Every finding on record at Lee Health And Rehab Center

Based on staff interview, clinical record review and facility document review the facility staff failed to notify the resident's representative of a change in condition requiring medical intervention for 1 of 3 residents, Resident #1.The findings included:Resident #1's clinical record listed diagnoses which included but not limited to metabolic encephalopathy, aphasia and dysphagia.Resident #1's face sheet did not list an authorized representative/responsible party but did list four emergency contacts.Resident #1's most recent minimum data set with an assessment reference date of 11/03/25 assigned the resident brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident was severely cognitively impaired. Resident #1's comprehensive care plan was reviewed and contained a plan for .requires tube feeding r/t (related to) nutritional needs. Interventions for this plan included Observe/document/report to MD PRN (as needed): Aspiration-fever SOB (shortness of breath), Tube dislodged, Infection at tube site, Self-extubation, tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distention, tenderness and Check tube for placement and gastric contents/residual volume per facility protocol or MD orders. See orders.Resident #1's progress notes were reviewed and contained a note which read in part, Date of Service: 11/06/2025. Visit Type: Post Acute Care Visit 5 .Chief Complaint/Reason for this Visit: Dislodges gastrostomy tube .HPI (history of present illness) Relating to this Visit: The patient is an . presenting with a dislodged gastrostomy tube. The gastrostomy tube, which is a 20 FR (French) was initially placed in the hospital for feeding purposes. The patient is currently undergoing treatment for cancer outside of the facility. She receives Glucerna at a rate of 60 ml per hour for 16 hours a day. The staff reported that they found the patient had pulled out the tube with the balloon still intact. The abdomen was cleaned and dried, and the tube was reinserted without difficulty, with minimal bleeding at the site. Placement was confirmed with auscultation and aspiration, and a KUB (kidneys, ureter, bladder) was ordered to check the tube placement. The patient has positive bowel sounds and even, unlabored respirations .Assessment and Plan: Assessment: The patient experienced a dislodged gastrostomy tube, which was reinserted without difficulty. The placement was confirmed with auscultation and aspiration, and a KUB was ordered to verify the tube's position. There was minimal bleeding at the site, and the patient has positive bowel sounds. Plan: Continue monitoring the gastrostomy tube site for any signs of infection or further dislodgement. Await results of the KUB to confirm proper placement. Educate staff on ensuring the tube remains secure to prevent future dislodgement. There is no documentation that the resident's emergency contact was notified of the gastrostomy tube dislodgement and subsequent replacement. Spoke with registered nurse (RN) #1 on 04/08/26 at 3:30 pm. RN #1 stated that resident had pulled out her gastrostomy tube and the FNP (family nurse practitioner) had reinserted it. RN #1 was asked if anyone notified the resident's emergency contact that tube had been dislodged and replaced and RN #1 stated, Not that I know of, I know I didn't.Spoke with facility administrator on 04/08/26 at 4:15 pm. Administrator stated the facility had completed an action plan related to failure to notify the resident's emergency contact. Administrator provided a copy of the facility corrective action plan related to failure to notify, which read in part, Corrective Action Plan. Problem identified: Failed to follow notification of change policy to RP (responsible party) and failure to document in medical record. Plan Start Date: 11/17/25. Plan Completion Date: 2/23/26. Root Cause Analysis: Licensed nurse failed to document her assessment, observations and services provided in the medical record and failed to notify legal representative of the change .Why did the problem occur? Licensed nurse advised UM (unit manager) and NP (nurse practitioner) of Gastrostomy tube dislodgement but failed to document in the medical record and notify the legal representative of the change and reinsertion Gastrostomy tube by NP .How will corrective action be accomplished for those patients affected by the problem: 24-hour report summary will be reviewed by nursing management for accurate documentation in medical record of assessments, interventions and RP notification of change in condition per policy. Education will be completed with licensed nurses regarding documentation in medical record policy and notification of change policy to legal representative. UM's (unit managers) educated on duties to review 8/24/72 hour summary report for accuracy of documentation based on their rounds. How will the Center identify other patients having the potential to be affected by the same problem: All residents are at risk of being potentially affected if licensed nurses do not follow documentation in medical records and notification of change policy. What measures and systemic changes will be put into place to ensure that the problem will not recur: 24/72-hour report will be scrubbed Mon-Fri for ACCURATE DOCUMENTATION OF CHANGE IN CONDITION IN MR (medical record) AND RP notification. Any concerns identified will be addressed immediately. How will the center monitor its performance to make sure that solutions are sustained: The DON (director of nursing) or Designee view 24-hour summary for accurate documentation in change in conditions including legal representative notification 5x a week for 2 weeks, then 3 x week x 2 weeks then weekly for 2 weeks then monthly x 2 and report findings to QAPI (quality assurance and performance improvement committee.Requested and was provided with a facility policy entitled Notification of Changes which read in part, The purpose of this policy is to ensure the Center promptly informs the patient, consults the patient's physician/physician extender; and notifies the patient's legal representative when there is a change requiring notification.1a. Circumstances requiring notification include: i. Accidents resulting in injury or accidents that require emergent/urgent physician/physician extender intervention .2a. ii. When a patient is mentally competent, a designated family member should be notified of significant changes in the patient's health status because the patient may not be able to notify them personally, especially in the case of sudden illness or accident.Surveyor reviewed credible evidence and confirmed that each item had been completed and on-going monitoring was confirmed. Interviews with staff were conducted and it was confirmed staff were knowledgeable regarding provider and/or resident representative notification of significant changes in resident condition. A review of the current sampled residents revealed no concerns with provider and/or resident representative notification of significant changes in resident condition.The concern of not notifying the resident's emergency contact was discussed with the administrator, director of nursing and regional director of clinical services on 04/08/26 at 5:30 pm.No further information was provided prior to exit.This is a past non-compliance deficiency.

Based on observation, staff interview and facility document review, the facility staff failed to store food in accordance with professional standards for food service safety in one of 3 resident refrigerators. The findings included: On 3/6/25 at 8:26 AM this surveyor checked the resident refrigerator on one of 3 units. The thermometer read 40 degrees. This surveyor noted an 8-ounce carton of Very Vanilla Soy Silk beverage with an expiration date of 12/19/24. This surveyor took the beverage to the Registered Dietician (RD) who stated, This isn't something we provide. It probably belonged to a patient who has been discharged . This surveyor pointed out that there was no name on the carton. The RD did verify the date and that the item was expired. This surveyor asked if dietary or nursing would have been responsible to check the date and discard the drink, they stated, I am not here all the time, so I hesitate to say, I don't want to give you the wrong information. They stated they would get the correct information to the survey team. This surveyor did request the food storage policy. On 3/6/25 at 11:15 AM the RD brought the policy and stated, according to our policy, dietary is supposed to check dates and maintain the nutrition room refrigerators. They stated that they did verify that the beverage did belong to a resident who had been discharged and would not been served to anyone else. This surveyor reiterated that there was no resident name on the carton. The RD stated the drink was discarded. With no name on the carton, there was no way to ensure staff would not have offered the beverage to another resident if this surveyor had not brought it to their attention. The policy entitled Outside Food and Storage of Food Brought in by Family or Visitors with a reviewed/revised date of 1/22/24 read in part, 2. All food items that are already prepared by the family or visitor brought in must be labeled with the patient's name and dated. a. The center may refrigerate labeled and dated prepared items in the nourishment refrigerator. b. Perishable food must be consumed by the patient within 3 days. c. If not consumed within 3 days, food will be thrown away by center staff. On 3/7/25 at 3:00 PM the survey team met with the Administrator, Regional Social Worker, the Clinical Services Specialist and the Director of Nursing. The above concern was discussed with them at that time. No further information was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to ensure residents receive treatment and care in accordance with the comprehensive person-centered care plan and medical provider orders for 1 of 24 sampled residents, Resident #61. The findings included: For Resident #61, the facility staff failed to follow the medical provider's order for the administration of the narcotic pain medication Oxycodone. Resident #61's diagnosis list indicated diagnoses, which included, but not limited to Displaced Intertrochanteric Fracture of the Left Femur, End Stage Renal Disease, and Chronic Obstructive Pulmonary Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/21/25 assigned the resident a brief interview for mental status (BIMS) summary score of 10 out of 15 indicating the resident was moderately cognitively impaired. Resident #61's comprehensive person-centered care plan included a focus area stating [Resident #61] has potential for pain r/t [related to] left femur fracture and decreased mobility with an intervention dated 2/15/25 to Administer pain medication as ordered. Report s/s [signs/symptoms] negative side effects. Resident #61's current medical provider orders included an order dated 2/14/25 for Oxycodone HCL 10 mg by mouth every four (4) hours as needed for severe pain 7-10. A review of Resident #61's February 2025 and March 2025 Medication Administration Records (MARs) revealed the resident received Oxycodone for a pain intensity (PI) level below seven (7) on 17 separate occasions from 2/15/25 through 3/06/25. Oxycodone 10 mg was administered with a PI below seven (7) on: 2/15/25 12:30 PM for PI of 1 2/17/25 9:00 AM for PI of 4 2/17/25 4:00 PM for PI of 4 2/18/25 3:00 PM for PI of 1 2/21/25 9:00 AM for PI of 4 2/21/25 3:29 PM for PI of 4 2/21/25 8:34 PM for PI of 5 2/22/25 1:42 AM for PI of 5 2/22/25 10:00 AM for PI of 4 2/22/25 2:00 PM for PI of 4 2/23/25 1:00 PM for PI of 4 2/27/25 9:31 PM for PI of 5 2/28/25 1:48 AM for PI of 5 2/28/25 5:57 AM for PI of 5 3/01/25 12:00 PM for PI of 5 3/02/25 8:00 AM for PI of 4 3/02/25 12:00 PM for PI of 4 On 3/06/25 at 10:15 AM, surveyor spoke with the Administrator, Director of Nursing (DON), and Clinical Service Specialist and discussed the concern of staff administering Resident #61's Oxycodone outside of the ordered parameters. No further information regarding this concern was presented to the survey team prior to the exit conference on 3/06/25.

Based on interviews, clinical record review, and facility document review, the facility staff failed to provide medication in accordance with provider orders for 1 of 6 residents in the survey sample, Resident #3. The findings were: For Resident #3, the facility staff failed to administer the antibiotic as ordered by the provider. Resident #3's admission record listed diagnoses to include but not limited to, monoplegia of lower limb following cerebrovascular disease affecting right dominant side, type 2 diabetes mellitus with diabetic neuropathy, mood (affective) disorder, anxiety disorder, pneumonia, and urinary tract infection. An Admissions/Social Services Assistant's worksheet, provided by the administrator, assigned the resident a brief interview for mental status summary score of 15 out of 15. During a phone conversation with the facility ombudsman on 6/28/23 at 8:50 a.m., the ombudsman reported Resident #3 had not received antibiotics upon admission as ordered. Resident #3 was interviewed on 6/28/23 at 1:00 p.m. and said she had not received her antibiotic on the day she was admitted , nor had she received it for two more days. The clinical record included a provider's order for Augmentin Oral Tablet 500-125 mg (Amoxicillin and Pot Clavulanate), give 1 tablet by mouth every 12 hours for infection for 7 days with a start date of 06/24/23 at 21:00. The first dose on 06/24/23 at 21:00 was not administered. A licensed practical nurse's (LPN) progress note regarding that dose read, resident refused due to allergy to penicillin's [sic]. The next dose due, 06/25/23 at 09:00, was not administered with a different LPN's progress note which read, Awaiting arrival from pharmacy. The unit manager, a registered nurse (RN) documented a progress note on 06/25/23 at 16:40 that read, Resident verbalized she could take the Augmentin with her penicillin allergy. This was reported to pharmacy so they could send medication ordered. Pharmacy advised the nurse could pull from stat box one Augmentin 250-125mg and on [sic] Amoxicillin 250mg to equal prescribed dose. MD notified and gave order to pull one Augmentin 250-125mg capsule and one amoxicillin 250mg capsule to equal the prescribed dose of Augmentin 500-125mg until correct dose arrives from pharmacy. According to the medication administration record (MAR), the following two doses were given as ordered. The antibiotic order was updated to include the diagnosis of acquired pneumonia and extend the dates for administration to ensure the resident received all ordered doses. The 06/26/23 21:00 dose was not administered. The LPN's progress note read, medication not available from pharm or pull box. This LPN was not available for interview however the administrator, who was the facility's previous director of nursing, reported she had spoken to that LPN who was a new nurse and did not realize she could pull the two medications from the Cubex (medication dispenser machine) and combine them to equal the ordered medication. The administrator acknowledged this dose should have been given. The current DON had provided education to staff regarding pulling the medications from the Cubex. The administrator stated the first two doses Resident #3 did not receive was because the staff were awaiting clarification regarding the resident's penicillin allergy. The facility's Cubex medication list was reviewed with the administrator and DON. The list included AMOX TR-K CLV 250-125 MG TAB and AMOXICILLIN 250 MG CAPSULE. The administrator reported that these two medications given together would equal Resident #3's ordered antibiotic. The off-site pharmacy manager was interviewed via phone on 06/28/23 at 2:59 p.m. He acknowledged Resident #3's antibiotic order was going back and forth since 6/25/23 due to resident's allergies. The manager acknowledged the two medications available in the Cubex would be the same as the ordered antibiotic. The pharmacy manager and the facility's medical director had approved the medication and the extended time frame to ensure the resident received all ordered doses. This surveyor attempted to re-interview Resident #3 at approximately 3:30 p.m. however the administrator reported the resident had just been discharged home. The policy titled, Medication Administration. Policy 5.3 GENERAL GUIDELINES FOR MEDICATION ADMINISTRATION with an effective date of 06/21/2017 was reviewed and read in part, Procedure . 9. If a medication is unavailable, contact the pharmacy and document accordingly. The administrator denied having a policy or procedure for how to pull medications from their Cubex. No further information was provided before the exit conference.

