATE] TABLET one tablet by mout . scheduled for [DATE] 1:00PM.not available not given RX bringing the PM. Surveyor requested and the nurse consultant provided a facility policy entitled Medication Shortages/Unavailable Medications on [DATE] at approximately 10:00 am. This policy read in part, 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 the action specified in Sections 2 or 3 of this Policy 7.0, as applicable. 2. If a medication shortage is discovered during normal pharmacy hours: 2.1 Facility nurse should call pharmacy to determine the status of the order. 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 a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. 2.3 If the medication is not available in the Emergency Medication Supply, the facility staff should notify the pharmacy and arrange for an emergency delivery. 3. If a medication shortage is discovered after normal pharmacy hours: 3.1 A licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply. 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 3.3.3 Use of an emergency (back-up) third party pharmacy. The concern of not the facility not having the resident's medications available for administration was discussed with the administrative staff (administrator, administrator-in-training, director of nursing, regional nurse consultant) during a meeting on [DATE] at approximately 4:20 pm. No further information was provided prior to exit. 5. For Resident #66 the facility staff failed to ensure the medications [MEDICATION NAME] and Diphedryl [MEDICATION NAME] were available for administration. Resident #66's face sheet listed [DIAGNOSES REDACTED]. Resident #66's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of [DATE] assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns. Resident #66's clinical record was reviewed on [DATE]. The orders section of the clinical record contained a signed physician's orders [REDACTED]. Resident #66's eMAR (electronic medication administration record) for the month of [DATE] was reviewed and contained an entry, which read in part [MEDICATION NAME] 50 mcg tablet one tablet by mouth once daily. The eMAR for [DATE], [DATE] and [DATE] was coded N, which indicates the medication was not administered. The administration notes section of the eMAR contained a note, which read in part 5:55AM, [DATE] (Scheduled: 6:00AM, [DATE]; [MEDICATION NAME] 50 mcg Tablet) [MEDICATION NAME] 50 mcg Tablet one tablet by m . scheduled for [DATE] 6:00 AM.med ordered. The orders section of Resident #66's clinical record contained a signed physician's orders [REDACTED]. Resident #66's eMAR for [DATE] contained an entry, which read in part Diphedryl ,[DATE] mg/5 ml [MEDICATION NAME] rinse and spit ,[DATE] tsp before meals. This entry was coded N on [DATE] at 7:30 am, and [DATE] at both 7:30 am and 11:30 am. The administration notes section of the eMAR contained notes, which read in part 11:34AM, [DATE] (Scheduled: 7:30AM, [DATE]; Diphedryl 12.5 mg/5 ml [MEDICATION NAME]) Diphedryl 12.5 mg/5 ml [MEDICATION NAME] rinse and . scheduled for [DATE] 7:30 AM.Medication not available and 11:34AM, [DATE] (Scheduled: 11:30AM, [DATE]; Diphedryl 12.5 mg/5 ml [MEDICATION NAME]) Diphedryl 12.5 mg/5 ml [MEDICATION NAME] rinse and . scheduled for [DATE] 11:30 AM.Medication not available. Surveyor requested and the nurse consultant provided a facility policy entitled Medication Shortages/Unavailable Medications on [DATE] at approximately 10:00 am. This policy read in part, 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 the action specified in Sections 2 or 3 of this Policy 7.0, as applicable. 2. If a medication shortage is discovered during normal pharmacy hours: 2.1 Facility nurse should call pharmacy to determine the status of the order. 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 a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. 2.3 If the medication is not available in the Emergency Medication Supply, the facility staff should notify the pharmacy and arrange for an emergency delivery. 3. If a medication shortage is discovered after normal pharmacy hours: 3.1 A licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply. 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 3.3.3 Use of an emergency (back-up) third party pharmacy. The concern of not the facility not having the resident's medications available for administration was discussed with the administrative staff (administrator, administrator-in-training, director of nursing, regional nurse consultant) during a meeting on [DATE] at approximately 4:20 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review, facility document review and in the course of a complaint investigation the facility staff failed to ensure that pain management is provided to residents who require such services for 6 of 31 residents, #120, #236, #34, #101, #66 and #25. This is a complaint deficiency. 