Every finding on record at Heritage Hall Wise

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure that 1 of 23 residents were utilizing provider ordered Oxygen (Resident #63). The findings included: The facility staff failed to follow the providers orders for Oxygen administration. Resident #63's diagnoses included acute respiratory failure with hypoxia and hypercapnia, chronic obstructive pulmonary disease, and history of other malignant neoplasm of bronchus and lung. Section C (cognitive patterns) of Resident #63's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 07/03/24 included a brief interview for mental status (BIMS) summary score of 4 out of a possible 15 points. Per the MDS manual a score of 0-7=severe impairment. Section O (special treatments, procedures, programs) was coded to indicate this resident used Oxygen. Resident #63's current medication summary report/physician order summary included a current (active) physician order dated 06/24/24 for Oxygen at 4 liters per minute. During a review of Resident #63's medication administration records (MARs) and treatment administration records (TARs) for July 2024 the surveyor was unable to locate the order for Oxygen. Resident #63's comprehensive care plan (CCP) included the focus area of cardiovascular/respiratory. Interventions included Oxygen at 6 liters per minute via nasal cannula continuous. Diagnosis shortness of breath. Date Initiated: 03/07/24. Per the Nurse Consultant the facility staff failed to update the CCP when the resident was readmitted on [DATE] to the current order of 4 liters a minute. Throughout the course of the survey the surveyor did not observe Resident #63 with their provider ordered Oxygen in use. During these observations Resident #63 was never observed to have any respiratory issues. On 07/30/24 at 3:15 p.m., during an interview with Licensed Practical Nurse (LPN) #1 this nurse reviewed Resident #63's clinical record and confirmed the Oxygen was not on the residents MAR. LPN #1 stated they had worked at the facility for 2 years and this resident never wore Oxygen. The Nurse Consultant stated this unit was LPN #1's routine assignment. On 07/30/24, the nursing staff notified the physician that the resident refused to wear their Oxygen and the physician discontinued the order. On 07/30/24, during an end of the day meeting with the Administrator, Administrator in Training, Nurse Consultant, Director of Nursing (DON), and Assistant Director of Nursing, the issue with the residents' Oxygen not being in place and the order not being on the MAR and/or TAR was reviewed. On 07/31/24 at 8:30 a.m., the DON and Nurse Consultant stated the Oxygen had been discontinued by the provider and the care plan had been updated. The facility administrative staff provided the surveyor with a copy of their policy titled, Oxygen Administration. This policy read in part, .The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident . No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan (CCP) for 2 of 23 residents (Residents #35 and #63). The findings included: 1. For Resident #35, the facility staff failed to review and revise the CCP to capture the current treatment orders to the residents lower legs. Resident #35's diagnoses included type 2 diabetes, edema, and hypertension. Section C (cognitive patterns) of Resident #35's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 07/03/24 included a brief interview for mental status (BIMS) score of 8 out of a possible 15 points. Per the MDS manual a score of 8=moderately impaired. Section M (skin) was coded to indicate Resident #35 was receiving application of nonsurgical dressings (with or without topical medications) other than to feet and applications of ointments/medications other than to feet. Resident #35's current medication summary included a provider order dated 06/19/24 to cleanse bilateral lower extremities with soap and water, then apply Unna boots from toes to knees (calamine/zinc) every day shift every 7 day(s) for Edema/Weeping. Resident #35's CCP included the focus area of skin the facility staff had documented the following interventions. Cleanse venous ulcer on right inner shin with wound cleanser, apply Iodosorb gel with calcium alginate. Cover with bordered gauze. Every day shift for Venous ulcer. Date Initiated: 03/26/2024 Cleanse venous ulcer on right inner shin with wound cleanser. Apply Calcium alginate. cover with bordered gauze every day shift for venous ulcer. Date Initiated: 03/13/24. This CCP did not include any information regarding the Unna boots. On 07/30/24 at 1:39 p.m., during an interview with the MDS coordinator this staff reviewed Resident #35's CCP and confirmed the CCP still included Resident #35's previous treatment orders. The MDS coordinator stated they only knew about changes when the staff made them aware. During an end of the day meeting on 07/30/24 at 5:00 p.m., the issue with Resident #35's CCP not being revised to include their current treatment order was reviewed with the Administrator, Administrator in Training, Director of Nursing (DON), Nurse Consultant, and Assistant Director of Nursing. Prior to the exit conference on 08/01/24 the DON and Nurse Consultant provided the survey team with a copy of an updated CCP that had been revised to include the current Unna boot treatment. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. Resident #63's CCP included the intervention for 6 liters of Oxygen via nasal cannula for shortness of breath. The provider order was for Oxygen at 4 liters per minute. Resident #63's diagnoses included acute respiratory failure with hypoxia and hypercapnia, chronic obstructive pulmonary disease, and history of other malignant neoplasm of bronchus and lung. Section C (cognitive patterns) of Resident #63's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 07/03/24 included a brief interview for mental status (BIMS) score of 4 out of a possible 15 points. Per the MDS manual a score of 4=severe impairment. Section O (special treatments, procedures, programs) was coded to indicate this resident used Oxygen. Resident #63's medication summary report included an order dated 06/24/24 for Oxygen at 4 liters per minute. Resident #63's CCP included the focus area of cardiovascular/respiratory. Interventions included Oxygen at 6 liters per minute via nasal cannula continuous. Diagnosis shortness of breath. Date Initiated: 03/07/24. Throughout the course of the survey the surveyor did not observe Resident #63 with their provider ordered Oxygen in use. During these observations Resident #63 was never observed to have any respiratory issues. On 07/30/24 at 3:15 p.m., during an interview with Licensed Practical Nurse (LPN) #1, this nurse stated they had worked at the facility for 2 years and this resident never wore Oxygen. The Nurse Consultant stated this unit was LPN #1's routine assignment. During an end of the day meeting on 07/30/24 at 5:00 p.m., the issue with Resident #63's CCP not being revised to include their current Oxygen order was reviewed with the Administrator, Administrator in Training, Director of Nursing (DON), Nurse Consultant, and Assistant Director of Nursing. On 07/30/24 the Nurse Consultant transcribed an order for the Oxygen to be discontinued. Prior to the exit conference on 08/01/24 the DON provided the surveyor with a copy of an updated CCP indicating the intervention of Oxygen had been resolved. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to accurately complete Minimum Data Set (MDS) assessments for 2 of 23 residents (Residents #32 and #85). The findings included: 1. For Resident #32, the facility staff coded the MDS assessment to indicate this resident was receiving anticoagulant medications when in fact they were receiving antiplatelet medications. Resident #32's diagnoses included hemiplegia and hemiparesis following cerebral infarction and heart failure. Section C (cognitive patterns) of Resident #32's annual MDS assessment with an assessment reference date (ARD) of 05/01/24 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Per the MDS manual a score of 15=cognitively intact. Section N (medications) was coded to indicate Resident #32 was receiving anticoagulant medication and was not receiving antiplatelet medication. Resident #32's clinical record included provider orders dated 12/01/23 for aspirin 81 mg and Plavix 75 mg every morning. Both medications are classified as antiplatelet's. On 07/30/24 at 5:00 p.m., during an end of the day meeting with the Administrator, Administrator in Training, Director of Nursing (DON), Nurse Consultant, and Assistant Director of Nursing the issue with the inaccurate MDS assessment was reviewed. On 07/31/24 at 8:37 a.m., the Nurse Consultant and DON verified the MDS had been coded incorrectly regarding the medication and provided the surveyor with information indicating the MDS had been corrected. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #85, the facility staff coded a discharge MDS to indicate the resident was discharged to a short-term general hospital when in fact they were discharged home. Resident #85's diagnoses included aftercare following surgery for neoplasm and dysphagia. Section C (cognitive patterns) of Resident #85's discharge MDS assessment with an assessment reference date (ARD) of 05/06/24 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Per the MDS manual a score of 15=cognitively intact. Section A (identification information) was coded to indicate the resident had a planned discharge and was discharged to a short-term general hospital. Resident #85's clinical record included a progress note dated 05/06/24 that read in part, Resident is being discharged from facility at this time. All paperwork and belongings are signed for. Discharge paperwork sent with resident. On 07/31/24 at 1:30 p.m., the Director of Nursing (DON) reviewed the discharge MDS assessment and progress note with the surveyor and confirmed Resident #85 had been discharged home. The issue with the inaccurate MDS was reviewed with the Administrator, Administrator in Training, DON, Assistant Director of Nursing, and Nurse Consultant on 07/31/24 at 3:30 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to notify a resident's responsible party of changes in condition for one of eight sampled residents, Resident #6. Resident #6's responsible party was not notified of significant weight losses. The findings include: Resident #6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 8/27/21, was dated as being completed on 8/30/21. Resident #6 was assessed as sometimes being able to make themself understood and as usually able to understand others. Resident #6 was assessed as having problems with short-term memory and as having problems with long-term memory. Resident #6 was documented as requiring assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Resident #6's facility documentation indicated the resident had the following weight fluctuations: 6/6/21 - 111.5 pounds 7/1/21 - 99.4 pounds (10.8% loss) 8/4/21 - 102.2 pounds 9/1/21 - 84.5 pounds (17.3% loss) No evidence was found to indicate Resident #6's responsible party was notified of the 7/1/21 and 9/1/21 significant weight losses. Resident #6's care plan for NUTRITION / DEHYDRATION/ FLUID MAINTENANCE (with a problem onset date of 8/27/21) included an approach/intervention of INFORM MD/RESPONSIBLE PART (sic) OF SIGNIFICANT WEIGHT LOSS/GAINS. On 2/10/22 at 9:58 a.m., the facility's Regional Nurse Consultant reported Resident #6's responsible party had not been notified of the resident's significant weight losses. The facility's Administrator and Director of Nursing was present during this interview. The following information was found in a facility policy titled Change in a Resident's Condition or Status (with a revised date of December 2016): Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . On 2/10/22 at 12:52 p.m., the failure of facility staff to notify Resident #6's responsible party of weight changes was discussed, for a final time, with the facility's Administrator, Director of Nursing, and Regional Nurse Consultant.