Based on staff interview and clinical record review the facility staff failed to maintain a complete and accurate clinical record for 2 of 21 residents, Residents #104 and #255. 1. For Resident #104, the facility staff failed to obtain a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 2. For Resident #255, the facility staff failed to accurately complete a Durable Do Not Resuscitate (DDNR) order form. The findings included: 1. Section C (cognitive patterns) of Resident #104's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 05/19/22 included a brief interview for mental status summary score (BIMS) of 9 out of a possible 15 points. Section H (bladder and bowel) was coded to indicate the resident had a foley catheter in place. The clinical record included the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The residents comprehensive care plan included the focus area has an indwelling foley catheter in place. 06/01/22 1:10 p.m., the surveyor observed a foley catheter on the right side of the residents bed draining dark colored urine. During a review of the clinical record, the surveyor was unable to locate an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .foley cath intact and patent. Yellow urine noted . 06/01/22 1:11 p.m., Licensed Practical Nurse (LPN) #2 reviewed the clinical record and stated they were unable to locate order for the foley catheter. LPN #2 then stated the order was probably not put in when the resident had been readmitted (05/12/22). 06/01/22 1:15 p.m., the Director of Nursing (DON) was made aware that Resident #104 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 06/01/22, the facility staff transcribed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . No further information regarding this issue was provided to the survey team prior to the exit conference. 2. There was no completed minimum data set (MDS) assessment on this resident. The clinical record included the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record included an original DDNR order form from the Virginia Department of Health dated 05/13/22. Section 2 of this form had been left blank. Under section 1, the DDNR read in part, I further certify [must check 1 or 2]: 1. The patient is CAPABLE of making an informed decision . 2. The patient is INCAPABLE of making an informed decision . The box bedside of #2 had been marked. Section 2 read If you checked 2 above, check A, B, or C below: All three boxes (A, B, and C) had been left blank (unchecked). The residents clinical record included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 06/01/22 11:37 a.m., the Director of Nursing (DON) was made aware of the incomplete DNR. 06/01/22 4:35 p.m., the Administrator and DON were notified of the incomplete DNR. Prior to the exit conference, the DON provided the surveyor with an updated DNR form. 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 ensure that residents receive treatment and care by not following physician's orders [REDACTED].#74) in the survey sample as evidenced by the staff not administrating the physician ordered medications on [MEDICAL TREATMENT] days. The findings included: The facility staff failed to administer medications as ordered by the physician on [MEDICAL TREATMENT] days. Resident #74 was a resident in the facility at the time of this survey. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/8/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15/15. Resident #74 was also coded as requiring limited assistance of 1 staff member for dressing, personal hygiene and bathing. The resident had the following [DIAGNOSES REDACTED]. The surveyor conducted a review on 1/8/2020 of Resident #74's clinical record and noted the following physician orders [REDACTED].> Eliquis 2.5 mg (milligram) BID (twice a day) for blood clot prevention [MEDICATION NAME] 10 mg 1 tablet every 12 hours for high blood pressure [MEDICATION NAME] 50 mg BID for high blood pressure The surveyor also reviewed the MAR (medication administration record) for Resident #74. During such review, the surveyor noted the documentation of 3 which by the chart code 3 meant Absent from home. The code of 3 was noted on the December, 2019 and January, 2020 for the above documented physician ordered medications for the following dates and times: [MEDICATION NAME] was not administered to the resident at 9 am on 12/4, 12/6, 12/9, 12/11, 12/13, 12/16, 12/18, 12/20, 1/6/2020 and 1/8/2020. Eliquis was not administrated to the resident at 9 am on 12/3, 12/6, 12/9, 12/11, 12/13, 12/16, 12/18, 12/20, 12/22, 12/24, 12/27, 1/6/2020 and 1/8/2020. [MEDICATION NAME] was not administrated to the resident at 9 am on 12/4, 12/6, 12/9, 12/11, 12/13, 12/16, 12/18, 12/20, 1/6/2020 and 1/8/2020. The surveyor notified the DON (director of nursing) on 1/8/2020 at 1 pm of the above documented findings. DON stated, We will get this fixed. The surveyor notified the administrator, DON, and regional nurse of the above documented findings at 4:30 pm. On 1/8/2020 at approximately 11 am, the surveyor reviewed a physician order [REDACTED]. Omit AM (morning) medication when the resident is at [MEDICAL TREATMENT] every Monday, Wednesday and Friday. No further information was provided to the surveyor prior to the exit conference on 1/8/2020 at 1:15 pm.

Based on staff interview, clinical record review, and facility document review, the physician failed to act upon a pharmacy recommendation for the month of (MONTH) 2019 for 1 of 23 residents, Resident #41. Resulting in this same recommendation being made by the consultant pharmacist in (MONTH) 2019. This recommendation was completed in (MONTH) 2019. The findings included: The physician failed to act upon a pharmacy recommendation. The consultant pharmacist had recommended an AIMS (Abnormal Involuntary Movement Scale) test be completed on (MONTH) 10, 2019. This test was not completed until a second pharmacy recommendation was made on (MONTH) 8, 2019. A review of the clinical record was completed on (MONTH) 9, 2020. The electronic health record included, but was not limited to the following diagnoses, [MEDICAL CONDITION] without behavioral disturbance, major [MEDICAL CONDITION], unspecified [MEDICAL CONDITION], and generalized anxiety disorder. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of (MONTH) 18, 2019 included a BIMS (brief interview for mental status) summary score of 9 out of a possible 15 points. The clinical record included the following pharmacy consultant notes. Jun 10, 2019, Medications and chart reviewed + [MEDICATION NAME] 7.5mg TID (three times a day), [MEDICATION NAME] 25mg HS (bedtime/hour of sleep), [MEDICATION NAME] 125mg Q (every) 12 (hours) Recommendation for nursing-AIMS. October 8, 2019, Medications and chart reviewed Recommendation for nursing-AIMS. The surveyor was unable to find any pharmacy recommendations regarding these progress notes. On (MONTH) 9, 2020 at 10:43 a.m., the administrator and DON (director of nursing) were made aware of the missing pharmacy recommendations. On (MONTH) 9, 2020 at 11:26 a.m., the DON verbalized to the surveyor that the facility failed to complete the AIMS test for (MONTH) and a second recommendation was made in (MONTH) and an AIMS was completed on (MONTH) 8, 2019. The DON also provided the surveyor with a copy of the recommendations made by the consulting pharmacist. For (MONTH) 10, 2019 the pharmacist had wrote, This resident is currently receiving antipsychotic therapy with [MEDICATION NAME] 25mg HS and therefore requires an Abnormal Involuntary Movement Test (AIMS) at baseline and every 6 months while on antipsychotic therapy. I was unable to locate a recent AIMS test in the chart. Please complete an AIMS test now, and every 6 months while the resident remains on antipsychotic therapy. This same recommendation was made on (MONTH) 8, 2019. Prior to the exit conference, the facility provided the surveyor with a copy of their policy/procedure titled MEDICATION REGIMEN REVIEW POLICY. This policy read in part, The pharmacist must report any irregularities to the Attending Physician, the facility's Medical Director and Director of Nursing, and these reports must be acted upon in a manner that meets the needs of the residents .If the Attending Physician declines or otherwise rejects the Consultant Pharmacist's recommendation, an explanation as to the rationale for the rejection shall be documented in the resident's medical record . No further information regarding this issue was provided to the survey team prior to the exit conference on (MONTH) 9, 2020.

Based on observations and staff interviews the facility staff failed to ensure that the storage of all expired drugs and biologicals including expired laborary blood tubes in (one) of 3 (three) medication storage rooms (West Hall medication storage room) were disposed of from storage. The following findings were noted: 1. The facility staff failed to dispose of expired Aspirin suppositories and expired [MEDICATION NAME] suppositories. The facility's medication storage room on West Hall was observed by one surveyor along with facility staff on 01/07/2020 at 3:25 p.m. The medication refrigerator contained 10 (ten) 25mg [MEDICATION NAME] suppositories with an expiration date of 10/20/19 and 12 (twelve) 600mg Aspirin suppositories with an expiration date of 10/20/19. The facility's registered nurse (RN) working on West Hall acknowledged the suppositories were out of date and was unsure who was responsible for disposing of those expired medications. One of the facility's LPNs (licensed practical nurse) said the box the suppositories were kept in was referred to as the omnicell box (Omnicell is an automated medication supply system, omnicell box contained medications that required refrigeration) and therefore, the pharmacy staff was responsible for checking those medications. The LPN said the pharmacy staff was in the facility checking on the omnicell medications last week. The facility's director of nursing (DON) was informed of the above findings on 01/07/2020 at 4:14 p.m. The DON stated the suppositories were stock medications and were not for any specific resident and acknowledged that the pharmacy staff was supposed to check those medications, remove the expired medications and replace them. The DON was not sure why the pharmacy staff did not remove the expired suppositories. No further information was provided to the survey team prior to the exit conference. 2. The facility staff failed to remove expired laboratory blue top tubes (used for blood collection) from a supply cabinet. The facility's medication storage room on West Hall was observed by one surveyor along with facility staff on 01/07/2020 at 3:25 p.m. In an upper supply cabinet, an open pack of laboratory blue top tubes for blood collection were found with an expiration date of 12/31/19. One of the facility's RNs (registered nurses) acknowledged the blue top tubes were expired and removed them from the cabinet. The RN was not certain who was responsible for checking laboratory supplies for expiration dates. The facility's director of nursing (DON) was informed of the above findings on 01/07/2020 at 4:14 p.m. The DON stated there was no written policy that addressed who was responsible for checking expiration dates of laboratory tubes. The DON said it was everyone's responsibility to look for expired items but the facility's house supervisors were supposed to check for expired items/medications regularly. No further information was provided to the survey team prior to the exit conference.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide the receiving provider with information that included the contact information of the practitioner responsible for the care of the resident, Resident representative information including contact information, Advance Directive information, all special instructions or precautions for ongoing care, as appropriate, comprehensive care plan goals, and all other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care for 6 of 26 residents (Resident #72, Resident #54, Resident #85, Resident #46, Resident #24 and Resident #1). The findings included: 1. The facility staff failed to provide the receiving provider the current comprehensive care plan goals and code status for Resident #72. The clinical record of Resident #72 was reviewed 12/4/18 through 12/6/18. Resident #72 was admitted to the facility 10/3/18 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #72's significant change in status minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/31/18 assessed the resident with a BIMS (brief interview for mental status) as 13/15. The 10/15/18 22:04 (10:04 p.m.) progress note read Primary nurse reports to MD (medical doctor) called at 2130 (9:30 p.m.) with update on resident's condition and MD gave order to send resident to Hospital (name omitted) ER (emergency room ) for eval (evaluation) due to little improvement after previous interventions/orders. C-Trans called and made aware of need to transport to ER for eval. Report called to Nurse Connect (name of nurse connect omitted). Resident aware. Called resident's sister and made aware as well. The 10/15/18 22:30 (10:30 p.m.) progress note read C-Trans here to transport resident to hospital (name omitted) ER at this time. The 10/16/18 4:26 a.m. progress note read that the resident was being transferred to another hospital. The 10/15/18 or 10/16/18 progress notes did not have documentation of information sent with the resident to the hospital. The surveyor interviewed the director of nursing (DON) on 12/06/18 11:51a.m. on the process and paperwork when a resident is transferred to the hospital. The DON stated she notifies the MD (medical doctor)/RP (responsible party), sends a transfer form, MAR (medication administration record) and PN (progress notes). The DON stated, when asked, if she sends a copy of the comprehensive care plan goals, she stated she didn't. The surveyor met with the director of nursing (DON), assistant director of nursing (ADON), both corporate registered nurses and the interim administrator on 12/6/18 at 12:02 p.m. on the process for transferring a resident to the hospital. The DON stated notify MD/RP, call hospital and give report, after hours notified, call EMS (emergency medical services), send transfer treatment form, MAR, any special treatments, and pertinent laboratory tests. The DON stated comprehensive care plan goals were not sent. The facility provided the Nursing Home to Hospital Transfer Form for Resident #72 dated 10/16/18 and timed 5:27 a.m. The form did not include the code status or comprehensive care plan goals. The form did include primary goals of care at time of transfer and rehabilitation and/or medical therapy with intent of returning home marked but there were no comprehensive care plan goals documented. The surveyor informed the administrative staff of the above concern in the end of the day meeting on 12/6/18 at 4:14 p.m. No further information was provided prior to the exit on 12/6/18. 