1. For Resident #34, facility staff failed to account for all pain medication signed out of the narcotic ledger and documented pain medication administration for doses not signed out of the ledger. Resident #34 was admitted to the facility with [DIAGNOSES REDACTED]. On the most recent minimum data set assessment, the resident scored ,[DATE] on the Brief Interview for Mental Status and was assessed as without signs of [MEDICAL CONDITIONS], or behaviors affecting care. The resident was assessed as receiving scheduled pain medication ,[DATE] days in the look back period and as needed pain medication in the look back period and as being without pain. The surveyor was unable to interview the resident. A complaint filed with the office of licensure and certification indicated that Resident #34 was one of the residents whose pain medication had been diverted by a nurse. Clinical record review on [DATE] revealed staff documented administering the pain medication [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME] 7.5mg-325 mg every 6 hours for pain) more often than signed out of the ledger from [DATE] through February 2020. The medication was not available in the medication stat box.: [DATE] staff documented on the medication administration record four scheduled doses and an as needed dose at 7:25 AM; the narcotic sign out sheet documented the as needed dose was obtained at 9 AM [DATE] four doses documented as administered, but no 6 AM dose was signed out of the narcotic ledger [DATE] 6 AM dose signed out twice, one administration documented [DATE] 6 PM dose of [MEDICATION NAME] documented as administered but no 6 PM dose was signed out of the narcotic ledger [DATE] 12 AM dose of [MEDICATION NAME] documented as administered but no 12 AM dose was signed out of the narcotic ledger; the administration record indicated a dose or [MEDICATION NAME] was administered at 11:02 AM but the Individual Narcotic Record documented the dose was signed out of the narcotic ledger at 9 AM All doses of [MEDICATION NAME], whether documented as administered or not administered, were documented as effective in follow-up medication administration detail notes. No account sheet for narcotics was from ,[DATE] through [DATE] was available. The administrator and director of nursing were notified of the concern that nurses documented administering pain medications that were not given to the resident. 2. For Resident #120, facility staff documented pain medication administration for doses not signed out of the ledger. Resident #120 was admitted to the facility with [DIAGNOSES REDACTED]. On the most recent minimum data set assessment, the resident scored ,[DATE] on the Brief Interview for Mental Status and was assessed as without signs of [MEDICAL CONDITIONS], or behaviors affecting care. The resident was assessed as receiving scheduled pain medication ,[DATE] days in the look back period and as needed pain medication ,[DATE] days in the look back period and as being without pain. The surveyor was unable to interview the resident. Clinical record review on [DATE] revealed staff documented administering the pain medication [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME] 5mg-325 mg every 6 hours for pain) more often than signed out of the ledger on 8 days from [DATE] through [DATE]. The medication was not available in the medication stat box.: [DATE] three doses documented as administered, but only the 12 PM dose was signed out of the narcotic ledger [DATE] four doses documented as administered, but only the 6 PM dose was signed out of the narcotic ledger [DATE] three doses documented as administered, but only the 12 AM dose was signed out of the narcotic ledger [DATE] four doses documented as administered, but no medication was signed out of the narcotic ledger [DATE] four doses documented as administered, but only the 6 PM dose was signed out of the narcotic ledger [DATE] four doses documented as administered, but no 6 PM dose was signed out of the narcotic ledger [DATE] the 12 AM dose was documented as administered and effective, but no medication was signed out of the individual narcotic record. [DATE] the 12 AM dose was documented as administered and effective, but no medication was signed out of the individual narcotic record. All doses of [MEDICATION NAME], whether documented as administered or not administered, were documented as effective in follow-up medication administration detail notes. There was no Individual Narcotic Record sheet for [DATE]-[DATE]. The surveyor asked two times for that sheet on [DATE]. The other documents were provided to surveyor on [DATE]. The administrator and director of nursing were notified of the concern that nurses documented administering pain medications that were not given to the resident. 