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to integrate the hospice clinical documentation into the residents clinical record for 1 of 8 residents, Resident #5. The clinical record did not include the HOSPICE DEATH REPORT SUMMARY/MEDICATION DISPOSAL documentation. The findings included: This was a closed record review. Resident #5's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C (cognitive patterns) of Resident #5's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 01/05/22 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. Section O (special treatment/procedures/programs) was coded to indicate the resident was receiving hospice services. The hospice agreement read in part, .Facility and Hospice shall each prepare and maintain accurate and complete clinical records concerning each Hospice Patient in accordance with prudent record keeping procedures .Facility and Hospice shall coordinate record keeping . Resident #5's clinical record was reviewed on 02/08/22 and 02/09/22 the surveyor was unable to locate hospice documentation in regards to the resident's death. On 02/09/22 at 4:15 p.m., during a meeting with the administrator, RNC (regional nurse consultant), and DON (director of nursing) the missing documentation was reviewed. On 02/10/22 at 8:15 a.m., the RNC provided the surveyor with a document titled HOSPICE DEATH REPORT SUMMARY/MEDICATION DISPOSAL. On 02/10/22 at 9:50 a.m., the DON confirmed the hospice information was not in the clinical record and it had been faxed to the facility on [DATE]. No further information regarding this issue was provided to the survey team prior to the exit conference on 02/10/22.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to maintain a complete an accurate clinical record for 2 of 8 residents, Residents #5 and #1. For Resident #5, the facility staff failed to document a decline in condition. Resident #1 tested positive for COVID-19 on [DATE]. Resident #1's clinical record failed to include vital signs for [DATE], [DATE], and [DATE] per facility policy for COVID-19 monitoring. The findings included: 1. Resident #5's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C (cognitive patterns) of Resident #5's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of [DATE] included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. Section G (functional status) had been coded to indicate the resident required supervision of two staff (,d+[DATE]) for bed mobility, transfers, and locomotion on unit. Walk in room, corridor, and locomotion off the unit was coded (,d+[DATE]) for supervision with set up help only. Section J (health conditions) was coded (0) to indicate the resident had not had any falls since admission/entry or reentry or the prior assessment. Section O (special treatment/procedures/programs) was coded to indicate the resident was receiving hospice services. Resident #5's comprehensive care plan included the problems areas of ADL's (activities of daily living), falls/injuries, and hospice. Resident #5 expired at the facility on [DATE]. The nursing staff had documented the following progress notes: [DATE] at 5:41 p.m., LPN (licensed practical nurse) #6 Resident lying in bed with eyes closed, skin cool and dry, respirations even. Hospice services continue as ordered O2 (oxygen) @ (at) 3lm/nc (liters per minute per nasal cannula) prn (as needed). Medicated for pain as scheduled and as needed, verbalizes all needs without difficulty. PO (by mouth) fluids and call bell in reach. [DATE] at 6:57 p.m., LPN #3 Resident is in bed, call light at reach and o2 bnc (nasal cannula) .is sleeping at this time and prn medication administered .consumed 0% of .supper will continue to monitor .remains on hospice and has a DNR (do not resuscitate) code status. [DATE] at 10:53 p.m., LPN #3 Called to room per CNA (certified nursing assistant) resident is noted without vital signs and unresponsive. Hospice notified and awaiting hospice arrival. On [DATE] at 3:11 a.m., LPN #6 LE (late entry) for 1255am funeral home for resident .was released to .funeral home. The facility provided documentation that one set of vital signs were obtained on [DATE]: temperature 97.6, blood pressure ,d+[DATE], oxygen saturation 82%, heart rate 90, and respirations 12. The facility also provided a document that referenced this resident not ok, general decline. This document was not part of the clinical record. On [DATE] at 2:15 p.m., LPN #3 was interviewed and stated when they entered Resident #5's room, Resident #5 was on the floor beside of the bed with no visible signs of injury, had a decline in condition, they had expected the resident to pass away, and they had checked on this resident every 15 minutes or so on the day Resident #5 expired. On [DATE] at 5:20 p.m., NA (nursing assistant) #2 stated they had found Resident #5 on the floor beside the bed. NA #2 had notified the nurse and put Resident #5 back in the bed. NA #2 stated Resident #5 had been confused that day, had a death rattle, was not doing well, and they believed they had checked them every single hour. NA #2 added Resident #5 was very independent. On [DATE] at 10:25 a.m., the DON (director of nursing) stated when a resident expired if the nurse working the hall was not an RN (registered nurse) the RN in the building would document a note in the resident's clinical record. The DON confirmed there was no nursing note documented by a staff RN when Resident #5 expired. On [DATE] at 9:50 a.m., the DON stated the nursing staff should have documented Resident #5's change in condition, documented the resident was found in the floor, and that the physician had been notified that Resident #5 had expired. On [DATE] at 1:45 p.m., the facility provided a copy of their policy titled, Charting and Documentation which read in part, All services provided to the resident .or any changes in the resident's medical, physical, functional .condition, shall be documented in the residents medical record .Documentation in the medical record will be .complete and accurate .Documentation of procedures and treatments will include care-specific details, including .The date and time the procedure/treatment was provided .The assessment data and/or any unusual findings obtained during the procedure/treatment .Notification of family, physician, or other staff, if indicated . Resident #5's FACE SHEET' indicated the resident was their own responsible party. No further information regarding this issue was provided to the survey team prior to the exit conference on [DATE]. 2. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], was dated as being completed on [DATE]. Resident #1 was assessed as usually able to make themself understood and as usually able to understand others. Resident #1 was assessed as having problems with short-term memory and as having problems with long-term memory. The following information was found in a facility policy/procedure titled Coronavirus (with an effective date of ,d+[DATE] and a revised date of [DATE]): Actively monitor all residents upon admission and at least daily for fever and respiratory symptoms (shortness of breath, new or change in cough, and sore throat). If respiratory symptoms noted, document in resident medical record. The facility's DAILY CHARTING FOR FOLLOW - UP OCCURRENCES forms were reviewed. These forms included the vital signs of multiple residents on the same page. Resident #1's vital signs for [DATE], [DATE], and [DATE] were included on these forms. (The vital signs included the resident's blood pressure, heart rate, respiratory rate, temperature, and pulse oximeter reading.) On [DATE] at 10:15, the facility's Director of Nursing (DON) was asked about the monitoring of residents after testing positive for COVID-19. The DON reported residents who are COVID-19 positive would be monitored at least daily for signs and symptoms of COVID-19 including a full set of vital signs (blood pressure, heart rate, respiratory rate, temperature, and pulse oximeter reading). At this time, the aforementioned DAILY CHARTING FOR FOLLOW - UP OCCURRENCES forms were reviewed with the DON. The DON confirmed Resident #1's vital signs for [DATE], [DATE], and [DATE] were not documented in the resident's clinical record. During an interview on [DATE] at 12:20 p.m., the DON reported they would expect vital signs to be obtained as part of this assessment. The following information was found in a facility policy titled Charting and Documentation (with a revised date of [DATE]): All services provided to the resident, process toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the residents medical record.The following information is to be documented in the resident medical record: . Objective observations . Changes in the resident's condition .Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. On [DATE] at 12:52 p.m., the failure of Resident #1's vital signs to be documented as part of the clinical record was discussed with the facility's Administrator, Director of Nursing, and Regional Nurse Consultant. The DAILY CHARTING FOR FOLLOW - UP OCCURRENCES forms not including a time for when the vital signs were obtained and the name of the individual who obtained the vital signs was also discussed.