2. The facility staff failed to provide the receiving provider the comprehensive care plan goals for Resident #54. The clinical record of Resident #54 was reviewed 12/4/18 through 12/6/18. Resident #54 was admitted to the facility 10/10/17 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #54's 14- day minimum data set assessment (MDS) with an assessment reference date (ARD) of 11/29/18 assessed the resident with a BIMS (brief interview for mental status) as 09/15. A progress note dated 11/14/18 at 10:30 read Called to room per sitter, res (resident) noted to have SOB (shortness of breath). VS (vital signs) at this time BP (blood pressure) 181/77, P (pulse) 81, T (temperature) 99.1, R (respirations) 40, O2 (oxygen saturation level) 96% on 2 LPM (liters per minute) BS (blood sugar) 49. Daughter in room and aware of res condition. MD (medical doctor) in facility and notified. Verbal orders given for [MEDICATION NAME] 1 gm (gram) IM (intramuscular). Solu-[MEDICATION NAME] 125 mg (milligrams), [MEDICATION NAME] 40 mg IM all x1 dose now. Orders received to send res to ER (emergency room ) for eval (evaluation). Progress note dated 11/14/18 10:43 read C Trans ambulance services notified of transport. Hospital (name omitted) given report. Daughter in room and aware. Progress note dated 11/14/18 at 15:08 (3:08 p.m.) read Per hospital (name omitted) res being admitted to ICU (intensive care unit) dx (diagnosis) resp (respiratory) failure. The 11/14/18 progress notes did not have documentation of information sent with the resident to the hospital on [DATE]. The surveyor interviewed the director of nursing (DON) on 12/06/18 11:51a.m. on the process and paperwork when a resident is transferred to the hospital. The DON stated she notifies the MD (medical doctor)/RP (responsible party), sends a transfer form, MAR (medication administration record) and PN (progress notes). The DON stated, when asked, if a copy of the comprehensive care plan goals are sent, she stated she didn't. The surveyor met with the director of nursing (DON), assistant director of nursing (ADON), both corporate registered nurses and the interim administrator on 12/6/18 at 12:02 p.m. on the process for transferring a resident to the hospital. The DON stated notify MD/RP, call hospital and give report, after hours notified, call EMS (emergency medical services), send transfer treatment form, MAR, any special treatments, and pertinent laboratory tests. The DON stated comprehensive care plan goals were not sent. The facility provided the Nursing Home to Hospital Transfer Form for Resident #54 dated 11/14/18 and timed 11:13 a.m. The form did not include the comprehensive care plan goals. The form did include primary goals of care at time of transfer. Marked was chronic long-term goals. However, there were no specific comprehensive care plan goals. The surveyor informed the administrative staff of the above concern in the end of the day meeting on 12/6/18 at 4:14 p.m. No further information was provided prior to the exit on 12/6/18. 3. The facility staff failed to provide the receiving provider with the comprehensive care plan goals for Resident #85. The clinical record of Resident #85 was reviewed 12/4/18 through 12/6/18. Resident #85 was admitted to the facility 9/15/15 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #85's significant change in status minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/13/18 assessed the resident with short term memory problems, long term memory problems, and moderately impaired cognitive skills for daily decision making. Resident #85's 8/18/18 progress note read in part that the resident had dark stools and was sent to the emergency roiagnom on [DATE]. Guardian was notified. Resident #85 was admitted to the hospital with [REDACTED]. The surveyor was unable to find evidence the facility sent the comprehensive care plan goals to the receiving provider when the resident was transferred on 8/18/18. The Nursing Home to Hospital Transfer Form dated 8/18/18 did not include comprehensive goals-only primary goals of care at time of transfer. The surveyor interviewed the director of nursing (DON) on 12/06/18 11:51a.m. on the process and paperwork when a resident is transferred to the hospital. The DON stated she notifies the MD (medical doctor)/RP (responsible party), sends a transfer form, MAR (medication administration record) and PN (progress notes). The DON stated when asked if a copy of the comprehensive care plan goals are sent, she stated she didn't. The surveyor met with the director of nursing (DON), assistant director of nursing (ADON), both corporate registered nurses and the interim administrator on 12/6/18 at 12:02 p.m. on the process for transferring a resident to the hospital. The DON stated notify MD/RP, call hospital and give report, after hours notified, call EMS (emergency medical services), send transfer treatment form, MAR, any special treatments, and pertinent laboratory tests. The DON stated comprehensive care plan goals were not sent. The facility provided the Nursing Home to Hospital Transfer Form for Resident #85 dated 8/18/18 at 2:15 a.m. The form did not include the comprehensive care plan goals. The form did include primary goals of care at time of transfer for chronic long term care The surveyor informed the administrative staff of the above concern in the end of the day meeting on 12/6/18 at 4:14 p.m. No further information was provided prior to the exit on 12/6/18. 4. For Resident #24, the facility staff failed to provide a copy of the comprehensive care plan goals to receiving facility when Resident #24 was transferred. Resident #24 is a [AGE] year-old female who was originally admitted to the facility on [DATE], with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident #24 was reviewed on 12/5/18 at 1:14 pm. The most recent MDS (minimum data set) assessment for Resident #24 was a quarterly assessment with an ARD (assessment reference date) of 11/20/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident #24 had a BIMS (brief interview for mental status) score of 15 out of 15. On 12/05/18 the surveyor reviewed Resident #24's progress notes. It contained a progress note in the clinical record documented on 09/11/18 at 7:30 pm which read in part, Charge nurse telephoned ER (emergency room ) to inquire on Resident's status. Resident admitted to (facility name withheld) with Dx (diagnosis):[MEDICAL CONDITION], PNA (pneumonia), UTI (urinary tract infection). RP (responsible party) is at ER with Resident On 12/05/18 at 4:27 pm during the end of day meeting with the survey team and administrative team, the DON (director of nursing) was asked by the surveyor what documents are provided to the receiving facility when a Resident is transferred? The DON replied, Transfer form, copy of MAR (medication administration record) and face sheet. On 12/06/18 at 8:00 am, the DON provided the surveyor with a copy of a Nursing Home to Hospital Transfer Form that was sent with Resident #24 upon transfer to the emergency roiagnom on [DATE]. The surveyor reviewed the transfer form and could not locate any documentation on the form that indicated the care plan goals were sent with Resident #24 upon transfer to the hospital. On 12/06/18 at 11:47 am during a meeting with the administrative team, the DON agreed that the facility did not send comprehensive care plan goals with Resident #24 upon transfer to hospital on [DATE]. The administrative team was made aware of issue during end of day meeting on 12/06/18 at 11:53 am. No further information regarding this issue was provided to the survey team prior to the exit conference on 12/06/18. 5. For Resident #46, the facility staff failed to provide a copy of the comprehensive care plan goals to receiving facility when Resident #46 was transferred. Resident #46 is an [AGE] year-old female who was originally admitted to the facility on [DATE], with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident #46 was reviewed on 12/5/18 at 8:29 am. The most recent MDS (minimum data set) assessment for Resident #46 was an annual assessment with an ARD (assessment reference date) of 10/10/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident #46 had a BIMS (brief interview for mental status) score of 06 out of 15. On 12/05/18 the surveyor reviewed Resident #46's progress notes. It contained a progress note in the clinical record documented on 09/20/18 at 3:38 pm which read in part, R/C (report called) from (facility name withheld) nurse stating this Resident is being admitted on the med surge floor with Dx (diagnosis) of [MEDICAL CONDITION] with hypoxemia and pleural effusion to right lower lung. On 12/05/18 at 4:27 pm during the end of day meeting with the survey team and administrative team, the DON (director of nursing) was asked by the surveyor what documents are provided to the receiving facility when a Resident is transferred? The DON replied, Transfer form, copy of MAR (medication administration record) and face sheet. On 12/06/18 at 8:00 am, the DON provided the surveyor with a copy of a Nursing Home to Hospital Transfer Form that was sent with Resident #46 upon transfer to the emergency roiagnom on [DATE]. The surveyor reviewed the transfer form and could not locate any documentation on the form that indicated the care plan goals were sent with Resident #46 upon transfer to the hospital. On 12/06/18 at 11:47 am during a meeting with the administrative team, the DON agreed that the facility did not send comprehensive care plan goals with Resident #46 upon transfer to hospital on [DATE]. The administrative team was made aware of issue during end of day meeting on 12/06/18 at 11:53 am. No further information regarding this issue was provided to the survey team prior to the exit conference on 12/06/18. 6. For Resident #1 the facility staff failed to provide a copy of the comprehensive care plan goals to the receiving facility when the Resident was transferred to the hospital. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 11/27/18 coded the Resident as 5 out of 15 in section C, cognitive patterns. This is a quarterly MDS. Resident #1's clinical record was reviewed on 12/05/18. It contained a progress note dated 08/14/18 which read in part, 8/14/2018 18:19 Received call from sister, .(name omitted), regarding Resident en route to (facility name omitted), . The surveyor spoke with the DON (director of nursing) on 12/06/18 at approximately 1155 regarding what type of paperwork is sent when a Resident is transferred to the hospital. DON stated the facility sends copies of the facility transfer form, MAR (Medication Administration Record, [REDACTED]. DON stated that they do not send copies of the Resident's comprehensive care plan goals. The concern of not sending the Resident's comprehensive care plan goals when a Resident is transferred was discussed with the administrative team during a meeting on 12/06/18 at approximately 1615. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide a written notice of transfer when 6 of 26 residents were transferred to other facilities. The residents effected were Resident #72, Resident #54, Resident #85, Resident #46, Resident #24, and Resident #1. The findings included: 1. The facility staff failed to send written notice to the resident or resident representative of Resident #72's transfer to the acute care hospital on [DATE]. The clinical record of Resident #72 was reviewed 12/4/18 through 12/6/18. Resident #72 was admitted to the facility 10/3/18 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #72's significant change in status minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/31/18 assessed the resident with a BIMS (brief interview for mental status) as 13/15. The 10/15/18 22:04 (10:04 p.m.) progress note read Primary nurse reports to MD (medical doctor) called at 2130 (9:30 p.m.) with update on resident's condition and MD gave order to send resident to Hospital (name omitted) ER (emergency room ) for eval (evaluation) due to little improvement after previous interventions/orders. C-Trans called and made aware of need to transport to ER for eval. Report called to Nurse Connect (name of nurse connect omitted). Resident aware. Called resident's sister and made aware as well. The 10/15/18 22:30 (10:30 p.m.) progress note read C-Trans here to transport resident to hospital (name omitted) ER at this time. The 10/16/18 4:26 a.m. progress note read that the resident was being transferred to another hospital. The 10/15/18 or 10/16/18 progress notes did not have documentation of information sent with the resident to the hospital. The surveyor interviewed the facility social worker on 12/06/18 at 1128. She stated she completes a transfer/discharge form when a resident is discharged home, to an ALF (assisted living facility) or to another nursing facility. The social worker stated she does not do a transfer form when residents are sent to the hospital and does not provide a written notice to the resident or resident representative. The surveyor interviewed the director of nursing (DON) on 12/06/18 11:51a.m. on the process and paperwork when a resident is transferred to the hospital. The DON stated she notifies the MD (medical doctor)/RP (responsible party), sends a transfer form, MAR (medication administration record) and PN (progress notes). The DON stated, when asked, if a copy of the comprehensive care plan goals are sent, she stated she didn't. The surveyor met with the director of nursing (DON), assistant director of nursing (ADON), both corporate registered nurses and the interim administrator on 12/6/18 at 12:02 p.m. on the process for transferring a resident to the hospital. The DON stated notify MD/RP, call hospital and give report, after hours notified, call EMS (emergency medical services), send transfer treatment form, MAR, any special treatments, and pertinent laboratory tests. The DON stated comprehensive care plan goals were not sent. The DON also stated no written documentation of transfers are sent to the family when the resident is transferred to hospital. The surveyor informed the administrative staff of the above concern in the end of the day meeting on 12/6/18 at 4:14 p.m. and requested the facility policy on transfers. No further information was provided prior to the exit on 12/6/18. 2. The facility staff failed to send written notice to the resident or resident representative of Resident #54's transfer to the acute care hospital on [DATE]. The clinical record of Resident #54 was reviewed 12/4/18 through 12/6/18. Resident #54 was admitted to the facility 10/10/17 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #54's 14- day minimum data set assessment (MDS) with an assessment reference date (ARD) of 11/29/18 assessed the resident with a BIMS (brief interview for mental status) as 09/15. A progress note dated 11/14/18 at 10:30 read Called to room per sitter, res (resident) noted to have SOB (shortness of breath). VS (vital signs) at this time BP (blood pressure) 181/77, P (pulse) 81, T (temperature) 99.1, R (respirations) 40, O2 (oxygen saturation level) 96% on 2 LPM (liters per minute) BS (blood sugar) 49. Daughter in room and aware of res condition. MD (medical doctor) in facility and notified. Verbal orders given for [MEDICATION NAME] 1 gm (gram) IM (intramuscular). Solu-[MEDICATION NAME] 125 mg (milligrams), [MEDICATION NAME] 40 mg IM all x1 dose now. Orders received to send res to ER (emergency room ) for eval (evaluation). Progress note dated 11/14/18 10:43 read C Trans ambulance services notified of transport. Hospital (name omitted) given report. Daughter in room and aware. Progress note dated 11/14/18 at 15:08 (3:08 p.m.) read Per hospital (name omitted) res being admitted to ICU (intensive care unit) dx (diagnosis) resp (respiratory) failure. The 11/14/18 progress notes did not have documentation of information sent with the resident to the hospital on [DATE]. The surveyor interviewed the facility social worker on 12/06/18 at 1128. She stated she completes a transfer/discharge form when a resident is discharged home, to an ALF (assisted living facility) or to another nursing facility. The social worker stated she does not do a transfer form when residents are sent to the hospital and does not provide a written notice to the resident or resident representative. The surveyor interviewed the director of nursing (DON) on 12/06/18 11:51a.m. on the process and paperwork when a resident is transferred to the hospital. The DON stated she notifies the MD (medical doctor)/RP (responsible party), sends a transfer form, MAR (medication administration record) and PN (progress notes). The DON stated when asked if a copy of the comprehensive care plan goals are sent, she stated she didn't. The surveyor met with the director of nursing (DON), assistant director of nursing (ADON), both corporate registered nurses and the interim administrator on 12/6/18 at 12:02 p.m. on the process for transferring a resident to the hospital. The DON stated notify MD/RP, call hospital and give report, after hours notified, call EMS (emergency medical services), send transfer treatment form, MAR, any special treatments, and pertinent laboratory tests. The DON stated comprehensive care plan goals were not sent. The DON also stated no written documentation of transfers are sent to the family when the resident is transferred to hospital. The surveyor informed the administrative staff of the above concern in the end of the day meeting on 12/6/18 at 4:14 p.m. and requested the facility policy on transfers. No further information was provided prior to the exit on 12/6/18. 