3. For Resident #236, facility staff failed to ensure pain medication was available for administration and documented pain medication administration for doses not signed out of the ledger. Resident #236 was admitted to the facility with [DIAGNOSES REDACTED]. On the most recent minimum data set assessment, the resident scored ,[DATE] on the brief interview for mental status and was assessed as without signs of [MEDICAL CONDITIONS], or behaviors affecting care. The resident was noted to receive scheduled pain medication and to be assessed by staff as not exhibiting signs of pain. Clinical record review on [DATE] revealed staff documented administering the pain medication [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME] 5mg-325 mg every 6 hours for pain) more often than signed out of the ledger in [DATE] and that the medication was unavailable in [DATE]. The medication was not available in the medication stat box.: [DATE] three doses documented as administered, but 10 PM dose was not signed out of the narcotic ledger. A dose was signed out with a remainder of 4 pills on ,[DATE] at 21:00, then marked through as an error. The ,[DATE] 21:00 dose was signed out on the first entry on a new ledger sheet. [DATE] two doses documented as administered, but only the 2 PM dose was signed out of the narcotic ledger [DATE] the remainder of the resident's [MEDICATION NAME] medication wasted by staff claiming it was expired. The medication was unavailable until delivered to the facility. The Individual narcotic ledger documented the medication was delivered on [DATE]. The first dose was signed out on ,[DATE] at 13:00. The medication administration record documented the medication was unavailable on ,[DATE] at 6 AM and 10 PM and on ,[DATE] at 6 AM. The medication administration documented administration of the medication on ,[DATE] at 14:00. ( The medication was not available in the stat box.) The administrator and director of nursing were notified of the concern with availability and documentation of medications administered while not in the building or not signed out of the narcotic ledger. 4. For Resident #101 the facility staff failed to ensure that the resident's scheduled pain medication was administered per the physician's orders [REDACTED].>Resident #101's face sheet listed diagnoses, which included but not limited to dysphagia, gastro-[MEDICAL CONDITION] reflux disease, anxiety, [MEDICAL CONDITION], and cognitive communication deficit. Resident #101's most recent annual MDS (minimum data set) with an ARD (assessment reference date) of [DATE] assigned the resident a BIMS (brief interview for mental status) score of 14 out of 15 in section C, cognitive patterns. Section J, health conditions, coded the resident as receiving scheduled pain medication. Resident #101's comprehensive care plan was reviewed and contained a care plan for Rsd (resident) states -- has frequent c/o (complaint of) pain to -- legs. -- receives scheduled pain medications per orders. Approaches for this care plan include Provide medications per orders. Resident #101's clinical record was reviewed on [DATE]. It contained a signed physician's orders [REDACTED]. Resident #101's eMAR's (electronic medication administration record) for the months of June and [DATE] were reviewed and contained entries, which read in part [MEDICATION NAME] 7XXX,[DATE] mg tablet one tablet by mouth four time a day. The eMAR for June was coded with N on [DATE] at 1:00 pm. The administration notes section of the eMAR contained a note dated [DATE], which read in part 2:48PM, [DATE] (Scheduled: 1:00PM, [DATE]; [MEDICATION NAME] 7XXX,[DATE] TABLET) [MEDICATION NAME] 7XXX,[DATE] TABLET one tablet by mout . scheduled for [DATE] 1:00PM.not available not given RX bringing the PM. The eMAR for July was coded with N on [DATE] at 5:00 pm and 9:00 pm. the administration notes section of the eMAR contained notes dated [DATE], which read in part 8:18PM, [DATE] (Scheduled: 5:00PM, [DATE]; [MEDICATION NAME] 7XXX,[DATE] TABLET) [MEDICATION NAME] 7XXX,[DATE] TABLET one tablet by mout . scheduled for [DATE] 5:00 PM was held.special requirement not met and 9:18PM, [DATE] (Scheduled: 9:00PM, [DATE]; [MEDICATION NAME] 7XXX,[DATE] TABLET) [MEDICATION NAME] 7XXX,[DATE] TABLET one tablet by mout . scheduled for [DATE] 9:00 PM was held.special requirement not met. Surveyor reviewed Resident #101's nursing notes, located in the notes section of the clinical record. The surveyor could not locate any notes that indicated why the resident's medication was not administered. Surveyor spoke with the ADON (assistant director of nursing) on [DATE] at approximately 10:55 am regarding Resident #101's [MEDICATION NAME]. ADON stated that she had no explanation why the resident's medication was not administered. ADON also stated that a nurse's note should be made if the medication is not administered indicating the reason. The concern of failing to provide pain management for Resident #101 was discussed with the administrative team (administrator, administrator-in-training, director of nursing, ADON, regional nurse consultant) was discussed during a meeting on [DATE] at approximately 4:20 pm. No further information provided prior to exit. 5. For Resident #66 the facility staff failed to ensure the resident's scheduled pain medication was administered per the physician's orders [REDACTED]. Resident #66's face sheet listed [DIAGNOSES REDACTED]. Resident #66's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of [DATE] assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns. Section J, health conditions, coded the resident as receiving