Based on observations, interviews, clinical record review, and the review of documents, it was determined the facility staff failed to ensure medications were correctly stored on 2 of 2 units and in one (1) resident's room (Resident #7). The findings include: 1. The facility staff failed to ensure open vials of [MEDICATION(S)] (PPD) injectable solution was correctly labeled and stored on two (2) of two (2) nursing units. [MEDICATION(S)] PPD solution is an intradermal injection used to assist with diagnosing [CONDITION(S)] (TB). The facility staff provided the survey team with a Medication Storage Guidance document which included the following information about the [MEDICATION(S)] PPD injectable solution: Date when opened and discard unused portion after 30 days. On 8/16/21 at 10:40 a.m., the facility's medication storage refrigerator, on Unit #2, was observed with Employee #22 (a registered nurse (RN)). One (1) open vial of [MEDICATION(S)] PPD injectable solution was noted to not be dated; and one (1) open vial of [MEDICATION(S)] PPD injectable solution was noted to be dated 5/18/21. On 8/16/21 at 10:56 a.m., the facility's medication storage refrigerator, on Unit #1, was observed with Employee #23 (a licensed practical nurse (LPN)). One (1) open vial of [MEDICATION(S)] PPD injectable solution was noted to not be dated. During an interview on 8/16/21 at 4:00 p.m., Employee #24 (a nurse consultant) reported the aforementioned vials of [MEDICATION(S)] PPD injectable solution will be discarded. The incorrect storage of the aforementioned vials of [MEDICATION(S)] PPD injectable solution was discussed with the facility's Administrator, Director of Nursing (DON), and two (2) Nurse Consultants, during a survey team meeting, on 8/16/21 at 5:30 p.m. 2. For Resident #7, the facility staff failed to secure an individual unlabeled container of clear nebulizer medication solution. The nebulizer solution was observed on the resident's over bed table in their room. Resident #7's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 5/28/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, Cognitive Patterns. On 8/15/21 at 10:08 am, while speaking to Resident #7 in their room, the surveyor observed an individual unlabeled container of clear nebulizer medication solution standing in a cup on the resident's over bed table. Surveyor asked the resident what the medication was and they stated that's for my smoking pipe pointing to a nebulizer located on the nightstand. Resident #7 stated they use it twice a day. At 10:13 am, the UM (unit manager) accompanied the surveyor to the resident's room and observed the container of nebulizer solution. At 10:17 am, the UM stated they tossed it and the nurse working now did not leave it in there. UM further stated they would talk to the other nurses about it. Resident #7's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #7's July and August 2021 MARs (medication administration record) revealed the medication was last initialed as being administered on 7/24/21. On 8/15/21 at 11:40 am, surveyor notified the DON (director of nursing) of the observation of the individual unlabeled container of clear nebulizer medication solution observed in Resident #7's room. On 8/15/21 at 4:30 pm, surveyor notified the administrator, DON, and Regional Nurse Consultants of the observation of the container of nebulizer medication solution observed in Resident #7's room. No further information regarding this issue was presented to the survey team prior to the exit conference on 8/16/21.

Based on interviews and the review of documents, it was determined the facility staff failed to inclued intergrating the hospice plan of care services and clinical documentation into the facility's clinical documentation for 1 of 21 sampled patients (Resident #37). The findings include: Resident #37's clinical documentation, maintained at the facility, failed to include the hospice's plan of care and hospice staff visit notes. Resident #37's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 6/30/21, was signed as completed on 7/1/21. Resident #37 was assessed as rarely or never able to make self understood and as rarely or never able to understand others. Resident #37 was assessed as having short-term and long-term memory problems. Resident #37 was assessed as being totally depended on others for bed mobility, transfers, dressing, eating, personal hygiene, and bathing. Resident #37's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #37 was documented as receiving hospice care. Resident #37's provider orders included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The following information was found in a facility policy titled Hospice Program (with a revised date of July 2017): Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being. During an interview on 8/16/21 at 2:50 p.m., the facility's Director of Nursing (DON) reported the hospice documentation was not in the resident's clinical record; the DON reported the hospice documentation had been faxed to the facility on [DATE]. On 8/16/21 at 3:06 p.m., a copy of the hospice care plan for Resident #37 was requested from the facility's DON. On 8/16/21 at 3:43 p.m., Employee #28 (a licensed practical nurse (LPN)) provided a copy of the hospice care plan to the survey team. Employee #28 reported the care plan had to be faxed from the hospice. The faxed machine had dated the hospice care plan as being faxed on 8/16/21 at 3:30 p.m. The facility's written agreement with the hospice providing care to Resident #37 included the following information: - HOSPICE'S RESPONSIBILITIES . Hospice shall furnish to Facility a copy of its recommended Plan of Care for each Hospice Patient. - RECORDS . Facility and Hospice shall each prepare and maintain accurate and complete clinical records concerning each Hospice Patient in accordance with prudent record keeping procedures and as required by law. Facility and Hospice shall each retain such records for such time periods as required by applicable law. Facility and Hospice shall coordinate record keeping. The failure of the facility staff to ensure Resident #37's hospice care plan and hospice notes were maintained as part of the resident's clinical documentation at the facility was discussed with the facility's Administrator, Director of Nursing (DON), and two (2) Nurse Consultants, during a survey team meeting, on 8/16/21 at 5:30 p.m.

Based on observations, interviews, the review of documents, and during medication pass observations, it was determined the facility staff failed to ensure a medication error rate of less than 5%. There were two (2) errors in 31 opportunities resulting in a medication error rate of 6.45%. The findings include: Medications errors were observed while completing the Medication Administration Task. There were two (2) errors in 31 opportunities resulting in a medication error rate of 6.45%. On 8/15/21 at 8:52 a.m., Employee #21 (a licensed practical nurse) was observed administering medications to Resident #57. The following medications were ordered but not administered: Calcium 600-Vit D3 800 one tablet by mouth every day and [MEDICATION(S)] eye drops one drop to each eye every day. On 8/15/21 at 9:59 a.m., Employee #21 was asked about the failure to administer Resident #57's Calcium/Vit D tablet and [MEDICATION(S)] eye drops. Employee #21 confirmed the Calcium/Vit D tablet had not been administered because it was not available; Employee #21 stated they would have to call the medical provider to obtain an order to hold this medication. Employee #21 also confirmed they did not administer eye drops to Resident #57. Review of Resident #57's medication administration records (MARs) revealed documentation indicating the Calcium/Vit D tablet and the [MEDICATION(S)] eye drops had been administered on the morning of 8/15/21; Employee #21 confirmed the documentation of the medications being administered was incorrect and would need to be corrected. The following information is found in a facility policy titled Administering Medications (with a revised date of April 2019): Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any required time frame. The aforementioned medication errors resulting in a greater than 5% medication error rate was discussed with the facility's Administrator, Director of Nursing (DON), and two Nurse Consultants, during a survey team meeting, on 8/16/21 at 5:30 p.m.