3. The facility staff failed to send written notice to the resident or resident representative of Resident #85's transfer to the acute care hospital on [DATE]. The clinical record of Resident #85 was reviewed 12/4/18 through 12/6/18. Resident #85 was admitted to the facility 9/15/15 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #85's significant change in status minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/13/18 assessed the resident with short term memory problems, long term memory problems, and moderately impaired cognitive skills for daily decision making. Resident #85's 8/18/18 progress note read in part that the resident had dark stools and was sent to the emergency roiagnom on [DATE]. Guardian was notified. Resident #85 was admitted to the hospital with [REDACTED]. The surveyor interviewed the facility social worker on 12/06/18 at 1128. She stated she completes a transfer/discharge form when a resident is discharged home, to an ALF (assisted living facility) or to another nursing facility. The social worker stated she does not do a transfer form when residents are sent to the hospital and does not provide a written notice to the resident or resident representative. The surveyor interviewed the director of nursing (DON) on 12/06/18 11:51a.m. on the process and paperwork when a resident is transferred to the hospital. The DON stated she notifies the MD (medical doctor)/RP (responsible party), sends a transfer form, MAR (medication administration record) and PN (progress notes). The DON stated when asked if a copy of the comprehensive care plan goals are sent, she stated she didn't. The surveyor met with the director of nursing (DON), assistant director of nursing (ADON), both corporate registered nurses and the interim administrator on 12/6/18 at 12:02 p.m. on the process for transferring a resident to the hospital. The DON stated notify MD/RP, call hospital and give report, after hours notified, call EMS (emergency medical services), send transfer treatment form, MAR, any special treatments, and pertinent laboratory tests. The DON stated comprehensive care plan goals were not sent. The DON also stated no written documentation of transfers are sent to the family when the resident is transferred to hospital. The surveyor informed the administrative staff of the above concern in the end of the day meeting on 12/6/18 at 4:14 p.m. No further information was provided prior to the exit on 12/6/18. 4. For Resident #24, the facility staff failed to provide a written notice of transfer when Resident #24 was transferred to a local hospital. Resident #24 is a [AGE] year-old female who was originally admitted to the facility on [DATE], with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident #24 was reviewed on 12/5/18 at 1:14 pm. The most recent MDS (minimum data set) assessment for Resident #24 was a quarterly assessment with an ARD (assessment reference date) of 11/20/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident #24 had a BIMS (brief interview for mental status) score of 15 out of 15. On 12/05/18 the surveyor reviewed Resident #24's progress notes. It contained a progress note in the clinical record documented on 09/11/18 at 7:30 pm which read in part, Charge nurse telephoned ER (emergency room ) to inquire on Resident's status. Resident admitted to (facility name withheld) with Dx (diagnosis):[MEDICAL CONDITION], PNA (pneumonia), UTI (urinary tract infection). RP (responsible party) is at ER with Resident The surveyor could not locate documentation in Resident #24's clinical record that indicated that Resident #24 and/or Resident #24's authorized representative was notified of Resident #24's transfer to the emergency roiagnom on [DATE] in writing. On 12/06/18 at 2:45 pm the surveyor spoke with DON (director of nursing) and it was clarified that the facility staff did not notify Resident #24 and/or Resident #24's authorized representative of transfer to hospital on [DATE] in writing. The administrative team was made aware of issue during a meeting with survey team on 12/06/18 at 4:25 pm. No further information regarding this issue was provided to the survey team prior to the exit conference on 12/06/18. 5. For Resident #46, the facility staff failed to provide written notice of transfer when Resident #46 was transferred to a local hospital. Resident #46 is an [AGE] year-old female who was originally admitted to the facility on [DATE], with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident #46 was reviewed on 12/5/18 at 8:29 am. The most recent MDS (minimum data set) assessment for Resident #46 was an annual assessment with an ARD (assessment reference date) of 10/10/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident #46 had a BIMS (brief interview for mental status) score of 06 out of 15. On 12/05/18 the surveyor reviewed Resident #46's progress notes. It contained a progress note in the clinical record documented on 09/20/18 at 3:38 pm which read in part, R/C (report called) from (facility name withheld) nurse stating this Resident is being admitted on the med surge floor with Dx (diagnosis) of [MEDICAL CONDITION] with hypoxemia and pleural effusion to right lower lung. The surveyor could not locate documentation in Resident #46's clinical record that indicated that Resident #46 and/or Resident #46's authorized representative was notified of Resident #46's transfer to the emergency roiagnom on [DATE] in writing. On 12/06/18 at 2:45 pm the surveyor spoke with DON (director of nursing) and it was clarified that the facility staff did not notify Resident #46's authorized representative of transfer to hospital on [DATE] in writing. The administrative team was made aware of issue during a meeting with survey team on 12/06/18 at 4:25 pm. No further information regarding this issue was provided to the survey team prior to the exit conference on 12/06/18. 6. For Resident #1 the facility staff failed to provide a written notice of transfer to the Resident/representative when Resident was transferred to the hospital. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 11/27/18 coded the Resident as 5 out of 15 in section C, cognitive patterns. This is a quarterly MDS. Resident #1's clinical record was reviewed on 12/05/18. It contained a progress note dated 08/14/18 which read in part, 8/14/2018 18:19 Received call from sister, .(name omitted), regarding Resident en route to (facility name omitted), . The surveyor could not locate any documentation that indicated the a written notice of transfer was provided to the Resident or representative. Surveyor spoke with the social worker on 12/06/18 at approximately 1150. Social worker stated that she completes a transfer/discharge form when a Resident is discharged home, or to another facility. Social worker stated that she does not complete a transfer/discharge form when a Resident is sent to the hospital with the anticipation of return to the facility. The concern of not providing a written notice of transfer was discussed with the administrative team during a meeting on 12/06/18 at approximately 1615. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review the facility staff failed to follow professional standards of practice for 5 of 26 Residents, #70, #105, #154, #155, and #156. The findings included: 1. For Resident #70, the facility staff failed to follow the rights of medication administration. Which resulted in the Resident receiving the incorrect amount of the medication [MEDICATION NAME] and receiving a medication that had been discontinued in (MONTH) of (YEAR). According to the national institute of health website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 21/ accessed 12/07/2018 there are 7 rights to medication administration. Right patient, right drug, right dose, right time, right route, right reason, and right documentation. The clinical record review revealed that Resident #70 had been admitted to the facility 07/31/2014. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 10/31/2018 included a BIMS (brief interview for mental status) summary score of 14 out of a possible 15 points. The Residents CCP (comprehensive care plan) included the focus areas has altered GI (gastro-intestinal) status-chooses not to take medication for constipation prevention at times despite education by nursing staff. Interventions included but were not limited to, give medications as ordered. The facility used a Paxit system for administering medications. This system packaged the Residents tablets/capsules inside of a plastic bag that included the Residents name, room number, time of medication administration, date, name of facility, and the name of the Residents medications listed in alphabetical order. The bottom of the bag included the statement Refer to MAR (medication administration record) for medication administration times and instructions . Inside of the paxit, the medications were individually packaged in blister packs making each medication easily identifiable. On 12/05/2018 at 9:34 AM the surveyor observed LPN (licensed practical nurse) #1 during a medication pass and pour observation. During this observation, LPN #1 prepared and administered the Residents morning medications using the paxit system. When preparing the medications LPN #1 prepared 17 grams of [MEDICATION NAME] and mixed it with water. This was not included in the paxit medication bag. The paxit bag included 1 tablet of [MEDICATION NAME][MEDICATION NAME] 4 mg along with the Residents other morning medications. LPN #1 removed all the medications from the paxit bag, removed them from their blister packets, and placed them in a medication cup to administer to Resident #70. After preparing all of the Residents morning medications LPN #1 entered the Residents room and administered the medications. After the medication observation, the surveyor reconciled the Residents medications using the Residents EHR (electronic health record). A review of the Residents EHR revealed that Resident #70 had a physicians order for polyethylene [MEDICATION NAME] ([MEDICATION NAME]) powder give 8.5 grams by mouth one time a day for constipation. Not 17 grams as administered by LPN #1. The surveyor was unable to locate an active order for the [MEDICATION NAME][MEDICATION NAME]. The EHR included a physician order [REDACTED]. On 12/05/2018 at 10:45 AM, the surveyor and LPN #1 reviewed the Residents physician orders. After reviewing the orders LPN #1 verbalized to the surveyor that she had administered 17 grams of [MEDICATION NAME] and not 8.5. LPN #1 also verbalized that the [MEDICATION NAME][MEDICATION NAME] looked as if it had been discontinued. On 12/05/2018 at 11:55 AM LPN #1 approached the surveyor, stated she had made 2 medication errors, that the physician was in the facility, and had been notified. On 12/06/2018 at 1:45 PM, the DON (director of nursing) provided the survey team with a copy of their policy/procedure titled Physician Medication Orders. The DON stated we use this policy and it based on a standard of practice. This policy/procedure read in part, .Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medication in this state . The administrative staff were notified of the issues regarding the Residents [MEDICATION NAME] and [MEDICATION NAME][MEDICATION NAME] during a meeting with the survey team on 12/06/2018 at 4:14 PM. The facility provided the surveyor with a copy of an in-service attendance form titled Obtain medications for new admissions. The date of this in-service was documented as 12/05/18. The 2nd page of this document read in part, .Upon all new admissions', The Charge Nurse is responsible to call Pharmacy to have Patients profile uploaded into the Omnicel. You are to ensure that Pharmacy is using our back up Pharmacy to ensure all medication is available ASAP. NO EXCEPTIONS . Prior to the exit conference the DON stated she had contacted the pharmacy and the issue with the [MEDICATION NAME][MEDICATION NAME] appeared to be a linking problem. No further information regarding these issues were provided to the survey team prior to the exit conference. 