scheduled pain medication and occasionally having pain. Resident #66's comprehensive care plan was reviewed and contained a care plan for Pain. Approached for this care plan include provide pain med as ordered. Resident #66's clinical record was reviewed on [DATE]. The orders section of the clinical record contained a physician's orders [REDACTED]. Resident #66's eMAR (electronic medication record) for the month of [DATE] was reviewed and contained an entry, which read in part [MEDICATION NAME] ,[DATE] mg tablet 1 tablet by mouth three times daily. This entry was coded N on [DATE] and [DATE] at 6 am. The administration notes section of the eMAR contained notes, which read in part 7:53AM, [DATE] (Scheduled: 6:00AM, [DATE]; [MEDICATION NAME] ,[DATE] mg tablet) [MEDICATION NAME] ,[DATE] mg tablet 1 tablet by . scheduled for [DATE] 6:00 AM was held.shortness of breath and 8:15AM, [DATE] (Scheduled: 6:00AM, [DATE]; [MEDICATION NAME] ,[DATE] mg tablet) [MEDICATION NAME] ,[DATE] mg tablet 1 tablet by . scheduled for [DATE] 6:00 AM was not administered- Other.special requirement not met. Resident #66's eMAR for the month of [DATE] was reviewed and contained an entry, which read in part [MEDICATION NAME] ,[DATE] mg tablet 1 tablet by mouth three times daily. This entry was coded N on [DATE] and [DATE] at 10 pm, and [DATE] at 2 pm. The administration notes section of the eMAR contained notes, which read in part 7:53AM, [DATE] (Scheduled: 10:00Pm, [DATE]; [MEDICATION NAME] ,[DATE] mg tablet) [MEDICATION NAME] ,[DATE] mg tablet 1 tablet by . scheduled for [DATE] 10:00 PM was held.special requirement not met, 8:12AM, [DATE] (Scheduled: 10:00PM, [DATE]; [MEDICATION NAME] ,[DATE] mg tablet) [MEDICATION NAME] ,[DATE] mg tablet 1 tablet . scheduled for [DATE] 10:00 PM was held.special requirement not met, and 8:12AM, [DATE] (Scheduled: 2:00PM, [DATE]; [MEDICATION NAME] ,[DATE] mg tablet) [MEDICATION NAME] ,[DATE] mg tablet 1 tablet by . scheduled for [DATE] 2:00 PM was held.special requirement not met'. Surveyor reviewed the notes section of the resident's clinical record and could not locate a nurse's note for the above named dates to indicate why the resident's [MEDICATION NAME] was not administered. Surveyor spoke with the ADON (assistant director of nursing) on [DATE] at approximately 10:55 am regarding Resident #66's [MEDICATION NAME]. ADON stated that she had no explanation why the resident's medication was not administered. ADON also stated that a nurse's note should be made if the medication is not administered indicating the reason. The concern of failing to provide pain management for Resident #66 was discussed with the administrative team (administrator, administrator-in-training, director of nursing, ADON, regional nurse consultant) was discussed during a meeting on [DATE] at approximately 4:20 pm. No further information provided prior to exit. 6. The facility staff failed to ensure Resident #25's pain medication was administered as ordered by the provider. Resident #25's minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], had the resident's Brief Interview for Mental Status scored a 15 out of 15. The resident was assessed as requiring extensive assistance of two (2) or more individuals with bed mobility, transfers, and toilet use. Resident #24 was documented as having received a scheduled pain medication regimen. Resident #24's [DIAGNOSES REDACTED]. Resident #25's medication administration documentation indicated the following medication doses of [MEDICATION NAME]/[MEDICATION NAME] were documented as not being administered: [DATE] at 6:00 a.m.; [DATE] at 10:00 p.m., [DATE] at 2:00 p.m., [DATE] at 10:00 p.m., and [DATE] at 6:00 a.m. No documentation was found by or provided to the surveyor to address why the aforementioned medication doses were not administered. On [DATE] at 1:35 p.m., the failure of the facility staff to provide the aforementioned doses of [MEDICATION NAME]/[MEDICATION NAME] was discussed with a facility unit manager (Staff Member (SM) #22). SM #22 acknowledged no documentation was found to address why the medications were not given to Resident #25. The following information was found in a facility policy titled Administering Medications (with a revised date of [DATE]): Medications are administered in a safe and timely manner, and as prescribed . If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document on the MAR (medication administration record) accordingly . Resident #25's care plan included the problem of back and leg pain for which the resident received medications; the goal was documented as: PAIN WILL REMAIN UNDER CONTROL THIS QUARTER. One of the approaches/interventions documented as part of this pain care plan was: PROVIDE PAIN MEDICATION PER ORDERS. On [DATE] at 4:20 p.m., the failure of facility staff to provide Resident #25's pain medications as ordered was discussed during a survey team meeting with the facility's administrator, assistant administrator, director of nursing, assistant director of nursing, and corporate nurse; no additional information, related to this issue, was provided.