Based on interviews and the review of documents, it was determined the facility staff failed to maintain complete and accurate clinical record for two (2) of 21 sampled residents (Resident #77 and Resident #82) and one (1) resident (Resident #57) observed during the Medication Administration Task. The findings include: 1. Resident #57's clinical record included documentation that indicated two (2) medications were administered when they had not been administered. On [DATE] at 9:59 a.m., Employee #21 as asked about the documentation that Resident #57 had been administered a Calcium/Vit D tablet and [MEDICATION(S)] eye drops on the morning of [DATE] when the medications had not been administered. Employee #21 confirmed the Calcium/Vit D tablet had not been administered because it was not available. Employee #21 also confirmed they did not administer eye drops to Resident #57. Review of Resident #57's medication administration records (MARs) included documentation that the Calcium/Vit D tablet and the [MEDICATION(S)] eye drops had been administered on the morning of [DATE]; Employee #21 confirmed the documentation of the aforementioned medications being administered was incorrect and would need to be corrected. The following information was found in the facility document titled DOCUMENTATION NURSING CLINICAL RECORDS (this document was not dated): Following the required components for nursing documentation a permanent medical record is maintained for each resident . Accurate documentation that correspond with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The aforementioned incorrect medication administration documentation was discussed during a meeting, on [DATE] at 4:42 p.m., with the facility's Administrator, Director of Nursing (DON), and two (2) Nurse Consultants. 2. Resident #77's provider orders failed to include a code status for the resident. Resident #77's minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], was signed as completed on [DATE]. Resident #77 was assessed as able to make self understood and as usually able to understand others. Resident #77's Brief Interview for Mental Status (BIMS) summary score was a 13 out of 15. Resident #77 was assessed as requiring assistance of two (2) or more individuals with bed mobility, transfers, dressing, and personal hygiene. Resident #77's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #77's clinical record failed to reveal a provider order to address the resident's code status. Resident #77's medical provider orders were reviewed with Employee #29 (a registered nurse) on the afternoon of [DATE]. Employee #29 confirmed Resident #77's clinical record did not include a medical provider order addressing the resident's code status. Employee #29 was asked if the facility's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #77's clinical record included documentation from a prior medical facility that indicated the resident had been a full code at the prior facility. During a telephone interview on [DATE] at 4:30 p.m., the facility's Medical Director (MD) was asked about medical provider orders for a resident's code status. The MD reported residents should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a meeting, on [DATE] at 4:42 p.m. with the facility's Administrator, Director of Nursing (DON), and two (2) Nurse Consultants, a policy to guide admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility policy titled SELF-DETERMINATION RIGHTS POLICIES stated in the absence of a valid Do Not Resuscitate (DNR) order that cardiopulmonary resuscitation (CPR) would be initiated if a resident was found in cardiopulmonary arrest. Interviews with facility staff members confirmed that CPR would be provided if there were no DNR order for a resident experiencing cardiopulmonary arrest. The absence of a medical provider code status order for Resident #77 was discussed during a meeting, on [DATE] at 5:30 p.m., with the facility's Administrator, Director of Nursing (DON), and two (2) Nurse Consultants. 3. Resident #82's provider orders failed to include a code status for the resident. Resident #82's minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], was signed as completed on [DATE]. Resident #82 was assessed as able to make self understood and as able to understand others. Resident #82's Brief Interview for Mental Status (BIMS) summary score was a 12 out of 15. Resident #82 was assessed as being dependent on others for bed mobility, transfers, dressing, and personal hygiene. Resident #82's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #82's clinical record failed to reveal a provider order to address the resident's code status. Resident #82's medical provider orders were reviewed with Employee #29 (a registered nurse) on the afternoon of [DATE]. Employee #29 confirmed Resident #82's clinical record did not include a medical provider order addressing the resident's code status. Employee #29 was asked if the facility's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #82's clinical record included documentation from a prior medical facility that indicated the resident had been a 'DNR (do not resuscitate) but allowed to be intubated' at the prior facility. During a telephone interview on [DATE] at 4:30 p.m., the facility's Medical Director (MD) was asked about medical provider orders for a resident's code status. The MD reported residents should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a meeting, on [DATE] at 4:42 p.m. with the facility's Administrator, Director of Nursing (DON), and two (2) Nurse Consultants, a policy to guide admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility policy titled SELF-DETERMINATION RIGHTS POLICIES stated in the absence of a valid Do Not Resuscitate (DNR) order that cardiopulmonary resuscitation (CPR) would be initiated if a resident was found in cardiopulmonary arrest. Interviews with facility staff members confirmed that CPR would be provided if there were no DNR order for a resident experiencing cardiopulmonary arrest. The absence of a medical provider code status order for Resident #82 was discussed during a meeting, on [DATE] at 5:30 p.m., with the facility's Administrator, Director of Nursing (DON), and two (2) Nurse Consultants.

Based on observations, interviews, and the review of documents, it was determined the facility staff failed to follow handwashing procedures during Medication Administration Task observations. The findings include: A facility staff member (Employee #25) (a licensed practical nurse (LPN)) failed to perform hand hygiene when changing gloves during the process of checking Resident #9's blood sugar and subsequently administering an insulin injection to the resident. On 8/14/21 at 4:50 p.m., Employee #25 was observed to check Resident #9's blood sugar and to provide Resident #9 an insulin injection. Employee #25 was observed to wash their hands at the beginning of the episode of care and at the conclusion of the episode of care. Employee #25 was observed to change their gloves, without performing hand hygiene, three (3) times during the process of checking the resident's blood sugar and the administration of insulin. Employee #25 changed their gloves without performing hand hygiene at the following steps of the process: (a) after cleaning the glucometer, (b) after performing the finger stick blood sugar (FSBS) test and prior to cleaning the glucometer, and (c) after cleaning the glucometer and prior to administering the insulin. The following information was found in a facility document titled Handwashing/Hand Hygiene (with a revised date of August 2019): - This facility considers hand hygiene the primary means to prevent the spread of infections. - Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . Before preparing or handling medications . After handling used dressing, contaminated equipment . After removing gloves . The failure of a facility staff member to perform hand hygiene when changing gloves was discussed during a survey team meeting, with the facility's Administrator, Director of Nursing (DON), and two Nurse Consultants, on 8/16/21 at 5:30 p.m.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 21 residents in the survey sample, Resident #7. The findings included: For Resident #7, the facility staff failed to dispose of the resident's excess topical medication in a manner to prevent the resident from gaining access. Resident #7's diagnosis list indicated diagnoses, which included, but not limited to Acute Kidney Failure Unspecified, Chronic Kidney Disease Stage 4 (Severe), Chronic Obstructive Pulmonary Disease Unspecified, Heart Failure Unspecified, Unspecified [CONDITION(S)] Unspecified Site, Pain in Left Knee, Pain in Right Knee, and Essential Hypertension. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 5/28/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, Cognitive Patterns. On 8/14/21 at 2:48 pm during initial rounding in Resident #7's room, surveyor observed five (5) medicine cups each containing a small amount of a white cream substance. The cups were sitting on a nightstand located directly across from the foot of the Resident #7's bed. Surveyor observed Resident #7's roommate walk by the nightstand with the medicine cups; the roommate is independently mobile and must pass by the nightstand in order to exit the room. Resident #7 was not in their room at the time of the observation. At 2:50 pm, LPN (licensed practical nurse) #1 accompanied the surveyor to Resident #7's room and observed the five medicine cups containing the white cream substance. Surveyor asked LPN #1 what the substance was in the cups and LPN #1 stated that's a good question, I'll get (his/her) nurse. At 2:52 pm, LPN #2 entered Resident #7's room and stated the medicine cups contained Aspercreme and Resident #7 gets the medicine cups out of the trash and if there is any left in them (he/she) keeps them. LPN #2 proceeded to collect the five medicine cups and threw them away in Resident #7's trash can. On 8/15/21 at 10:08 am, surveyor met with Resident #7 in their room and asked the resident about the medicine cups containing the white cream substance observed the day prior. Resident #7 stated that's for my knees. Surveyor asked the resident if staff leave the cups in their room for them to use and Resident #7 stated yeah and it helps my knees. Surveyor spoke with the DON (director of nursing) on 8/15/21 at 11:40 am and notified them of the surveyor's observation on 8/14/21. Surveyor reviewed Resident #7's clinical record and was unable to locate a physician's order for Aspercreme. However, Resident #7's current physician's orders included an active order dated 10/19/20 stating [MEDICATION(S)] 1% gel apply 2 GM to left foot four times daily and an active order dated 2/15/21 stating [MEDICATION(S)] 1% gel apply 2 gm to bilateral knees four times daily. On 8/15/21 at 4:30 pm during a meeting with the administrator, DON, and Regional Nurse Consultants, surveyor discussed the concern of the observation of the five medicine cups containing a white cream substance in Resident #7's room. Surveyor spoke with the DON the following day at approximately 11:00 am and the DON stated they did not think Resident #7 had a self-administration of medications assessment and this morning they have went around to the nurses and instructed them to throw away medicine cups outside of the resident's room. No further information regarding this issue was presented to the survey team prior to the exit conference on 8/16/21.

Based on staff interview and clinical record review, the facility staff failed to ensure the residents receive treatment and care in accordance with the comprehensive person-centered care plan for 1 of 21 residents in the survey sample, Resident #67. The findings included: For Resident #67, the facility staff failed to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #67's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 7/23/21 assigned the resident a BIMS (brief interview for mental status) score of 3 out of 15 in section C, Cognitive Patterns. In section I, Active Diagnoses, Resident #67 was coded for the presence of Heart Failure and Hypertension. Resident #67's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] <150 hold med DX: [CONDITION(S)]. A review of Resident #67's August 2021 MAR (medication administration record) on 8/15/21 revealed [MEDICATION(S)] was administered with the resident's systolic blood pressure below 150 on 13 separate occasions: 8/01/21 given with BP (blood pressure) of 128/80 8/02/21 given with BP of 136/80 8/03/21 given with BP of 130/72 8/04/21 given with BP of 140/80 8/05/21 given with BP of 138/80 8/06/21 given with BP of 138/74 8/08/21 given with BP of 135/89 8/09/21 given with BP of 149/83 8/10/21 given with BP of 144/70 8/11/21 given with BP of 142/86 8/12/21 given with BP of 142/86 8/13/21 given with BP of 133/61 8/14/21 given with BP of 132/76 On 8/15/21 at 11:40 am, surveyor notified the DON (director of nursing) of Resident #67 receiving [MEDICATION(S)] with a systolic blood pressure below 150 on 13 occasions thus far during August. Resident #67's current comprehensive person-centered care plan included a problem area stating in part Cardiovascular/Respiratory: (Resident #67)'s vital signs have been stable. No s/s (signs/symptoms) of JVD (jugular vein distension), [CONDITION(S)] or SOB (shortness of breath) have been noted since admission. DX: [CONDITION(S)] (chronic obstructive pulmonary disease), [CONDITION(S)] ([CONDITION(S)] accident), Type 2 DM (diabetes mellitus), Heart Failure . An approach states medications/labs as ordered. Inform MD of any changes. On 8/15/21 at 4:30 pm during a meeting with the administrator, DON, and regional nurse consultants, surveyor discussed the concern of Resident #67's medication errors for [MEDICATION(S)] administration. No further information regarding this issue was presented to the survey team prior to the exit conference on 8/16/21.