2. For Resident #105, the facility staff failed to administer medications that were available at the facility and in the back up medication supply. The facility staff also failed to obtain medications that were not available in the back up medication supply at the facility at a backup pharmacy resulting in the Resident not receiving physician ordered medications. The clinical record review revealed that Resident #105 had been admitted to the facility 11/28/2018. [DIAGNOSES REDACTED]. There was no completed MDS (minimum data set) assessment on this Resident. However, the Resident was alert and orientated to person and place. The Residents care plan included the following focus area has respiratory problem related to acute illness or chronic condition. Interventions included administer medications as ordered. During initial tour of the facility on 12/04/2018, a family member of this Resident expressed a concern to the surveyor that the Resident had not received some of her medications when she had been admitted . On 12/04/2018 at 3:14 PM, during an interview with Resident #105 the Resident stated they had been admitted late one evening and it took a couple of days to get my medicines straightened out. 12/04/18 at 4:33 PM, the surveyor asked RN (registered nurse) #1 if they had a backup pharmacy. RN #1 verbalized to the surveyor that they use-to-use one in town and now we use one in a neighboring city. A review of the Residents EHR (electronic health record) revealed that the facility nursing staff had coded the following medications with a 9 on 11/28/18 [MEDICATION NAME] (hypertension), and [MEDICATION NAME] (hypertension). For 11/29/18 nifediac (hypertension), osteo Bi-Flex, vitamin C, vitamin E, eliquis ([MEDICAL CONDITION]-the facility had documented they had administered this on 11/28/18), [MEDICATION NAME], and [MEDICATION NAME] ([MEDICATION NAME]). For 11/30/18 [MEDICATION NAME] (the facility had documented this had been administered on 11/28/18). Per the pre-printed code on the eMAR (electronic medication administration record) a 9=Other/See Nurses Note. On 11/29/2018 the nursing staff documented that they were awaiting pharmacy for the [MEDICATION NAME], eliquis, [MEDICATION NAME], nifediac, osteo Bi-flex, vitamin C, and vitamin E. A review of the facility stat box and omnicell list revealed that the medications [MEDICATION NAME], vitamin C, and [MEDICATION NAME] would have been available in the back up medication boxes for administration. On 12/05/2018 at 4:27 PM, during a meeting with the administrative staff the DON (director of nursing) was asked the procedure to obtain medications for new admissions or if medications were not available. The DON verbalized to the survey team that if the medication is available in the omnicell, the nursing staff would have to call the pharmacy to access the Residents profile and they could use a backup pharmacy. On 12/06/18 at 9:14 AM, the surveyor interviewed pharmacist #1 via phone in regards to new admissions/unavailable medications. Pharmacist #1 verbalized to the surveyor that the procedure for the omnicell was as follows-orders are sent to the pharmacy and once they are verified, they are entered into the system. Pharmacist #1 also stated that they have a stat box at the facility and some medications can be pulled from that or they can utilize the backup system for more urgent medications such as blood pressure medications and antibiotics. The facility policy/procedure titled UNAVAILABLE MEDICATIONS read in part, .If the ordered medications are not available, the pharmacist is notified for delivery at next scheduled delivery time or if needed prior to the next scheduled med pass time, the pharmacy will contact the back-up pharmacy for the medication. A pharmacist is available 24 hours a day by phone .The attending physician is to be notified of medication that is not available from the pharmacy. The physician may order an alternative medication from EDK/STAT kits until the original medication is available. Reference: Potter and Perry, Fundamentals of Nursing 6th edition, page 419. Professional standards dictate that care be administered according to physician direction: The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders [REDACTED]. The facility provided the surveyor with a copy of an in-service attendance form titled Obtain medications for new admissions. The date of this in-service was documented as 12/05/18. The 2nd page of this document read in part, .Upon all new admissions', The Charge Nurse is responsible to call Pharmacy to have Patients profile uploaded into the Omnicel. You are to ensure that Pharmacy is using our back up Pharmacy to ensure all medication is available ASAP. NO EXCEPTIONS . The administrative staff were notified of the issue regarding the availability and administration of the Residents medications during a meeting with the survey team on 12/06/18 at 4:14 PM. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #154, the facility staff failed to administer medications that were available at the facility in the back up medication supply and failed to obtain medications that were not available in the back up medication supply at the facility from a backup pharmacy. This resulted in the Resident not receiving physician ordered medications. The clinical record review revealed that Resident #154 had been admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. There was no MDS (minimum data set) assessment completed on this Resident. However, the Resident was alert and orientated to person and place. During a medication pass and pour observation with LPN (licensed practical nurse) #2 on 12/05/18 at 10:03 AM LPN #2 verbalized to the surveyor that the Residents [MEDICATION NAME] had not arrived from the pharmacy for administration. The Residents physician order [REDACTED].Give 10 cc orally three times a day for mouth care patient must spit out . The order date was documented as 12/04/18. When reviewing the Residents clinical record on 12/06/18 it was noted that LPN #2 had documented on the Residents eMAR (electronic medication administration record) that she had administered the [MEDICATION NAME] at 9:00 AM and 1:00 PM on 12/05/18. When interviewing LPN #2 she stated she had marked that in error and she had not obtained the medication until around 3:30 PM from the backup pharmacy. Indicating the Resident had missed two doses. Reference: Potter-Perry Fundamentals of Nursing, 6th Edition, page 477 Documentation is anything written or printed that is relied on as record or proof for authorized persons. Documentation within a client record is a vital aspect of nursing practice. Nursing documentation must be accurate, comprehensive and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice. Further review of the Residents EHR (electronic health record) revealed that the facility nursing staff had coded the following medications with a 9 on 12/03/18 [MEDICATION NAME] ([MEDICAL CONDITION]), [MEDICATION NAME] (antipsychotic), and atrovent nasal spray ([MEDICAL CONDITION]). For 12/04/18 [MEDICATION NAME] (bladder spasms), atrovent nasal spray, and [MEDICATION NAME]. Per the pre-printed code on the eMAR (electronic medication administration record) a 9=Other/See Nurses Note. A review of the facility stat box and omnicell list revealed that the medications [MEDICATION NAME], and [MEDICATION NAME], would have been available in the back up medication boxes for administration. On 12/05/2018 at 4:27 PM during a meeting with the administrative staff the DON (director of nursing) was asked the procedure for obtaining medications for new admissions or if medications were not available. The DON verbalized to the survey team that if the medication is available in the omnicell, the nursing staff would have to call the pharmacy to access the Residents profile and they could use a backup pharmacy. During an interview with Resident #154 on 12/06/18 at 8:46 AM, Resident #154 stated they started his mouthwash. When asked how his mouth felt he stated before he used the mouthwash his mouth and throat hurt. On 12/06/18 at 9:14 AM, the surveyor interviewed pharmacist #1 via phone in regards to new admissions/unavailable medications. Pharmacist #1 verbalized to the surveyor that the procedure for the omnicell was as follows-orders are sent to the pharmacy and once they are verified, they are entered into the system. Pharmacist #1 also stated that they have a stat box at the facility and some medications can be pulled from that or they can utilize the backup system for more urgent medications such as blood pressure medications and antibiotics. When asked when the [MEDICATION NAME] had been called into the back up pharmacy pharmacist stated yesterday (12/05/18) at 3:48 PM. The facility policy/procedure titled UNAVAILABLE MEDICATIONS read in part, .If the ordered medications are not available, the pharmacist is notified for delivery at next scheduled delivery time or if needed prior to the next scheduled med pass time, the pharmacy will contact the back-up pharmacy for the medication. A pharmacist is available 24 hours a day by phone .The attending physician is to be notified of medication that is not available from the pharmacy. The physician may order an alternative medication from EDK/STAT kits until the original medication is available. Reference: Potter and Perry, Fundamentals of Nursing 6th edition, page 419. Professional standards dictate that care be administered according to physician direction: The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders [REDACTED]. The facility provided the surveyor with a copy of an in-service attendance form titled Obtain medications for new admissions. The date of this in-service was documented as 12/05/18. The 2nd page of this document read in part, .Upon all new admissions', The Charge Nurse is responsible to call Pharmacy to have Patients profile uploaded into the Omnicel. You are to ensure that Pharmacy is using our back up Pharmacy to ensure all medication is available ASAP. NO EXCEPTIONS . The administrative staff were notified of the issue regarding the availability and administration of the Residents medications during a meeting with the survey team on 12/06/18 at 4:14 PM. No further information regarding this issue was provided to the survey team prior to the exit conference. 4. For Resident #155, the facility staff failed to administer medications that were available at the facility in the back up medication supply and failed to obtain medications that were not available in the back up medication supply at the facility from a backup pharmacy. This resulted in the Resident not receiving physician ordered medications. The clinical record review revealed that Resident #155 had been admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. There was no MDS (minimum data set) assessment completed on this Resident. However, the Resident was alert and orientated to person and place. A review of the Residents EHR (electronic health record) revealed that the facility nursing staff had coded the following medications with a 9 on 12/03/18 sennosides (stool softner), [MEDICATION NAME] ([MEDICAL CONDITION]), and [MEDICATION NAME] suspension. For 12/04/18 atorvastatin (cholesterol), [MEDICATION NAME] (antidepressant), [MEDICATION NAME] ER (extended release), [MEDICATION NAME] ER (hypertension), [MEDICATION NAME] (stomach ulcers), carvedilol (hypertension) the facility nursing staff had documented that this medication had been administered on 12/03/18, and [MEDICATION NAME] (high blood pressure). Per the pre-printed code on the eMAR (electronic medication administration record) a 9=Other/See Nurses Note. A review of the facility stat box and omnicell list revealed that the medications atorvastatin, [MEDICATION NAME], sennosides, [MEDICATION NAME], and carvedilol, would have been available in the back up medication boxes for administration. On 12/05/2018 at 4:27 PM. during a meeting with the administrative staff the DON (director of nursing) was asked the procedure to obtain medications for new admissions or if medications were not available. The DON verbalized to the survey team that if the medication is available in the omnicell, the nursing staff would have to call the pharmacy to access the Residents profile and they could use a backup pharmacy. The Residents care plan included the focus area to administer medications as ordered. On 12/06/18 at 9:14 AM, the surveyor interviewed pharmacist #1 via phone in regards to new admissions/unavailable medications. Pharmacist #1 verbalized to the surveyor that the procedure for the omnicell was as follows-orders are sent to the pharmacy and once they are verified, they are entered into the system. Pharmacist #1 also stated that they have a stat box at the facility and some medications can be pulled from that or they can utilize the backup system for more urgent medications such as blood pressure medications and antibiotics. The facility policy/procedure titled UNAVAILABLE MEDICATIONS read in part, .If the ordered medications are not available, the pharmacist is notified for delivery at next scheduled delivery time or if needed prior to the next scheduled med pass time, the pharmacy will contact the back-up pharmacy for the medication. A pharmacist is available 24 hours a day by phone .The attending physician is to be notified of medication that is not available from the pharmacy. The physician may order an alternative medication from EDK/STAT kits until the original medication is available. Reference: Potter and Perry, Fundamentals of Nursing 6th edition, page 419. Professional standards dictate that care be administered according to physician direction: The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders [REDACTED]. The administrative staff were notified of the issue regarding the availability and administration of the Residents medications during a meeting with the survey team on 12/06/18 at 4:14 PM. The facility provided the surveyor with a copy of an in-service attendance form titled Obtain medications for new admissions. The date of this in-service was documented as 12/05/18. The 2nd page of this document read in part, .Upon all new admissions', The Charge Nurse is responsible to call Pharmacy to have Patients profile uploaded into the Omnicel. You are to ensure that Pharmacy is using our back up Pharmacy to ensure all medication is available ASAP. NO EXCEPTIONS . No further information regarding this issue was provided to the survey team prior to the exit conference. 5. For Resident #156, the facility staff failed to administer medications that were available at the facility in the back up medication supply and failed to obtain medications that were not available in the back up medication supply at the facility from a backup pharmacy. This resulted in the Resident not receiving physician ordered medications. The clinical record review revealed that Resident #156 had been admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. There was no MDS (minimum data set) assessment completed on this Resident. However, the Resident was alert and orientated to person and place. A review of the Residents EHR (electronic health record) revealed that the facility nursing staff had coded the following medications with a 9 on 11/29/18 [MEDICATION NAME] (hypertension) and [MEDICATION NAME] (pain). For 11/30/18, the facility had coded the antibiotic [MEDICATION NAME] with a 9. Per the pre-printed code on the eMAR (electronic medication administration record) a 9=Other/See Nurses Note. On 11/29/18, the facility staff had documented that they were waiting for the medications [MEDICATION NAME], and [MEDICATION NAME] from the pharmacy. A review of the facility stat box and omnicell list revealed that the medications [MEDICATION NAME] and [MEDICATION NAME] would have been available in the back up medication boxes for administration. On 12/05/2018 at 4:27 PM during a meeting with the administrative staff the DON (director of nursing) was asked the procedure to obtain medications for new admissions or if medications were not available. The DON verbalized to the survey team that if the medication is available in the omnicell, the nursing staff would have to call the pharmacy to access the Residents profile and they could use a backup pharmacy. The Resident had been care planned for pain-administer pain medication as ordered and contact isolation due to [MEDICAL CONDITION]. Resident #156 had been prescribed the antibiotic [MEDICATION NAME] for the [MEDICAL CONDITION]. On 12/06/18 at 9:14 AM, the surveyor interviewed pharmacist #1 via phone in regards to new admissions/unavailable medications. Pharmacist #1 verbalized to the surveyor that the procedure for the omnicell was as follows-orders are sent to the pharmacy and once they are verified, they are entered into the system. Pharmacist #1 also stated that they have a stat box at the facility and some medications can be pulled from that or they can utilize the backup system for more urgent medications such as blood pressure medications and antibiotics. The facility policy/procedure titled UNAVAILABLE MEDICATIONS read in part, .If the ordered medications are not available, the pharmacist is notified for delivery at next scheduled delivery time or if needed prior to the next scheduled med pass time, the pharmacy will contact the back-up pharmacy for