Based on staff interview, clinical record review, resident interview and facility document review the facility staff failed to provide notice of bed hold policy for 4 of 31 residents, #101, #74, #29, and #44. The findings included: 1. For Resident #101 the facility staff failed to offer a written notice of bed hold when the resident was discharged to the hospital. Resident #101's face sheet listed [DIAGNOSES REDACTED]. Resident #101's most recent annual MDS (minimum data set) with an ARD (assessment reference date) of 01/09/2020 assigned the resident a BIMS (brief interview for mental status) score of 14 out of 15 in section C, cognitive patterns. Resident #101's clinical record was reviewed on 02/06/2020. It contained a nurse's progress note, located in the notes section of the clinical record, dated 02/27/2020, which indicated the resident was sent to the hospital. The surveyor could not locate any information in the clinical record to indicate a bed hold had been offered to the resident or the resident representative. Surveyor requested and was provided with a copy of the resident's transfer summary dated 01/27/2020. The transfer summary did not include information regarding a bed hold. Medical records staff stated to surveyor on 02/06/2020 at approximately 4:15 pm that a bed hold had not been offered to the resident. Surveyor requested and the regional nurse consultant provided a copy of facility policy entitled Bed Holds and Returns on 02/06/2020 at approximately 4:50 pm. This policy read in part, Policy Statement: Prior to transfers and therapeutic leaves, Resident or resident representatives will be informed in writing of the bed-hold policy. The concern of not offering a notice of bed hold was discussed with the administrative team (administrator, administrator-in-training, director of nursing, assistant director of nursing, regional nurse consultant) during a meeting on 02/06/2020 at approximately 4:20 pm No further information provided prior to exit. 2. For Resident #74 the facility staff failed to offer a written notice of bed hold when the resident was discharged to the hospital. Resident #74's [DIAGNOSES REDACTED]. Resident #74's admission MDS (minimum data set) with an ARD (assessment reference date) of 11/30/19 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive status. Resident #74's clinical record was reviewed on 02/07/2020. It contained a nurse's progress note, located in the notes section of the clinical record, dated 12/07/19, which indicated the resident was sent to the hospital. The surveyor could not locate any information in the clinical record to indicate a bed hold had been offered to the resident or the resident representative. Surveyor asked the administrator for information regarding the bed hold for Resident #74 on 02/07/2020 at approximately 8:30 am. Administrator informed the surveyor that a bed hold was not offered to the resident. Surveyor requested and the regional nurse consultant provided a copy of facility policy entitled Bed Holds and Returns on 02/06/2020 at approximately 4:50 pm. This policy read in part, Policy Statement: Prior to transfers and therapeutic leaves, Resident or resident representatives will be informed in writing of the bed-hold policy. The concern of not offering a notice of bed hold was discussed with the administrative team (administrator, administrator-in-training, director of nursing, regional nurse consultant) during a meeting on 02/07/2020 at approximately 10:30 am No further information provided prior to exit. 3. For Resident #29, the facility staff failed to provide a written notice of bed hold upon discharge to an acute care facility. Resident #29's [DIAGNOSES REDACTED]. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/15/19 assigned the resident a BIMS (brief interview for mental status) score of 12 out of 15 in section C, Cognitive Patterns. A review of Resident #29's clinical record revealed documentation indicating the resident was transferred and admitted to an acute care hospital on [DATE]. The clinical record did not include documentation indicating a notice of bed hold was issued upon discharge from the facility on 11/16/19. On 2/04/20 at 2:37pm, the surveyor spoke with Resident #29 who stated they were sent to the hospital in November and It was a surprise to me, a slap in the face when I came back and my stuff was moved to another room. On 2/05/20 at 11:59am, the surveyor requested documentation that a notice of bed hold was provided to Resident #29. The administrator stated they do not have any documentation of a bed hold for Resident #29. The surveyor requested and received the policy Bed-Holds and Returns which stated in part: 3. Prior to transfer, written information will be given to the residents and the resident representatives that explains in detail: a. The rights and limitations of the resident regarding bed-holds; b. The reserve bed payment policy as indicated by the state plan (Medicaid residents); c. The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed- hold period (Medicaid residents); and d. The details of the transfer (per the Notice of Transfer) On 2/06/20 at 4:39pm, the administrative team consisting of the administrator, assistant administrator, director of nursing, assistant director of nursing, and the regional nurse consultant were made aware of Resident #28 not receiving a notice of bed hold on 11/16/19. No further information regarding this issue was presented to the survey team prior to the exit conference on 2/10/20. 4. The facility staff failed to provide written bed hold policy information to the resident or the resident's representative when Resident #44 was admitted to the hospital. Resident #44's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 9/25/19, had the resident's short-term and long-term memory assessed as Memory OK. The resident was assessed as requiring extensive assistance of two (2) or more individuals with bed mobility, transfers, and toilet use. Resident #44's [DIAGNOSES REDACTED]. Resident #44's clinical documentation provided evidence of the resident being admitted to the hospital on [DATE] and returning to the facility on [DATE]. No evidence was found to indicate the resident or the resident's representative was provided written bed hold information for this hospital admission. The following information was found in a facility policy titled Bed-Holds and Returns (with a revised date of March 2017): Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. On 2/7/20 at 10:17 a.m., the corporate nurse (Staff Member (SM) #21) reported that neither Resident #44 nor the resident's representative had been provided written bed hold information for the resident's 11/13/19 - 11/25/19 hospital stay.