Based on interviews and the review of documents, it was determined the facility staff failed to provide an ordered therapeutic diet for 1 of 21 sampled resident (Resident #37). The findings include: Facility staff members failed to provide Resident #37 with the medical provider ordered and care planned six (6) small meals a day. Resident #37's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 6/30/21, was signed as completed on 7/1/21. Resident #37 was assessed as rarely or never able to make self understood and as rarely or never able to understand others. Resident #37 was assessed as having short-term and long-term memory problems. Resident #37 was assessed as being totally depended on others for bed mobility, transfers, dressing, eating, personal hygiene, and bathing. Resident #37's diagnoses included, but were not limited to: [CONDITION(S)], Alzheimer's disease, malnutrition, anxiety, and depression. Resident #37 was documented as receiving hospice care. The following information was found in the facility's Dietary Policy and Procedure Manual under the heading of Accurate Diet Service: POLICY: Each resident will receive proper nutrition as prescribed by their physician. PROCEDURE: 1. Before each meal service a dietary employee will check the tray cards with a master list to assure the correct diet order is on the card . 4. The Director of Nursing Services and the Food Service Director with input from the consultant dietitian must review the resident's nutritional problems and coordinate all resolutions. Recommendations must be presented to the attending physician for his or her approval. Employee #26 (the Dietary Manager) reported there was no policy/procedure that specifically addressed providing six (6) small meals a day. Resident #37's provider orders included the following dietary orders: - Magic cup with meals dated 4/10/20, and - Resident is to receive six small meals a day dated 10/7/20. The following information was found on Resident #37's tray card: Diet Order: Pureed, Meals 6 Times A Day, Nectar Thick Liquid. Resident #37's nutritional care plan included the following approach: SIX SMALL MEALS A DAY AS ORDERED. On 8/16/21 at 1:22 p.m., Employee #26 (the Dietary Manager) was asked about Resident #37's six (6) meals a day order. Employee #26 stated the facility staff provided three regular meals and snacks at 10:00 a.m., 2:00 p.m., and 4:00 p.m. On 8/16/21 at 1:36 p.m., Employee #27 (a Registered Dietitian) was interviewed via telephone. Employee #27 confirmed Resident #37 was provided three (3) regular meals a day with snacks three (3) times a day. Employee #27 reported a menu for six (6) small meals a day had not been created. On 8/16/21 at 1:54 p.m., Resident #37's personal sitter was interviewed; the personal sitter was provided by the resident's family. The personal sitter reported Resident #37 was provided three (3) meals a day and that snacks are available. The personal sitter also stated the family brought snacks for the resident. The failure of the facility staff to provide Resident #37 with the ordered six (6) small meals a day was discussed for a final time with the facility's Administrator, Director of Nursing (DON), and two (2) Nurse Consultants, during a survey team meeting, on 8/16/21 at 5:30 p.m.

Based on observation, staff interview, family interview, and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for 1 of 3 residents, (R) Resident 1. The findings included: The facility staff were documenting R1 had oxygen in place. When in fact the resident was not currently using oxygen. R1's face sheet in the (EHR) electronic health record included the diagnosis, Alzheimer's dementia and dysphagia. Section C (cognitive patterns) of R1's significant change (MDS) minimum data set assessment with an (ARD) assessment reference date of 04/13/2021 was coded 1/1/3 to indicate the resident had problems with long and short term memory and was severely impaired in cognitive skills for daily decision making. Section O (special treatments and programs) was coded to indicate R1 used oxygen and was receiving hospice services. A review of R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order date 03/23/2021. A review of R1's 05/2021 (EMARs) electronic medication administration records revealed that the facility nursing staff were documenting the oxygen was being administered daily and had been signed by the nursing staff as being administered from 05/01-05/11/2021. Throughout the course of the survey (05/10-05/12/2021), the surveyor did not observe the oxygen in place. The surveyor did observe an oxygen concentrator in R1's room. 05/11/21 2:30 p.m., family members 1 and 2 stated R1 did not use oxygen and they did not want them to become dependent on it. 05/11/2021 5:30 p.m. (RN) registered nurse 1 stated R1 did not use oxygen all the time but had it the room if they needed it. RN 1 identified their initials on the EMAR and stated they probably checked it as being in use because it was in the room and that it should have been changed to (PRN) as needed. 05/11/2021, the administrative staff were made aware that the facility nursing staff were documenting for the use of R1's oxygen when it was not in use. On 05/12/2021, the (DON) director of nursing stated the oxygen had been changed to PRN. No further information regarding this issue was provided to the surveyor prior to exit on 05/12/2021.

Based on interviews and the review of documents, it was determined the facility staff failed to maintain complete and/or accurate clinical documentation for one (1) of three (3) sampled residents (Resident #1). The findings include: Facility staff members failed to maintain a complete and/or accurate clinical record for Resident #1. Resident #1's minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/11/2020 had the resident assessed as able to make self understood and as able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15. Resident #1 was documented as requiring the assistance of one (1) individual with bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Resident #1's [DIAGNOSES REDACTED]. A facility staff member documented two (2) pulse oximetry readings/results for Resident #1 when the resident was not present at the facility. Resident #1's clinical record included a nursing note dated 11/30/2020 at 7:34 a.m. This note was documented as a (l)ate entry for 0620 (6:20 a.m.). This note details notifying a provider of changes in Resident #1's condition, receiving orders to send Resident #1 to the emergency department, calling for ambulance transport, and calling report to the emergency department. Documentation of the time Resident #1 left the building was not found in Resident #1's clinical record at the facility. Documentation from Resident #1's ED visit indicated the resident arrived on 11/30/2020 at 7:41 a.m. Resident #1 did not return to the facility until 12/8/2020. On 11/30/2020 at 11:17 a.m., Resident #1 was documented as having a pulse oximetry reading/result of 98%; the resident was not present at the facility at this time. On 11/30/2020 at 2:35 p.m., Resident #1 was documented as having a pulse oximetry reading/result of 97%; the resident was not present at the facility at this time. A facility staff member incorrectly document the date and time of notifying a provider of Resident #1's change in condition. Review of Resident #1's clinical record included a nursing note dated 11/29/2020 at 7:34 a.m. documented by LPN #2. This note read as: Resident having in feet an legs. (sic) Right foot is purplish and red in color. (Medical Doctor) call (new order) for Venous Doppler (to) bilateral below knees. Voltran (sic) gel apply (four times a day) as needed for pain. This note did not address skin temperature, capillary refill time, pulses, or pain description. Resident #1's clinical record included an order dated 11/28/2020 for bilateral lower extremities venous doppler study and Voltran (sic) gel every four (4) hours as needed for pain. This order was taken by and written by LPN #2. This order did not include the time the provider gave LPN #2 the order. This order did not specify if the order was a telephone order or a verbal order. On 1/27/21 at 4:49 p.m., LPN #2 was interviewed about the aforementioned order dated 11/28/2020 and the note dated 11/29/2020. LPN #2 confirmed it was a telephone order given by the facility's Medical Director. LPN #2 stated the wrong date must have been written for the order. LPN #2 reported a time is usually not documented when taking a telephone order. On 1/29/21 at 11:56 a.m., a radiology staff member (RSM #1) from the mobile radiology company (that completed Resident #1's Venous Doppler ultrasound) was interviewed. RSM #1 reported Resident #1's Venous Doppler ultrasound was ordered on [DATE] at 4:04 p.m. Documentation provided by the mobile radiology company staff member confirmed the Venous Doppler ultrasound was ordered on [DATE] at 4:04 p.m. Resident #1's nursing notes did not include a note documenting Resident #1's provider being notified of the aforementioned assessment changes/findings on the afternoon of 11/28/2020. The following information was found in a facility policy titled Verbal Orders (with a revised date of February 2014): The individual receiving the verbal order must write it on the physician's orders [REDACTED].o. (verbal order) or t.o. (telephone order) . The individual receiving the verbal order will . record the date and time of the order. Facility staff members failed to document injection site/location for two (2) injections administered to Resident #1. On 11/16/2020 at 7:18 p.m., Resident #1 was documented as receiving a [MEDICATION NAME] 60 mg intramuscular injection; the site/location of the injection was not documented. On 11/17/2020 at 2:05 a.m., Resident #1 was documented as receiving a [MEDICATION NAME] 30 mg intramuscular injection at 1:40 a.m.; the site/location of the injection was not documented. The following information was found in a facility policy titled Administering Medications (with a revised date of April 2019): As required or indicated for a one-time medication, the individual administering the medication records in the resident's medical record: . The injection site (if applicable) . The following information was found in a facility policy titled Charting and Documentation (with a revised date of July 2017): - 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. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. - The following information is to be documented in the resident medical record: a. Objective observations; . c. Treatments or services performed; d. Changes in the resident's condition; . f. Progress toward or changes in the care plan goals and objectives. - Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. - Documentation of procedure and treatments will include care-specific details, including: . The assessment data and/or any unusual findings obtained during the procedure/treatment . During an interview on 2/3/21 at 10:06 a.m., with the facility's Administrator, Director of Nursing (DON), and Nurse Consultant, the findings of incomplete and/or inaccurate clinical documentation in Resident #1's clinical record was discussed.