the medication. A pharmacist is available 24 hours a day by phone .The attending physician is to be notified of medication that is not available from the pharmacy. The physician may order an alternative medication from EDK/STAT kits until the original medication is available. Reference: Potter and Perry, Fundamentals of Nursing 6th edition, page 419. Professional standards dictate that care be administered according to physician direction: The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders [REDACTED]. The administrative staff were notified of the issue regarding the availability and administration of the Residents medications during a meeting with the survey team on 12/06/18 at 4:14 PM. The facility provided the surveyor with a copy of an in-service attendance form titled Obtain medications for new admissions. The date of this in-service was documented as 12/05/18. The 2nd page of this document read in part, .Upon all new admissions', The Charge Nurse is responsible to call Pharmacy to have Patients profile uploaded into the Omnicel. You are to ensure that Pharmacy is using our back up Pharmacy to ensure all medication is available ASAP. NO EXCEPTIONS . No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, clinical record review, and facility document review the facility staff failed to follow physician's orders for 4 of 26 Residents, #105, #154, #155, and #156. The findings included: 1. For Resident #105, the facility staff failed to administer physician ordered medications. The clinical record review revealed that Resident #105 had been admitted to the facility 11/28/2018. [DIAGNOSES REDACTED]. There was no completed MDS (minimum data set) assessment on this Resident. However, the Resident was alert and orientated to person and place. The Residents care plan included the following focus area has respiratory problem related to acute illness or chronic condition. Interventions included administer medications as ordered. During initial tour of the facility on 12/04/2018, a family member of this Resident expressed a concern to the surveyor that the Resident had not received some of her medications when she had been admitted . On 12/04/2018 at 3:14 PM, during an interview with Resident #105 the Resident stated the facility had a problem stated they had been admitted late one evening and it took a couple of days to get my medicines straightened out. 12/04/18 at 4:33 PM, the surveyor asked RN (registered nurse) #1 if they had a backup pharmacy. RN #1 verbalized to the surveyor that they use-to-use one in town and now we use one in a neighboring city. A review of the Residents EHR (electronic health record) revealed that the facility nursing staff had coded the following medications with a 9 on 11/28/18 [MEDICATION NAME] (hypertension), and [MEDICATION NAME] (hypertension). For 11/29/18 nifediac (hypertension), osteo Bi-Flex, vitamin C, vitamin E, eliquis ([MEDICAL CONDITION]-the facility had documented they had administered this on 11/28/18), [MEDICATION NAME], and [MEDICATION NAME] ([MEDICATION NAME]). For 11/30/18 [MEDICATION NAME] (the facility had documented this had been administered on 11/28/18). Per the pre-printed code on the eMAR (electronic medication administration record) a 9=Other/See Nurses Note. On 11/29/2018 the nursing staff documented that they were awaiting pharmacy for the [MEDICATION NAME], eliquis, [MEDICATION NAME], nifediac, osteo Bi-flex, vitamin C, and vitamin E. A review of the facility stat box and omnicell list revealed that the medications [MEDICATION NAME], vitamin C, and [MEDICATION NAME] would have been available in the back up medication boxes for administration. On 12/05/2018 at 4:27 PM, during a meeting with the administrative staff the DON (director of nursing) was asked the procedure for obtaining medications for new admissions or if medications were not available. The DON verbalized to the survey team that if the medication is available in the omnicell, the nursing staff would have to call the pharmacy to access the Residents profile and they could also use a backup pharmacy. On 12/06/18 at 9:14 AM, the surveyor interviewed pharmacist #1 via phone in regards to new admissions/unavailable medications. Pharmacist #1 verbalized to the surveyor that the procedure for the omnicell was as follows-orders are sent to the pharmacy and once they are verified, they are entered into the system. Pharmacist #1 also stated that they have a stat box at the facility and some medications can be pulled from that or they can utilize the backup system for more urgent medications such as blood pressure medications and antibiotics. The facility policy/procedure titled UNAVAILABLE MEDICATIONS read in part, .If the ordered medications are not available, the pharmacist is notified for delivery at next scheduled delivery time or if needed prior to the next scheduled med pass time, the pharmacy will contact the back-up pharmacy for the medication. A pharmacist is available 24 hours a day by phone .The attending physician is to be notified of medication that is not available from the pharmacy. The physician may order an alternative medication from EDK/STAT kits until the original medication is available. The facility provided the surveyor with a copy of an in-service attendance form titled Obtain medications for new admissions. The date of this in-service was documented as 12/05/18. The 2nd page of this document read in part, .Upon all new admissions, The Charge Nurse is responsible to call Pharmacy to have Patients profile uploaded into the Omnicel. You are to ensure that Pharmacy is using our back up Pharmacy to ensure all medication is available ASAP. NO EXCEPTIONS . The administrative staff were notified of the issue regarding the availability and administration of the Residents medications during a meeting with the survey team on 12/06/18 at 4:14 PM. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #154, the facility staff failed to administer physician ordered medications. The clinical record review revealed that Resident #154 had been admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. There was no MDS (minimum data set) assessment completed on this Resident. However, the Resident was alert and orientated to person and place. During a medication pass and pour observation with LPN (licensed practical nurse) #2 on 12/05/2018 at 10:03 AM LPN #2 verbalized to the surveyor that the Residents [MEDICATION NAME] had not arrived from the pharmacy for administration. The Residents physician order summary included the order [MEDICATION NAME] Suspension .Give 10 cc orally three times a day for mouth care patient must spit out . The order date was documented as 12/04/18. When reviewing the Residents clinical record on 12/06/18 it was noted that LPN #2 had documented on the Residents eMAR (electronic medication administration record) that she had administered the [MEDICATION NAME] at 9:00 AM and 1:00 PM on 12/05/18. When interviewing LPN #2 she stated she had marked that in error and she had not obtained the medication until around 3:30 PM from the backup pharmacy. Indicating the Resident had missed 2 doses. Further review of the Residents EHR (electronic health record) revealed that the facility nursing staff had coded the following medications with a 9 on 12/03/18 [MEDICATION NAME] ([MEDICAL CONDITION]), [MEDICATION NAME] (antipsychotic), and atrovent nasal spray ([MEDICAL CONDITION]). For 12/04/18 [MEDICATION NAME] (bladder spasms), atrovent nasal spray, and [MEDICATION NAME]. Per the pre-printed code on the eMAR (electronic medication administration record) a 9=Other/See Nurses Note. A review of the facility stat box and omnicell list revealed that the medications [MEDICATION NAME], and [MEDICATION NAME], would have been available in the back up medication boxes for administration. On 12/05/2018 at 4:27 PM, during a meeting with the administrative staff the DON (director of nursing) was asked the procedure for obtaining medications for new admissions or if medications were not available. The DON verbalized to the survey team that if the medication is available in the omnicell, the nursing staff would have to call the pharmacy to access the Residents profile and they could use a backup pharmacy. During an interview with Resident #154 on 12/06/18 at 8:46 AM, Resident #154 stated they had started his mouthwash. When asked how his mouth felt he stated before he used the mouthwash his mouth and throat hurt. On 12/06/18 at 9:14 AM, the surveyor interviewed pharmacist #1 via phone in regards to new admissions/unavailable medications. Pharmacist #1 verbalized to the surveyor that the procedure for the omnicell was as follows-orders are sent to the pharmacy and once they are verified, they are entered into the system. Pharmacist #1 also stated that they have a stat box at the facility and some medications can be pulled from that or they can utilize the backup system for more urgent medications such as blood pressure medications and antibiotics. When asked when the [MEDICATION NAME] had been called into the back up pharmacy pharmacist stated yesterday (12/05/18) at 3:48 PM. The facility policy/procedure titled UNAVAILABLE MEDICATIONS read in part, .If the ordered medications are not available, the pharmacist is notified for delivery at next scheduled delivery time or if needed prior to the next scheduled med pass time, the pharmacy will contact the back-up pharmacy for the medication. A pharmacist is available 24 hours a day by phone .The attending physician is to be notified of medication that is not available from the pharmacy. The physician may order an alternative medication from EDK/STAT kits until the original medication is available. The facility provided the surveyor with a copy of an in-service attendance form titled Obtain medications for new admissions. The date of this in-service was documented as 12/05/18. The 2nd page of this document read in part, .Upon all new admissions, The Charge Nurse is responsible call Pharmacy to have Patients profile uploaded into the Omnicel. You are to ensure that Pharmacy is using our back up Pharmacy to ensure all medication is available ASAP. NO EXCEPTIONS . The administrative staff were notified of the issue regarding the availability and administration of the Residents medications during a meeting with the survey team on 12/06/18 at 4:14 PM. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #155, the facility staff failed to administer physician ordered medications. The clinical record review revealed that Resident #155 had been admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. There was no MDS (minimum data set) assessment completed on this Resident. However, the Resident was alert and orientated to person and place. A review of the Residents EHR (electronic health record) revealed that the facility nursing staff had coded the following medications with a 9 on 12/03/18 sennosides (stool softner), [MEDICATION NAME] ([MEDICAL CONDITION]), and [MEDICATION NAME] suspension. For 12/04/18 atorvastatin (cholesterol), [MEDICATION NAME] (antidepressant), [MEDICATION NAME] ER (extended release), [MEDICATION NAME] ER (hypertension), [MEDICATION NAME] (stomach ulcers), carvedilol (hypertension) the facility nursing staff had documented that this medication had been administered on 12/03/18, and [MEDICATION NAME] (high blood pressure). Per the pre-printed code on the eMAR (electronic medication administration record) a 9=Other/See Nurses Note. A review of the facility stat box and omnicell list revealed that the medications atorvastatin, [MEDICATION NAME], sennosides, [MEDICATION NAME], and carvedilol, would have been available in the back up medication boxes for administration. On 12/05/2018 at 4:27 PM, during a meeting with the administrative staff the DON (director of nursing) was asked the procedure for obtaining medications for new admissions or if medications were not available. The DON verbalized to the survey team that if the medication is available in the omnicell, the nursing staff would have to call the pharmacy to access the Residents profile and they could use a backup pharmacy. The Residents care plan included the focus area to administer medications as ordered. On 12/06/18 at 9:14 AM, the surveyor interviewed pharmacist #1 via phone in regards to new admissions/unavailable medications. Pharmacist #1 verbalized to the surveyor that the procedure for the omnicell was as follows-orders are sent to the pharmacy and once they are verified, they are entered into the system. Pharmacist #1 also stated that they have a stat box at the facility and some medications can be pulled from that or they can utilize the backup system for more urgent medications such as blood pressure medications and antibiotics. The facility policy/procedure titled UNAVAILABLE MEDICATIONS read in part, .If the ordered medications are not available, the pharmacist is notified for delivery at next scheduled delivery time or if needed prior to the next scheduled med pass time, the pharmacy will contact the back-up pharmacy for the medication. A pharmacist is available 24 hours a day by phone .The attending physician is to be notified of medication that is not available from the pharmacy. The physician may order an alternative medication from EDK/STAT kits until the original medication is available. The administrative staff were notified of the issue regarding the availability and administration of the Residents medications during a meeting with the survey team on 12/06/18 at 4:14 PM. The facility provided the surveyor with a copy of an in-service attendance form titled Obtain medications for new admissions. The date of this in-service was documented as 12/05/18. The 2nd page of this document read in part, .Upon all new admissions', The Charge Nurse is responsible call Pharmacy to have Patients profile uploaded into the Omnicel. You are to ensure that Pharmacy is using our back up Pharmacy to ensure all medication is available ASAP. NO EXCEPTIONS . No further information regarding this issue was provided to the survey team prior to the exit conference. 