Based on staff interview, facility document review and employee record reviews 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 5 of 25 new hire employees. The findings included: The facility failed to obtain a criminal background check for RN (registered nurse) #1, reference check reviews for CNA (certified nursing assistant) #1, CNA #2, LPN (licensed practical nurse) #1 and non-licensed staff member #1, and license verifications for CNA #1 and LPN #1 prior to employment with the facility. A review of the employee records revealed the following documentation: 1. RN #1's was employed by the facility on 8/02/18. RN #1's employee record did not contain documentation of a Virginia State Criminal Background Check prior to employment. RN #1 is currently employed by the facility. 2. CNA #1 was employed by the facility on 2/22/19. CNA #1's employee record did not contain documentation of license verification or a reference check review prior to employment. CNA #1 is no longer employed by the facility. 3. CNA #2 was employed by the facility on 2/07/18. CNA #2's employee record did not contain documentation of a reference check review prior to employment. CNA #2 is no longer employed by the facility. 4. LPN #1 was employed by the facility on 10/23/18. LPN #1's employee record did not contain documentation of license verification or a reference check review prior to employment. LPN #1 is no longer employed by the facility. 5. Non-licensed staff member #1 was employed by the facility on 2/13/19. The employee's record did not contain documentation of a reference check review prior to employment. Non-licensed staff member #1 is currently employed by the facility. On 2/06/20 at approximately 12:30pm, the surveyor notified the administrator of the employee documents that were not in the employee files as listed above. The administrator stated the facility did not have the documentation. The surveyor requested and received the policy Abuse, Neglect and Exploitation Prevention and Reporting which stated in part: 3. d. Background, reference and credentials' checks should be conducted on employees prior to or at the time of employment, by facility administration, in accordance with applicable state and federal regulations. Any person having knowledge that an employee's license or certification is in question should report such information to the Administrator. On 2/06/20 at 4:23pm, the administrative team consisting of the administrator, assistant administrator, director of nursing, assistant director of nursing, and the regional nurse consultant were notified of the lack of pre-employment documentation for RN #1, CNA #1, CNA #2, LPN #1, and non-licensed staff member #1. No further information regarding these issues were presented to the survey team prior to the exit conference on 2/10/20.

Based on clinical record review, staff interview and facility document review, the facility staff failed to notify the physician and the resident representative of an accident involving the resident which results in an injury and has the potential for requiring physician intervention for 1 of 31 residents, Resident #135. The findings included: For Resident #135, the facility staff failed to notify the physician and resident representative of resident's right arm becoming trapped in the bed rail resulting in redness to the right arm. Resident #135's [DIAGNOSES REDACTED]. The most recent annual MDS with an ARD (assessment reference date) of 1/14/20 coded the resident as being severely impaired in cognitive skills for daily decision making with short term and long term memory loss in section C, Cognitive Patterns. Resident #135 is also coded as requiring the extensive assistance of two or more staff members for bed mobility and being totally dependent on two or more staff members for transfers in section G, Functional Status. A review of Resident #135's medical record revealed a progress note dated 11/28/19 9:24 pm stating if resident's right arm is bruised, they got it stuck in rail climbing out of bed. The subsequent progress note dated 11/29/19 1:35 am states in part, redness remains to right arm. A progress note dated 12/04/19 6:14 pm states in part, resident's right arm is still red and acts as if moving it is tender to touch. The surveyor was unable to locate documentation in the medical record indicating the resident's physician and representative were notified of Resident #135's right arm becoming trapped in the bed rail. The surveyor requested and received the policy Change in a Resident's Condition or Status which stated in part: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): a. Accident or incident involving the resident 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source On 2/10/20 at approximately 2:20pm, the surveyor informed the administrator that the resident's medical record did not include documentation of physician and resident representative notification of resident's right arm being trapped in the bed rail. The administrator stated they are looking on the 24-Hour Report for documentation. No further information regarding this issue was presented to the survey team prior to the exit conference on 2/10/20.