Based on interviews, the review of documents, and in the course of a complaint investigation, it was determined the facility staff failed to assess a resident for relevant clinical information related to a change in condition for one (1) of three (3) sampled residents (Resident #1). The findings include: The facility staff failed to ensure Resident #1's nursing assessments appropriately and completely evaluated the resident when the resident began to voice/experience lower extremity changes. The facility staff failed to ensure Resident #1 was assessed by a medical provider: (a) when the resident complained of being paralyzed; (b) after the resident began having falls; and/or (c) when the resident began to have lower extremity skin assessment changes. Resident #1's minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/11/2020 had the resident assessed as able to make self understood and as able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15. Resident #1 was documented as requiring the assistance of one (1) individual with bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Resident #1's [DIAGNOSES REDACTED]. Resident #1's CNA Skin Check Form(s) were reviewed. It was noted that documentation on these forms indicted the resident would often refuse to have his skin assessed. An 11/16/2020 CNA Skin Check Form included the following note Refused (times three (3)) says his legs are killing him and that he's paralyzed. This form had an area for a nurse to sign and date upon reviewing the form; no nurse had signed and dated this form. This form did not include a time identifying when Resident #1 reported being paralyzed. No nursing assessment related to Resident #1's complaint of being paralyzed was found by or provided to the surveyor. No documentation of what the resident meant by paralyzed was found by or provided to the surveyor. Resident #1's clinical documentation included a nursing note dated 11/16/2020 at 7:18 p.m. This nursing note indicated the MD (medical doctor) was notified the resident was complaining of pain to bilateral lower extremities. This note also indicated the nurse assisted the resident with repositioning, provided 'as needed' pain medication, and applied warm towels to the lower extremities. This note did not address the resident's complaint of his legs being paralyzed. No evidence was found to indicate Resident #1's lower extremities had been assessed for weakness, sensation, movement, and/or range of motion. This note did not include a description of the pain or a pain scale rating. During an interview on 2/2/2021 at 2:05 p.m., with the facility's Administrator and Nurse Consultant, the nurse consultant reported Resident #1 had a history of [REDACTED]. The surveyor was provided documentation showing Resident #1 had received 'as needed' pain medications though out his stay at the facility. Review of Resident #1's electronic care plan (created on 11/11/2020) which addressed falls and injuries included the following statement: NO FALLS NOTED SINCE ADMISSION TO THIS FACILITY. The copy of Resident #1's paper care plan had the aforementioned statement marked out with a single line drawn through the statement; no date, time, or signature of the individual who marked the statement out was documented. The paper care plan identified falls beginning on 11/23/2020. Documentation of MD (medical doctor) notification, of the falls, was found in Resident #1's care plan. The falls were documented either as resulting in skin tears or as resulting in no injuries. Resident #1 was documented as having falls at the following times: 11/23/2020 at 9:30 p.m.; 11/25/2020 at 11:45 p.m.; 11/27/2020 at 12:10 a.m.; and 11/27/2020 at 4:50 a.m. One fall was documented as occurring when Resident #1 was using the bedpan. Two (2) of the falls were documented as occurring when the resident was attempting to self-transfer. One fall was documented as occurring while the resident was in the bathroom and the resident's wheelchair moved. The following information was found in a facility policy/procedure titled Assessing Falls and Their Causes (with a revised date of March 2018): - The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. - Falling may be related to underlying clinical or medical conditions, overall functional decline, medication side effects, and/or environmental risk factors. - As indicated, the attending physician will examine the resident or may initiate testing to try to identify causes. During an interview on 2/2/2021 at 2:05 p.m., with the facility's Administrator and Nurse Consultant, the nurse consultant reported Resident #1 had a history falls. The surveyor was provided with documentation the facility received when Resident #1 had been referred to the facility. Resident #1's referral information identified a history of falls. Review of Resident #1's clinical documentation indicated the resident had been at the facility for approximately one (1) year without experiencing a fall. During an interview on 2/3/2021 at 12:57 p.m., the facility's Administrator reported the first fall documented for Resident #1, during his stay at the facility, was the aforementioned 11/23/2020 fall. Resident #1's clinical record included an order dated 11/28/2020 (no time was documented) for a Venous Doppler ultersound to bilateral legs (below the knees) due to pain and [MEDICATION NAME] gel four (4) times a day as needed for pain. Resident #1's clinical record failed to include documentation of the provider notification which resulted in LPN (licensed practical nurse) #2 being provided the aforementioned orders on 11/28/2020. Resident #1's clinical record failed to include documentation of LPN #2's 11/28/2020 assessment of Resident #1 leading to the need to contact the provider. LPN #2 documented the following information in a nursing note dated 11/29/2020 at 7:34 a.m.: Resident having in feet an legs. (sic) Right foot is purplish and red in color. (Medical Doctor) call (new order) for Venous Doppler (to) bilateral below knees. Voltran (sic) gel apply (four times a day) as needed for pain. This note did not address skin temperature, capillary refill time, pulses, or pain description. LPN #2 was interviewed about the aforementioned order dated 11/28/2020 but the note being dated 11/29/2020; LPN #2 stated the wrong date must have been written on the order. LPN #2 was asked about assessing Resident #1 for capillary refill; LPN #2 stated he usually did but was unable to recall. On 1/29/21 at 11:56 a.m., a radiology staff member (RSM #1) from the mobile radiology company was interviewed. (This company completed Resident #1's Venous Doppler ultrasound.) RSM #1 reported Resident #1's Venous Doppler ultrasound was ordered on [DATE] at 4:04 p.m. Documentation provided by the mobile radiology company confirmed the Venous Doppler ultrasound was ordered on [DATE] at 4:04 p.m. The following information was found in a facility policy titled Change in a Resident's Condition or Status (with a revised date of May 2017): Prior to notifying the Physician (sic) or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The following information was found in a facility policy titled Acute Condition Changes - Clinical Protocol (with a revised date of March 2018): The attending physician (or practitioner providing coverage) will respond in a timely manner to notification of problems or changes in condition and status . The nurse and physician will discuss and evaluate the situation . The physician should request information to clarify the situation; for example vital signs, physical findings, a detailed sequence of events and description of symptoms. The following information was found in a facility policy titled Charting and Documentation (with a revised date of July 2017): - 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. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. - The following information is to be documented in the resident medical record: a. Objective observations; . c. Treatments or services performed; d. Changes in the resident's condition; . f. Progress toward or changes in the care plan goals and objectives. - Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. - Documentation of procedures and treatments will include care-specific details, including: . The assessment data and/or any unusual findings obtained during the procedure/treatment . The facility's Administrator, Director of Nursing (DON), and Nurse Consultant was interview on 2/2/21 at 10:10 a.m. The absence of nursing documentation providing information detailing Resident #1's lower extremity assessments was discussed. The administrative team was asked about the absence of documentation detailing the resident's capillary refill time, skin temperature, sensation, and the presence and/or the quality of lower extremity pulses. The facility's Nurse Consultant stated the expectation of facility staff is that they would chart by exception therefore only documenting if an abnormal finding was identified. The administrative team was asked for the facility's policy addressing and detailing charting by exception. The administrative team was asked for education and/or guidance provided to staff members about charting by exception. On 2/2/21 at 2:05 p.m., the facility's Administrator and Nurse Consultant were interviewed. The Nurse Consultant reported the facility did not have a policy and procedure that uses the phrase charting by exception; the Nurse Consultant referred the surveyor to the Charting and Documentation policy that was previously provided to the surveyor. The Nurse Consultant reported the facility did not have a policy that detail normal assessment findings to be considered when charging by exception. The Administrator and Nurse Consultant was asked how one could determine if something was assessed as normal or if something was not assessed; the Nurse Consultant reported the expectation is that nursing staff would complete an assessment. On 2/2/21 at 3:07 p.m., the facility's Administrator, Director of Nursing (DON), and Nurse Consultant were interviewed. Facility staff member training on 'charting by exception' was discussed. The Nurse Consultant reported none of the facility staff member's training would specifically speak to 'charting by exception' nor would the training address the expectation of staff members when 'charting by exception'. Resident #1's clinical record included a nurse practitioner (NP) Telemedicine Follow-up Visit note dated 11/13/2020. This note documented the resident as alert and oriented with no acute distress. Under the 'review of systems' area of this NP documentation the neurological section had 'weakness' circled and the musculoskeletal section had 'joint' and 'muscle pain' circled. Under the 'physical exam' area of this NP documentation had the area of Gen WN, NAD was marked with a check mark. (Instructions for completing this form indicated Check = normal, circle = abnormal.) During an interview