4. For Resident #156, the facility staff failed to administer physician ordered medications. The clinical record review revealed that Resident #156 had been admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. There was no MDS (minimum data set) assessment completed on this Resident. However, the Resident was alert and orientated to person and place. A review of the Residents EHR (electronic health record) revealed that the facility nursing staff had coded the following medications with a 9 on 11/29/18 [MEDICATION NAME] (hypertension) and [MEDICATION NAME] (pain). For 11/30/18, the facility had coded the antibiotic [MEDICATION NAME] with a 9. Per the pre-printed code on the eMAR (electronic medication administration record) a 9=Other/See Nurses Note. A review of the facility stat box and omnicell list revealed that the medications [MEDICATION NAME] and [MEDICATION NAME] would have been available in the back up medication boxes for administration. On 11/29/18, the facility staff had documented that they were waiting for the medications [MEDICATION NAME], and [MEDICATION NAME] from the pharmacy. On 12/05/2018 at 4:27 PM, during a meeting with the administrative staff the DON (director of nursing) was asked the procedure to obtain medications for new admissions or if medications were not available. The DON verbalized to the survey team that if the medication is available in the omnicell, the nursing staff would have to call the pharmacy to access the Residents profile and they could use a back up pharmacy. The Resident had been care planned for pain-administer pain medication as ordered and contact isolation due to [MEDICAL CONDITION]. Resident #156 had been prescribed the antibiotic [MEDICATION NAME] for the [MEDICAL CONDITION]. On 12/06/18 at 9:14 AM, the surveyor interviewed pharmacist #1 via phone in regards to new admissions/unavailable medications. Pharmacist #1 verbalized to the surveyor that the procedure for the omnicell was as follows-orders are sent to the pharmacy and once they are verified, they are entered into the system. Pharmacist #1 also stated that they have a stat box at the facility and some medications can be pulled from that or they can utilize the backup system for more urgent medications such as blood pressure medications and antibiotics. The facility policy/procedure titled UNAVAILABLE MEDICATIONS read in part, .If the ordered medications are not available, the pharmacist is notified for delivery at next scheduled delivery time or if needed prior to the next scheduled med pass time, the pharmacy will contact the back-up pharmacy for the medication. A pharmacist is available 24 hours a day by phone .The attending physician is to be notified of medication that is not available from the pharmacy. The physician may order an alternative medication from EDK/STAT kits until the original medication is available. The administrative staff were notified of the issue regarding the availability and administration of the Residents medications during a meeting with the survey team on 12/06/18 at 4:14 PM. The facility provided the surveyor with a copy of an in-service attendance form titled Obtain medications for new admissions. The date of this in-service was documented as 12/05/18. The 2nd page of this document read in part, .Upon all new admissions, The Charge Nurse is responsible to call Pharmacy to have Patients profile uploaded into the Omnicel. You are to ensure that Pharmacy is using our back up Pharmacy to ensure all medication is available ASAP. NO EXCEPTIONS . 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 during a medication pass and pour observation, the facility staff failed to ensure 4 of 26 Residents were free of significant medication errors. These errors effected Residents #39, #70, #154, and #156. The findings included: 1. For Resident #39, the facility staff crushed the medication potassium ER (extended release) prior to administering. The clinical record review revealed that Resident #39 had been admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 10/05/18 had been coded 1/1/2 to indicate the Resident had problems with long and short term memory and was moderately impaired in cognitive skills for daily decision making. On 12/05/18 at 8:08 AM the surveyor observed LPN (licensed practical nurse) #3 prepare and administer Resident #39's morning medications. During this observation LPN #3 was observed to open a blister packet that contained 10 meq of potassium ER and place it into a medication cup with all of the Residents other am medications. LPN #3 crushed all of the Residents medications, then proceeded into the Residents room, and administered the medications to Resident #39. On 12/05/18 at 10:37 AM, the surveyor spoke with pharmacist #1 via phone regarding the potassium. Pharmacist #1 verbalized to the surveyor that the potassium could be crushed. However, it would no longer be an extended release product. On 12/05/18 at 2:52 PM, the surveyor interviewed LPN #3 when asked if she had crushed the Residents potassium she stated she had. When asked if she usually crushed these medications, she stated she did and then stated we need to get that changed. Prior to the exit conference, the facility provided the surveyor with a copy of the Residents new potassium order Potassium Chloride Solution 20 MEQ/15ML .Give 10 mEq orally one time a day for supplement. Indicating the facility had the medication changed to a liquid after the medication pass. The facility provided the surveyor with a copy of document titled Potassium Chloride this document read in part, .Extended-release tablets: Swallow whole; do NOT crush or chew . The facility also provided the surveyor with a copy of an in-service attendance form dated 12/05/18 the instructions included, Do not crush extended release medication. Please pay close attention to ensure they are not crushed. The administrative staff were notified of the issues regarding Resident #39's potassium being crushed on 12/06/18 at 4:14 PM. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #70, the facility staff administered the medication [MEDICATION NAME][MEDICATION NAME]. This medication had been discontinued in (MONTH) of (YEAR). [MEDICATION NAME][MEDICATION NAME] provides relief for inflamed areas of the body. It is used to treat a number of different conditions, such as inflammation (swelling), severe allergies [REDACTED]. This medicine is available only with your doctor's prescription. https://www.mayoclinic.org/drugs-supplements/[MEDICATION NAME][MEDICATION NAME]-oral-route/description/drg- 237 accessed 12/10/18. The clinical record review revealed that Resident #70 had been admitted to the facility 07/31/2014. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 10/31/2018 included a BIMS (brief interview for mental status) summary score of 14 out of a possible 15 points. The Residents CCP (comprehensive care plan) included the intervention give medications as ordered. The facility used a Paxit system for administering medications. This system packaged the Residents tablets/capsules inside of a plastic bag that included the Residents name, room number, time of medication administration, date, name of facility, and the name of the Residents medications listed in alphabetical order. The bottom of the bag included the statement Refer to MAR (medication administration record) for medication administration times and instructions . Inside of the paxit, the medications were individually packaged in blister packs making each medication easily identifiable. On 12/05/2018 at 9:34 AM, the surveyor observed LPN (licensed practical nurse) #1 prepare and administer Resident #70's morning medications. During this observation, LPN #1 prepared and administered the Residents morning medications using the paxit system. The paxit bag included 1 tablet of [MEDICATION NAME][MEDICATION NAME] 4 mg along with the Residents other morning medications. LPN #1 removed all the medications from the paxit bag, removed them from the blister packs and placed them in a medication cup to administer to Resident #70. After preparing all of the Residents morning medications LPN #1 entered the Residents room and administered the medications to Resident #70. After the medication observations, the surveyor reconciled the Residents medications using the Residents EHR (electronic health record). The surveyor was unable to locate an active order for the [MEDICATION NAME][MEDICATION NAME]. The EHR included a physician order [REDACTED]. On 12/05/2018 at 10:45 AM, the surveyor and LPN #1 reviewed the Residents physician orders. After reviewing the orders, LPN #1 verbalized to the surveyor that the [MEDICATION NAME][MEDICATION NAME] looked as if it had been discontinued. The monthly medication regimen reviews completed by the pharmacist did not include any information to indicate the pharmacy had identified that the medication [MEDICATION NAME][MEDICATION NAME] was continuing to be packaged, sent, and administered to the Resident. On 12/06/18 at 3:03 PM, LPN #1 stated she had called the pharmacy on 12/05/18 to ensure the medication would be discontinued. After this interview, the surveyor and LPN #1 checked the paxit medication pack that had delivered to the facility after LPN #1 had contacted the pharmacy. This paxit still contained the medication [MEDICATION NAME][MEDICATION NAME]. The administrative staff were notified of the issues regarding the [MEDICATION NAME][MEDICATION NAME] during a meeting with the survey team on 12/06/2018 at 4:14 PM. Prior to the exit conference the DON (director of nursing) stated she had contacted the pharmacy and the issue with the [MEDICATION NAME][MEDICATION NAME] appeared to be a linking problem. No further information regarding these issues were provided to the survey team prior to the exit conference. 3. For Resident #154, the facility failed to flush a PICC (peripherally inserted central catheter) line with [MEDICATION NAME] and saline after accessing. A PICC line is a thin, soft, flexible tube-an intravenous (IV) line. Treatments, such as IV medications, can be given though a PICC. The clinical record review revealed that Resident #154 had been admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. There was no MDS (minimum data set) assessment completed on this Resident. However, the Resident was alert and orientated to person and place. During a medication pass and pour observation with LPN (licensed practical nurse) #2 on 12/05/2018 at 10:03 AM the surveyor observed LPN #2 prepare and administer the Residents medication [MEDICATION NAME] (sandostatin) 50 mcg. LPN #2 pulled up 1 ml of this medication into a syringe and entered the Residents room. LPN #2 attempted to insert this medication into one line of the Residents PICC. However, she was unable to do so. LPN #2 then returned to the medication cart and retrieved a 10 ml flush of saline. LPN #2 reentered the Residents room and flushed the Residents PICC with 9 ml's of saline. LPN #2 then placed the medication into the PICC line. LPN #2 did not flush this line after administering the medication. The Residents physician order [REDACTED].Use 1 milliliter intravenously three times a day for Supplement . The DON (director of nursing) and LPN #2 were interviewed on 12/05/18 at 11:04 AM regarding the flushing of the Residents PICC line. LPN #2 verbalized to the surveyor that she had not flushed the PICC line after administering the medication. On 12/05/18 at 12:26 PM, the DON verbalized to the surveyor that the nurse should have used the SASH (saline, administer medication, saline, [MEDICATION NAME]) method when flushing the PICC line and provided the surveyor with a copy of their policy/procedure titled Flushing Midline and Central Line IV Catheters under the heading Flushing Solutions the policy/procedure read in part, Use the SASH method (saline, administer medication, saline, [MEDICATION NAME]) for intermittent treatments. These catheters will have a clamp on the outside lumen. This PICC line was equipped with a clamp. On 12/06/18 at 10:11 AM, the surveyor confirmed with pharmacist #1 that sandostatin was a medication. The administrative staff were notified of the issue regarding the flushing of the Residents PICC line during a meeting with the survey team on 12/06/18 at 4:14 PM. No further information regarding this issue was provided to the survey team prior to the exit conference. 4. For Resident #156, the facility staff failed to obtain and administer the Residents antibiotic [MEDICATION NAME]. This medication was in the back-up medication box at the facility. This resulted in the Resident missing 2 doses. The Resident was on contact isolation for [MEDICAL CONDITION]. The clinical record review revealed that Resident #156 had been admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. There was no MDS (minimum data set) assessment completed on this Resident. However, the Resident was alert and orientated to person and place. A review of the Residents EHR (electronic health record) revealed that the facility nursing staff had coded the antibiotic medication [MEDICATION NAME] with a 9 on 11/29/18 at midnight and 6:00 AM. Per the pre-printed code on the eMAR (electronic medication administration record) a 9=Other/See Nurses Note. A review of the nursing progress notes for 11/29/18 revealed that the nursing staff had documented at 1:19 AM and 5:28 AM for the [MEDICATION NAME] .awaiting pharmacy. A review of the facility stat box and omnicell list revealed that the medication [MEDICATION NAME] would have been available in the back up medication boxes for administration. On 12/05/2018 at 4:27 PM, during a meeting with the administrative staff the DON (director of nursing) was asked the procedure to obtain medications for new admissions or if medications were not available. The DON verbalized to the survey team that if the medication is available in the omnicell, the nursing staff would have to call the pharmacy to access the Residents profile and they could use a backup pharmacy. The Resident had been care planned for contact isolation due to [MEDICAL CONDITION]. On 12/06/18 at 9:14 AM, the surveyor interviewed pharmacist #1 via phone in regards to new admissions/unavailable medications. Pharmacist #1 verbalized to the surveyor that the procedure for the omnicell was as follows-orders are sent to the pharmacy and once they are verified, they are entered into the system. Pharmacist #1 also stated that they have a stat box at the facility and some medications can be pulled from that or they can utilize the backup system for more urgent medications such as blood pressure medications and antibiotics. The facility policy/procedure titled UNAVAILABLE MEDICATIONS read in part, .If the ordered medications are not available, the pharmacist is notified for delivery at next scheduled delivery time or if needed prior to the next scheduled med pass time, the pharmacy will contact the back-up pharmacy for the medication. A pharmacist is available 24 hours a day by phone .The attending physician is to be notified of medication that is not available from the pharmacy. The physician may order an alternative medication from EDK/STAT kits until the original medication is available. The administrative staff were notified of the issue regarding the availability and administration of the Residents medications during a meeting with the survey team on 12/06/18 at 4:14 PM. The facility provided the surveyor with a copy of an in-service attendance form titled Obtain medications for new admissions. The date of this in-service was documented as 12/05/18. The 2nd page of this document read in part, .Upon all new admissions, The Charge Nurse is responsible to call Pharmacy to have Patients profile uploaded into the Omnicel. You are to ensure that Pharmacy is using our back up Pharmacy to ensure all medication is available ASAP. NO EXCEPTIONS . No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, clinical record review and facility document review the facility staff failed to follow established infection control procedures for 5 of 26 Residents, #155, #156, #27 and #79. The findings included: 1. For Resident's #155 and #156, the facility cohorted Resident #155 and #156 in the same room. Resident #155 was on contact isolation for [MEDICAL CONDITION]. Both Residents were continent and used the same bathroom. The clinical record review revealed that Resident #155 had been admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. There was no MDS (minimum data set) assessment completed on this Resident. However, the Resident was alert and orientated to person and place. The clinical record review revealed that Resident #156 had been admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. There was no MDS (minimum data set) assessment completed on this Resident. However, the Resident was alert and orientated to person and place. Resident #156 had been care planned for contact isolation. During initial tour