Based on staff interview, resident interview and clinical record review the facility staff failed to provide treatment and care as evidenced by the failure to follow physician's orders [REDACTED].#84, #66 and #8. The findings included: 1. For Resident #84 the facility staff failed to follow physician's orders [REDACTED]. Resident #84's [DIAGNOSES REDACTED]. Resident #84's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 01/02/2020 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns. Resident #84's clinical record was reviewed on 02/06/2020. It contained a signed physician's orders [REDACTED].<60 NOTIFY MD, 61-150=0 U, 151-180=18 U, 180-220=20 U, 221-250=22 U, 251-300= 25 U, 301-350=27 U, 351-400=29 U, > 400 GIVE 29 U AND NOTIFY MD. Resident #84's eMAR (electronic medication administration record) for the month of January 2020 was reviewed and contained an entry, which read in part HUMALOG 100 UNITS/ML KWIKPEN ACCU CHECKS AC (before meals) & hs (bedtime) SSI (sliding scale insulin) AS FOLLOWS BS (blood sugar) <60 NOTIFY MD, 61-150=0 U, 151-180=18 U, 180-220=20 U, 221-250=22 U, 251-300= 25 U, 301-350=27 U, 351-400=29 U, > 400 GIVE 29 U AND NOTIFY MD. On 01/11/2020, the eMAR was coded with N and the blood sugar level recorded as High. The administration notes section of the eMAR included notes dated 01/11/2020, which read in part 12:40PM, 1/11/20 (Scheduled: 11:30AM, 1/11/20; HUMALOG 100 UNITS/ML KWIKPEN) HUMALOG 100 UNITS/ML KWIKPEN ACCU CHECK . scheduled for 01/11/2020 11:30 AM was refused by resident. Pre Admin Blood Glucose: High and 12:40PM, 1/11/20 (Scheduled: 11:30AM, 1/11/20; HUMALOG 100 UNITS/ML KWIKPEN) Special requirements recorded when not administered: Blood Glucose: High. The surveyor reviewed the resident's nurse's progress notes, located in the notes section of the clinical record. The surveyor could not locate information the indicated the physician was contacted per the physician's orders [REDACTED].#84's blood glucose level of 01/11/2020. ADON stated that the physician should have been notified of BS level being high, and a nurse's note should have been make. Surveyor requested and DON (director of nursing) provided a copy of user manual for the blood glucose monitor used for Resident #84. The user manual included product specifications, which indicated a measurement range of 20-600 mg/dl. Surveyor asked the DON what it meant if the blood glucose monitor gave a reading of high, and DON stated that it meant the BS reading was greater than 600. The concern of not notifying the physician when the resident's blood sugar levels were outside of physician ordered parameters was discussed with the administrative team (administrator, administrator-in-training, DON, regional nurse consultant) on 02/06/2020 at approximately 4:30 pm. No further information was provided prior to exit. 2. For Resident #66 the facility staff failed to follow physician's orders [REDACTED]. Resident #66's face sheet listed [DIAGNOSES REDACTED]. Resident #66's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 12/13/19 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns. Resident #66's clinical record was reviewed on 02/06/2020. It contained a signed physician's orders [REDACTED]. 2.5 mg tablet take one tablet by mouth twice daily, [MEDICATION NAME] 1 mg tablet 1 tablet by mouth every 8 hours. The orders section of Resident #66's clinical record also contained a signed physician's orders [REDACTED]. Resident #66's eMAR (electronic Medication Administration Record [REDACTED]. On 06/05/19, the entry for [MEDICATION NAME] was not signed as administered. On 06/05/19 and 06/07/19 at 1pm, the entry for [MEDICATION NAME] was coded N. On 06/05/19 and 06/07/19 at 2pm, 06/06/19 at 6am, and 06/07/19 at 6am and 2pm the entry for [MEDICATION NAME] was coded N. On 06/0519 at 8am the entry for [MEDICATION NAME] was not signed as administered, and was coded N on 06/05/19 and 06/07/19. On 06/05/19 at 2pm, 06/06/19 at 6 am and 06/07/19 at 6am and 2pm the entry for [MEDICATION NAME] was coded N. The administration notes section of the eMAR contained notes for each missed dose of medication stating either documentation not complete or documentation incomplete by administering nurse. Resident #66's eMAR for the month of July 2019 was reviewed and contained entries, which read in part Diphedryl 12/5 mg/5 ml [MEDICATION NAME] rinse and spit 1-2 tsp before meals, [MEDICATION NAME] 75 mg capsule 1 capsule by mouth twice daily and [MEDICATION NAME] 1 mg tablet 1 tablet by mouth every eight hours. The entry for Diphedryl on 07/28/19 at 11:30 am was not signed. The entry for [MEDICATION NAME] on 07/28/19 at 1:00 pm was not signed. The entry for [MEDICATION NAME] on 07/29/19 at 2:00 pm was coded N. The administration notes section of the eMAR contained notes, which read in part 7:42PM, 7/28/19 (Scheduled: 11:30AM, 7/28/19; Diphedryl 12.5 mg/5 ml [MEDICATION NAME]) Unsigned Record Removed: Other, documentation not complete, 7:42PM 7/28/19 (Scheduled: 1:00PM, 7/28/19; [MEDICATION NAME] 75 mg Capsule) Unsigned Record Removed: Other, documentation not complete, and 1:18PM, 7/29/19 (Scheduled: 2:00PM, 7/29/19; [MEDICATION NAME] 1 mg tablet) [MEDICATION NAME] 1 mg tablet 1 tablet by mout eve . scheduled for 07/29/2019 2:00 PM was held.special requirement not met. The surveyor could not locate any nurse's notes in the notes section of the clinical record that indicated the reason for holding the medications. The orders section of Resident #66's clinical record contained a signed physician's orders [REDACTED]. Resident #66's eMAR for the month of September 2019 contained entries, which read in part [MEDICATION NAME]-[MEDICATION NAME] 25-100 tab 1 tab by mouth every 8 hours take along with 1/2 tab, [MEDICATION NAME]-[MEDICATION NAME] 25-100 tab 1/2 tab every 8 