with the facility's Medical Director on 2/1/21 at 1:41 p.m., the Medical Director explained that 'Gen WN, NAD' stood for 'general within normal limits, no acute distress'. The next medical provider documentation was dated 1/8/2021. Documentation indicated a medical provider had been notified of Resident #1's aforementioned falls and change in lower extremity skin assessment but no provider assessment of these issues was identified prior to the resident being sent to the emergency department (ED) on 11/30/2020. Resident #1's clinical documentation included the following nursing note date 11/30/2020 at 7:34 a.m.: Late entry for 0620. Resident complaining of increased pain in right lower extremity, the extremity appears mottled with a purple hue. Black scabs noted to 1st, 2nd, 3rd, and 4th digit (sic) to right foot. It is cold to touch in comparison to the left lower extremity. (Capillary refill) is noted to be 13 seconds in right foot and 3 seconds in left foot. Resident states he has minimum to no feeling in right lower extremity from half way down shin to foot and cannot move foot. Plantar reflex absent, unable to detect pedal pulse in right foot. (Vital signs) obtained (blood pressure) 90/52 (pulse) 89 (respirations) 20 (temperature) 97.9 (oxygen saturation) 97%. Resident shows no signs or symptoms of acute distress at this time . This note continues to show medical provider notification and resident transfer to an Emergency Department (ED). Resident #1's ED Provider note, dated 11/30/2020 at 8:03 a.m., included the following information under the History section: Patient presents via EMS (emergency medical services) with a 2 week history of pain in his right lower extremity. According to nursing home staff patient has had decreased pulses in his right foot for the last 3 days. There are some wounds, necrotic areas noted on the right foot. Patient denies fevers or chills. Does have some trouble moving his foot. The right leg is cooler to touch. Patient denies any direct trauma. Ultrasound was done yesterday showing no [MEDICAL CONDITION]. Patient denies any trauma, no prior injuries to this area. Patient is had (sic) difficulty walking due to the pain. No chest pain or shortness of breath, no abdominal pain, no nausea, vomiting, diarrhea . EMS notes they were not able to palpate a pulse in the patient's right foot. The history is provided by the patient and the EMS personnel. The ED provider's documentation included the following under the Medical Decision Making section of the note: .Patient does have some decreased movement at the right foot which has been present for 2 days per him . UPON REASSESSMENT, PATIENT'S RIGHT LOWER EXTREMITY LOOKED WORSE, WORSE MOTTLING, COOLER TO TOUCH. WENT AHEAD AND DISCUSSED THE CASE WITH VASCULAR SURGERY . Resident #1's Physician Discharge Summary, from the resident's hospital documentation, stated the resident had a right AKA (above the knee amputation) completed on 11/30/2020. The absence of a medical provider's assessment during the time of Resident #1's aforementioned lower extremity issues was discussed with the facility's Administrator, Director of Nursing (DON), and Nurse Consultant on 2/3/21 at 10:06 a.m. and 2:08 p.m. It was reported that currently all medical provider visits were occurring via telehealth/telemedicine visits. During the 2/3/21 interview at 10:06 a.m., the DON and the Nurse Consultant reported the provider could do a telehealth/telemedicine visit at any time. This is a complaint deficiency.

Based on clinical record review, Resident interview, staff interview, family interview, facility document review, and during the course of a complaint investigation, it was determined that the facility staff failed to allow 1 of 26 Residents in the survey sample to receive visitors of choice, Resident # 20. The findings included The facility staff failed to allow Resident # 20 to visit with her son at the facility. Resident # 20 was an [AGE] year-old-female who was originally admitted to the facility on [DATE] and had a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 20 was reviewed on 9/25/19 at 10:00 am. The most recent MDS assessment (minimum data set) for Resident # 20 was a quarterly assessment with an ARD (assessment reference date) of 7/31/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 20 had a BIMS (brief interview for mental status) score of 7 out of 15, which indicated that Resident # 20's cognitive status was severely impaired. The current plan of care for Resident # 20 was reviewed and revised on 8/6/19. The facility staff documented a Problem/Need for Resident # 20 as, Resident # 20 is invited and encouraged to attend and participate in activities, however she does refuse on most days. Resident # 20 remains active by music, interacting with others etc. Resident # 20 has very good family support and contact as family visits daily. Her favorite activity is spending time with family. On 9/26/19 at 9:06 am, the surveyor conducted an interview with Resident # 20 in her room. The surveyor asked Resident # 20 if her son (name withheld) had visited her lately. The surveyor observed Resident # 20 as she became tearful. Resident # 20 stated, No I haven't seen (name withheld) in a while. Maybe about three months or so, maybe even longer than that. He was my first born. The surveyor asked Resident # 20 why she had not seen her son in a while. Resident # 20 stated, He and (name withheld) are not allowed to come here. I guess they got in some trouble and are not allowed to come here. On 9/26/19 at 9:10 am, the surveyor spoke with Resident # 20's son via telephone. The surveyor asked Resident # 20's son if he was allowed to visit Resident # 20 at the facility. Resident # 20's son informed the surveyor that he was not allowed to visit Resident # 20 in the facility. Resident # 20's son stated, That said I caused trouble and I never opened my mouth. I am in a wheelchair. I am paraplegic. They just sent me a letter and said I can't come to the nursing home or any of their other properties, and if I do, I would be arrested. I just hate that I am not allowed to see my mother. She is [AGE] years old. She won't be here much longer. On 9/26/19 at 9:22 am, the surveyor interviewed the facility administrator. The surveyor asked the facility administrator if Resident # 20's son and daughter had been banned from the facility. The facility administrator informed the surveyor that Resident # 20's son and daughter had been banned from the facility. The surveyor asked the facility administrator what happened that warranted the decision. The facility administrator explained that Resident # 20's son and daughter would visit Resident # 20 around 7:30pm or 8:00pm when she would be getting ready to go to sleep for the night. The administrator stated they would come in threatening the nurses, and that one of the nurses brought pepper spray. The surveyor asked if both Resident # 20's son and daughter threatened the nurses. The administrator stated that Resident # 20's daughter would. The administrator stated that Resident # 20's daughter would want information on Resident # 20. The administrator stated the facility would provide information to Resident # 20's other daughter who was the responsible party. The administrator stated that the facility explained the process, offered social work assistance, and set up a special care plan meeting for all of the children. The administrator stated, (Daughter's name withheld) took the meeting and turned it into a bashing session. The administrator informed the surveyor that after the care plan meeting Resident # 20's daughter continued to come in making threats, which caused the facility nurses to cry. The administrator stated, After several discussions with them I decided to go the route to ask them to leave and they would not. The facility then contacted the police to have Resident # 20's son and daughter escorted out of the facility. The administrator stated that Resident # 20's son and daughter asked if they could visit Resident # 20 one last time and were allowed to, but that Resident # 20's daughter got Resident # 20 upset. The surveyor informed the administrator following the interview that the information that he provided during the interview supported that Resident # 20's daughter caused issues within the facility, but none of the information provided by the administrator reflected that Resident # 20's son had caused any issues that would support him being banned from the facility. The surveyor asked the administrator to provide documentation of any incidents that occurred when Resident # 20's family had caused any disturbances within the facility to create an unsafe environment. On 9/26/19 at 4:30 pm, the administrator provided the surveyor with a copy of the Care Plan Meeting Summary that was held on 3/5/19. The surveyor observed documentation on the care plan meeting summary that Resident # 20's son was Unable to attend the meeting. The administrator also provided the surveyor with copies of two Resident/Visitor Incident Witness Statement sheets that were documented on 5/17/19. After the surveyor reviewed the resident/visitor incident witness statement sheets, the surveyor did not observe any documentation that supported that Resident # 20's son caused any disturbances that would warrant him being banned from the facility. The administrator also provided the surveyor with a copy of a No Trespassing Notification that had been sent to Resident # 20's son that was dated 5/20/19. The no trespassing notification contained documentation that included but was not limited to, .You are hereby notified pursuant to Virginia Code §18.2-119 that you are forbidden to entering upon the building or grounds of any (Facility name withheld) Nursing Center for any reason whatsoever. You are further notified that violation of this notice will subject you to immediate arrest as a trespasser or a warrant will be sworn for your arrest and prosecution. Court appointed guardianship papers in the clinical Record for Resident # 20 contained documentation that included but was not limited to, .Ordered that all of the other children of the Respondent being (four of Resident # 20's children's name withheld) shall have reasonable access to the care providers and health care records of the Respondent. In addition said adult children shall have access to and visitation with the Respondent which shall be exercised only in accordance with any instructions and/or limitations or restrictions imposed by the Respondent's health care providers. The facility Visitation policy contained documentation that included but was not limited to, .Policy statement Our facility permits residents to receive visitors subject to the resident's wishes and the protection of the rights of the other residents in the facility. Policy Interpretation and Implementation 1. We recognize the resident's need to maintain contact with the community in which he or she has lived or is familiar. Therefore, the resident is permitted to have visitors as he/she wishes. 13. Incidents of any visitor's disruptive behavior must be documented in the resident's medical record or other facility approved form. On 9/26/19 at 5:01 pm, the administrator, director of nursing, and corporate nurse consultant were informed that after the interview with the administrator, review of Resident # 20's clinical record, the facility policy, and statements that had been provided by the facility, there was no documentation that supported the facility banning Resident # 20's son from the facility, which violated Resident # 20 right to have her son visit. The surveyor provided the administrative team with the opportunity to ask questions and to provide any additional information to support banning the son from entering the facility. The administrative team stated they had no further questions to ask. No further information regarding this issue was presented to the survey team prior to the exit conference on 9/26/19.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to notify the physician of a change in the status concerning pain management for 1 of 23 residents in the survey sample (Resident #85). The findings included: Resident #85 reported to the surveyor that she was experiencing increased pain that was not relieved by medication that was previously given to the resident. LPN (licensed practical nurse) #1 did not notify the physician in a timely manner after notification of pain not being relieved by medication given and the resident having increased pain. Resident #85 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/18/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 9 out of a possible score of 15. Resident #85 was also coded as requiring extensive assistance of 2 staff members for dressing and personal hygiene and was totally dependent on 2 staff members for bathing. On 9/25/19 at 9:25 am, the surveyor went into the resident's room. Resident #85 stated to the surveyor at 9:30 am that she was in pain and it was constant. Surveyor asked if she had let the nurse know about this and she stated, I have and I took something earlier but it just still hurts, nothing relieves it. Surveyor spoke to the LPN (licensed practical nurse) #1 and notified her of the statements that the resident just made to the surveyor. LPN #1 stated, She gets [MEDICATION NAME] every 6 hours and the next time she gets it is 12 noon. They increased her [MEDICATION NAME] for that reason of break through pain. I guess if she keeps hurting, I can call the doctor. At 10:10 am, the Surveyor went back in to resident's room and asked if the nurse had come to assess her pain since the surveyor was here earlier. The resident stated, No, no one has been in here except for you. I thank you for checking on me. And if you pray please pray for me. At approximately 10:20 am, the surveyor requested the following: Resident's current physician orders, current care plan, (MONTH) MAR (medication administration record), and nursing notes from 6 am this morning (9/25/19) to the present time of this request and facility policy on pain management from the administrator. At 10:24 am, the surveyor reviewed the clinical record of Resident #85. It was noted by the surveyor that Resident #85 had the following physician orders [REDACTED]. There was no nursing documentation in the resident's clinical record dated for 9/25/19 concerning the resident being assessed for increased pain or the physician being notified of the findings of this assessment. The last nursing documentation was documented for 9/25/19 at 3:10 AM. At 10:45 am, the surveyor interviewed LPN #1. The surveyor asked LPN #1 if she had assessed the pain of Resident #85 since the surveyor had notified her of the resident having complaints of pain and no relief of pain from pain medication as documented per the surveyor's interview with the resident at 9:25 am. LPN #1 stated, No, but I can. The surveyor then asked if the doctor had been notified of the above documented findings. LPN #1 stated, No, he hasn't. I will call him after I assess the resident if needed. At 11:22 am, the surveyor interviewed the unit manager of the above documented findings and asked when is the staff to assess and notify the physician for a resident experiencing increased pain with no relief received from prescribed medication as voiced by the resident to a nurse. Unit manager replied, You go and assess the pain right when you are notified of anyone having pain. If there is a change in pain levels or the resident is not having pain control with medications already administrated to the resident then the nurse should call the physician and notify him of this. The unit manager then stated, The nurse has called the doctor and has received orders for [MEDICATION NAME] 50 mg (milligram) to be given twice a day for pain. I have also put a corrective action in place concerning this issue. On 9/25/19 at 4:14 pm, the surveyor notified the administrative team, which consisted of the administrator, DON and the regional nurse consultant of the above documented findings. The surveyor again notified the administrative team of the above documented findings and issues concerning Resident #85 on 9/26/19 at 1:00 pm. No further information was provided to the surveyor or the survey team prior to the exit conference on 9/26/19.

Based on clinical record review, staff interview, and facility document review, the facility staff failed to provide services maintaining professional standards of practice for one of 26 Residents in the survey sample, Resident # 28. The findings included The facility staff documented administration of [MEDICATION NAME] for Resident # 28 that had not arrived in the facility. Resident # 28 was an [AGE] year-old-female that was originally admitted to the facility on [DATE], and had a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 28 was reviewed on 9/25/19 at 9:43 am. The most recent MDS (minimum data set) assessment for Resident # 28 was a quarterly assessment with an ARD (assessment reference date) of 8/7/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 28 had a BIMS (brief interview for mental status) score of 7 out of 15, which indicated that Resident # 28's cognitive status was severely impaired. Section K of the MDS assesses swallowing and nutritional status. In Section K0300, the facility staff documented that Resident # 28 had weight loss and was not on physician prescribed weight loss regimen. The current plan of care for Resident # 28 was reviewed and revised on 8/12/19. The facility staff documented a problem area for Resident # 28 as, Resident # 28 has no problems at this time with chewing/swallowing. She is fed by staff. She has top and bottom dentures but doesn't wear them at all times. Resident # 28 has fair intake and her weight is within normal range at this time. DX: (diagnoses) [MEDICAL CONDITION], [DIAGNOSES REDACTED], dementia, depression, old MI ([MEDICAL CONDITION]),[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease). Interventions included but were not limited to, Meds/Labs as ordered inform MD/RP (medical doctor/responsible party) of wt (weight) changes. Resident # 28 had orders that included but were not limited to, [MEDICATION NAME] 5 mg (milligram) capsule give one po (by mouth) Q (every) day DX decreased appetite, which was initiated by the physician on 8/16/19. The surveyor reviewed the (MONTH) 2019 Medication Administration Record [REDACTED] On 8/21/19 documentation in the clinical record reflected that [MEDICATION NAME] was refused by resident. On 8/25/19 documentation in the clinical record reflected that [MEDICATION NAME] was not administered-Other. Pending provider clarification. On 8/31/19 documentation in the clinical record reflected that [MEDICATION NAME] was unavailable. The surveyor observed that facility staff documented [MEDICATION NAME] 5 mg as having been administered to Resident # 28 on 8/22/19, 8/23/19, 8/24/19, 8/26/19, 8/27/19, 8/28/19, 8/29/19, and 8/30/19. The surveyor reviewed the (MONTH) 2019 Medication Administration Record [REDACTED] On 9/5/19 documentation in the clinical record reflected that [MEDICATION NAME] was not available. On 9/8/19 documentation in the clinical record reflected that [MEDICATION NAME] was not administered Pending Rx (prescription). On 9/9/19 documentation in the clinical record reflected that [MEDICATION NAME] was refused by resident. Refused x3. The surveyor observed that the facility staff documented that [MEDICATION NAME] 5 mg as having been administered to Resident # 28 on 9/1/19, 9/2/19, 9/3 /19, 9/4/19, 9/6/19, 9/7/19. On 9/26/19 at 11:53 am, the surveyor informed the director of nursing that [MEDICATION NAME] 5 mg had been documented as being unavailable on the dates listed above. The surveyor requested additional information as to why the [MEDICATION NAME] 5 mg was unavailable for Resident # 28 and requested to see the [MEDICATION NAME] controlled substance log from (MONTH) and (MONTH) 2019 for Resident # 28. On 9/26/19 at 2:00 pm, the director of nursing informed the surveyor that there were no [MEDICATION NAME] controlled substance logs for Resident # 28 for (MONTH) 2019. The director of nursing informed the surveyor that the physician had written a prescription on 8/16/19 for [MEDICATION NAME] 5 mg, but did not specify a quantity so the medication never came into the facility. The director of nursing stated that the facility nurses attempted to contact the physician to no avail to get a new prescription with a quantity. The director of nursing provided the surveyor with a copy of a prescription for [MEDICATION NAME] 5 mg that was written on 9/9/19 that specified a quantity of 30 capsules to be sent. The director of nursing informed the surveyor that even though the order was written on 8/16/19 the [MEDICATION NAME] was not delivered to the facility until 9/10/19. The director of nursing acknowledged that facility staff documented [MEDICATION NAME] 5 mg as having been administered to Resident # 28 when the medication was not in the building available for administration. The facility policy and standard of practice on Administering Medications contained documentation that included but was not limited to, .Policy Interpretation and Implementation 19. The individual administering the medication must initial the resident's MAR (medication administration record) on the appropriate line after giving each medication and before administering the next ones. On 9/26/19 at 5:01 pm, the administrator, the director of nursing, and corporate nurse consultant were made aware of the deficient practice as stated above and provided the opportunity to ask questions and submit additional information to dispute the deficient practice. The administrative team had no further questions and no further information regarding this issue was presented to the survey team prior to the exit conference on 9/26/19.