hours. Take along with whole tab, [MEDICATION NAME] 1 mg tablet 1 tablet by mouth every eight hours, Dexilant Dr 60 mg capsule-give 1 po QAM. The entry for [MEDICATION NAME] was coded N on 09/03/19 and 09/30/19 at 6:00 am. The entry for [MEDICATION NAME] was coded N on 09/03/19 and 09/30/19 at 6:00 AM. The entry for Dexilant was coded N on 09/03/19 and 09/30/19 at 6:00 am. The administration notes section of the eMAR contained a note date 09/03/19 for each medication not administered on this date, which read in part 'scheduled for 09/03/2019 6:00 AM was held.shortness of breath. Notes section also contained a notes dated 09/3019 for each medication not administered on this date, which read in part scheduled for 09/30/2019 was not administered-Other.special requirement not met. The surveyor could not locate any nurse's notes in the notes section of the clinical record that indicated the reason for holding the medications. Surveyor spoke with the DON (director of nursing) on 02/06/2020 at approximately 2:30 pm regarding Resident #66's medications not being administered. DON stated that she did not know why the documentation explaining the reason for not administering the medications read the way it did. DON also stated that a nurse's progress note should have been made each time the medication was not administered. The concern of not administering the resident's medications per the physician's orders [REDACTED]. Surveyor asked the team to explain what special requirement not met indicated on the resident's eMAR, and the regional nurse consultant stated a special requirement referred to physician ordered parameters used when administering medications such as sliding scale insulin, that is dependent on the blood sugar levels to determine the amount of medication to be given. No further information was provided prior to exit. 3. For Resident #8, facility staff failed to perform an intermittent catheterization every night at bedtime and document the results as ordered by the physician. Resident #8's [DIAGNOSES REDACTED]. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 1/30/20 assigned the resident a BIMS (brief interview for mental status) score of 6 out of 15 in section C, Cognitive Patterns. Resident #8 is also coded as frequently incontinent of urine and for the use of intermittent catheterization in section H, Bladder and Bowel. A review of Resident #8's medical record revealed an active physician's orders [REDACTED]. The resident's comprehensive care plan included the problem area of Urinary Incontinency: (name omitted) is at risk for UTIs (urinary tract infections) and skin breakdown related to hx (history) of UTIs, [MEDICAL CONDITIONS], and [MEDICAL CONDITIONS], approaches included, but were not limited to straight cath per orders. On 2/01/20, 2/02/20, 2/03/20 and 2/04/20 the Treatment Administration Record was coded with an N for the order straight cath every night at bedtime and document results. Surveyor could not locate documentation indicating the straight cath procedure was performed 2/01/20 - 2/04/20. On 2/06/20 at 3:15 pm, surveyor spoke with Resident #8 and asked if staff place a tube in the bladder to drain the urine at bedtime, resident stated, no they don't do that. On 2/06/20 at 3:20 pm, surveyor spoke with LPN (licensed practical nurse) #1 who stated they only straight cath the resident if they do not void during the shift, LPN #1 also stated they have never had a problem with the resident not voiding. On 2/06/20 at approximately 4:30 pm, the administrative team consisting of the administrator, assistant administrator, director of nursing, assistant director of nursing, and the regional nurse consultant were made aware of staff not following the physician's orders [REDACTED]. On 2/07/20 at 9:10 am, the administrator stated the intent of the physician's orders [REDACTED]. The administrator also stated the staff last night were inserviced and staff inservicing will continue. No further information regarding this issue was presented to the survey team prior to the exit conference on 2/10/20.

Based on staff interview, employee record review and facility document review the facility staff failed to obtain registry verification that a CNA (certified nursing assistant) has met competency evaluation requirements as evidenced by failure to obtain state license verification prior to employment for 1 of 8 new hire CNAs. The findings included: The facility failed to perform a license verification check for CNA #1 prior to employment. CNA #1 was employed by the facility on 2/22/19. A review of CNA #1's employee record did not contain documentation of a license verification check prior to employment. On 2/06/20 at approximately 12:30pm, the surveyor notified the administrator that CNA #1's employee record did not contain documentation of a license verification check. The administrator stated the facility did not have the documentation. The surveyor requested and received the policy Abuse, Neglect and Exploitation Prevention and Reporting which stated in part: 3. d. Background, reference and credentials' checks should be conducted on employees prior to or at the time of employment, by facility administration, in accordance with applicable state and federal regulations. Any person having knowledge that an employee's license or certification is in question should report such information to the Administrator. On 2/06/20 at 4:23pm, the administrative team consisting of the administrator, assistant administrator, director of nursing, assistant director of nursing, and the regional nurse consultant were notified that CNA #1's employee record did not contain documentation of a pre-employment license verification. No further information regarding this issue was presented to the survey team prior to the exit conference on 2/10/20.