of the facility on 12/04/18 at 12:10 PM the surveyor observed an isolation cart that contained PPE (personal protective equipment) outside the room that both of these Residents resided in. The unit manager was asked which Resident was on isolation and why. The unit manager stated Resident #156 was on isolation and Resident #155 had been admitted last night. Resident #156 was identified as having [MEDICAL CONDITION]. The unit manager stated both Residents were continent and were using the same commode. After this interview CNA (certified nursing assistant) #1 was observed taking a bedside commode into the Residents room. CNA #1 was asked if both of the Residents were continent, to which she replied yes. When asked if they had both been using the same commode she stated they had been. On 12/04/18 at 12:35 PM, the surveyor observed a visitor in the Residents room sitting beside of Resident #156's bed. This visitor did not have any PPE in place. The surveyor spoke to this visitor and the visitor stated that no one had explained anything to her regarding the need to wear PPE. Both Residents were interviewed and both stated they have been using the commode in the bathroom. The visitor then added that they just brought in the bedside commode. The surveyor observed the bin that was being used to place the dirty PPE was placed next to the bed of the Resident without the infection (#155). Resident #155's respiratory equipment was also observed to be uncovered. On 12/04/18 at 1:11 PM, the ADON (assistant director of nursing) who had been identified as the infection control nurse was interviewed regarding the cohorting of these two Residents. The ADON stated Resident #155 came late last night and he did not know why they were put in a room together. The ADON then stated they tried to put Residents with [MEDICAL CONDITION] in separate rooms. The director of admissions was identified as the person who would assign the rooms and was interviewed on 12/04/18 at 1:24 PM. During this interview, the director of admission stated she did not realize that Resident #156 was on isolation and she did not check the room. The director of admissions stated they would be moving Resident #155 to another room and everyone had been notified. On 12/04/18 at 3:01 PM, the surveyor observed that Resident #155 had been moved to another room. Prior to the exit offence the facility provided the surveyor with a copy of an in-service form titled PPE/Isolation Accommodations this form read in part, Please ensure that when a pt/res (patient/Resident) require isolation that all appropriate PPE that is required for the specific type of isolation is in place with particular attention to toileting requirements that may be impacted by the type of isolation .Please also ensure that any family/visitors are educated appropriately regarding PPE requirements of isolation. The facility policy on Transmission Based Precautions read in part, .Contact-direct contact with skin, or indirect contact with contaminated surfaces, and physical transfer of organisms (usually on the hands of healthcare workers) from an infected or colonized person to a susceptible host . The administrative staff were notified of the problems regarding the infection control issues and Resident #155 and #156 during a meeting with the survey team on 12/05/18 at 4:27 PM. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. The facility staff failed to follow contact precautions posted on the door to Resident #27's room. The clinical record of Resident #27 was reviewed 12/4/18 through 12/6/18. Resident #27 was admitted to the facility 4/26/18 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #27's significant change in status minimum data set (MDS) assessment with an assessment reference date (ARD) of 9/28/18 assessed the resident with a BIMS (brief interview for mental status) as 00/15. The surveyor observed the resident during the initial tour on 12/4/18 at 12:33 p.m. At the entrance to the door was a sign that read Contact Precautions. A three-drawer cart was observed at the entrance to the door. The surveyor checked each drawer. There were gloves, shoe covers, gowns, masks, and blood pressure equipment but no hand sanitizer on top of the cart or in the cart. The surveyor observed Resident #27 again on 12/4/18 at 3:18 p.m. Resident #27 was observed in bed and observed to have a Foley drainage bag attached to the bed frame. The surveyor asked certified nursing assistant #1 to check the anchorage of Resident #27's indwelling Foley catheter. C.N.A. #1 donned gloves, gowns, and shoe covers and entered the resident's room. No hand washing or hand hygiene was performed before donning gloves. C.N.A. #1 checked the Foley for anchorage and then removed the gloves, gown, shoe covers and exited the room. No handwashing or hand hygiene was observed. C.N.A. #1 walked to the nurse's station after leaving the resident's room. The surveyor did not observe any hand hygiene while C.N.A. #1 was at the nurse's station. C.N.A. #1 picked up something at the nurses station and proceeded to walk down the first hall adjacent to the nurse's station. The surveyor requested the infection control policy and the posted sign at the entrance to Resident #27's room from the director of nursing on 12/4/18 at 4:24 p.m. The sign on Resident #27's room entrance read Contact Precautions In addition to Standard Precautions 1. Wash hands. 2. Gowns are indicated if soiling is likely. 3. Gloves are indicated, when touching infective material. Change frequently after contact. 4. Bag linen to prevent contamination of self, environment, or outside of bag. 5. Discard infectious trash to prevent contamination of self, environment, or outside of bag. 6. Wash hands. The surveyor reviewed the facility policy titled Infection Prevention and Control Program on 12/6/18. The policy read in part 4. Hand Hygiene Protocol: a. All staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated objects, after PPE (personal protective equipment) removal, before and after eating, before and after toileting, and before going off duty. The director of nursing showed the surveyor the isolation carts currently in use on 12/6/18 at 1:46 p.m. The unit manager registered nurse #1 stated to the DON that the isolation cart used for Resident #27's roommate was the old set-up isolation cart-not the new ones. The surveyor informed the administrative staff of the above concern on 12/5/18 at 4:14 p.m. No further information was provided prior to the exit conference on 12/6/18. 3. For Resident #79 the facility staff failed to follow establish infection control procedures related to catheter use. Resident #79 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 11/11/18 coded the Resident as 0 of 15 in section C, cognitive patterns. This is an annual MDS. Surveyor observed Resident #79 on 12/0418 at approximately 1215. Resident was resting in low bed. Resident's catheter bag was observed hanging from side of bed. Catheter tubing was observed to be resting on the floor. Surveyor observed Resident #79 on 12/05/18 at approximately 0920. Resident was seated in geri-chair in the dining area. Resident's catheter bag was attached to the chair, with catheter tubing hanging in the floor under the chair. Surveyor observed CNA #1 wheel Resident #79 from the dining area to her room in the geri-chair. Catheter tubing was observed dragging along the floor under the geri-chair. Surveyor observed Resident #79 again on 12/05/18 at approximately 1300. Resident was resting in bed, with catheter bag attached to side of bed. Catheter tubing was resting on the floor. Surveyor spoke with unit manager on 12/05/18 at approximately 1305 regarding catheter tubing being in floor. Surveyor asked unit manager if tubing should be touching the floor and unit manager stated that it should not. Surveyor spoke with the infection control nurse on 12/06/18 at approximately 0900 regarding Resident #79's catheter tubing. Surveyor asked the infection control nurse if the catheter tubing should be touching the floor and the infection control nurse stated that it should not. Surveyor was provided with a copy of a facility policy entitled Catheter Care which read in part, H. Position catheter tubing and collection container so that: 3. Tubing is not touching the floor. The concern of the Resident's catheter tubing touching the floor was discussed with the administrative team during a meeting on 12/05/18 at approximately 1630. No further information was provide prior to exit.

Based on staff interview and clinical record review the facility staff failed to ensure a complete and accurate DDNR (durable do not resuscitate) form for 2 of 26 Residents, Residents #14 and #73. The findings included: 1. For Resident #14 the facility staff failed to ensure a complete DDNR form. Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 09/17/18 coded the Resident as 10 of 15 in section C, cognitive patterns. This a quarterly MDS. Resident #14's clinical record was reviewed on 12/05/18. It contained a Virginia Department of Health DDNR form dated 04/18/18 which read as follows: I further certify (must check 1 or 2): ( ) 1. The Patient is CAPABLE of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment. (Signature of patient is required). (x) 2. The Patient is INCAPABLE of making an informed decision about provided, withholding, or withdrawing a specific medical treatment because he/she is unable to understand the nature, extent or probable consequences of the proposed medical decision , or to make a rational evaluation of the risks and benefits of alternatives to that decision. If you checked 2 above, check A, B, or C below: ( ) A. While capable of making an informed decision, the Patient has executed a written advanced directive which directs that life-prolonging procedures be withheld or withdrawn. ( ) B. While capable of making an informed decision, the patient has executed a written advanced directive which appoints a Person Authorized to Consent on the Patient's Behalf with authority to direct that life-prolonging procedures be withheld or withdrawn. (Signature of Person Authorized to Consent on the Patient's Behalf is required.) ( ) C. The Patient has not executed a written advanced directive (living will or durable power of attorney for health care). (Signature of Person Authorized to Consent on the Patient's Behalf is required). Section 2 of the form had not been checked, nor had the Resident or the person authorized at consent on the Resident's behalf signed the form. The concern of the incomplete DDNR form was discussed with the administrative team during a meeting on 12/05/18 at approximately 1630. No further information was prior to exit. 2. For Resident #73, the facility staff failed to ensure the Residents DDNR (durable do not resuscitate) was complete. Section's 1 and 2 had been left blank. The clinical record review revealed that Resident #73 had been admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Resident's most recent MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/03/18 included a BIMS (brief interview for mental status) summary score of 11 out of a possible 15 points. The Resident's clinical record included a DDNR order form from the Virginia Department of Health. This form was dated 08/13/18 and read in part. Under section 1 I further certify (must check 1 or 2): 1. The patient is CAPABLE of making an informed decision . 2. The patient is INCAPABLE of making an informed decision . Neither box had been checked. Section 2 read, If you checked 2 above, check A, B, or C below . All three boxes had been left blank. This form had been signed by the Residents authorized representative. The administrative team were made aware of the above findings on 12/05/18 at 4:27 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, facility document review and clinical record review, the facility staff failed to offer a bed hold to 1 of 26 residents (Resident #85). The findings included: The facility staff failed to offer a bed hold to Resident #85 when the resident was transferred to the hospital on [DATE]. The clinical record of Resident #85 was reviewed 12/4/18 through 12/6/18. Resident #85 was admitted to the facility 9/15/15 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #85's significant change in status minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/13/18 assessed the resident with short term memory problems, long term memory problems, and moderately impaired cognitive skills for daily decision making. Resident #85's 8/18/18 progress note read in part that the resident had dark stools and was sent to the emergency roiagnom on [DATE]. Guardian was notified. Resident #85 was admitted to the hospital with [REDACTED]. The clinical record did not reveal that a bed hold had been offered to the resident's guardian. The surveyor informed the administrative staff of the above concern on 12/5/18 at 3:07 p.m. The corporate registered nurse #2 stated the resident was sent out over the weekend and returned the next day. The corporate registered nurse #2 stated a bed hold was not offered to Resident #85. The facility provided the bed hold policy that read in part 1. I understand Virginia Medicaid will not hold beds during a hospital admission. If a resident chooses to hold a bed, these days will be considered private pay and all monies must be paid in advance. If a resident chooses not to hold a bed by paying privately, I understand that the resident will be discharged from the center. The surveyor informed the administrative staff of the above concern during the end of the day meeting on 12/6/18 at 4:14 p.m. No further information was provided prior to the exit conference on 12/6/18.

Based on observation, staff interview and clinical record review the facility staff failed to develop a comprehensive care plan for 1 of 26 Resident, Resident #14. The findings included: For Resident #14 the facility staff failed to develop a care plan for skin picking behavior. Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 09/17/18 coded the Resident as 10 of 15 in section C, cognitive patterns. Section E, behaviors, listed the Resident as having no behaviors. This a quarterly MDS. Surveyor observed Resident #14 on 12/04/18 at approximately 1430. Resident was resting in bed. Surveyor observed to have several scratches to the right side of her face. Surveyor asked Resident what had happened to her face and Resident stated, I did that myself, I scratch at it sometimes, I don't know why. Surveyor observed Resident's fingernails to be long and ragged. Surveyor observed Resident #14 on 12/05/18 at approximately 0830. Resident was seated in wheelchair in hallway. Surveyor observed Resident picking at her arms, and observed several scratches on both arms. Resident stated to surveyor, I've been picking at them, I get nervous sometimes. Resident's nails were observed to be long and ragged. Resident #14's clinical record was reviewed on 12/05/18. It contained a CCP (comprehensive care plan), however, the surveyor could not locate a care plan that addressed behavior of picking at skin. The surveyor spoke with unit manager on 12/06/18 at approximately 1345. Surveyor asked unit manager scratches on Resident #14's face and arms and unit manager stated, She's a picker, as long as she's been here she's picked. The surveyor spoke with MDS coordinator on 12/0618 at approximately 1355. Surveyor asked the MDS coordinator why the Resident did not have a care plan that addressed her picking at herself and the MDS coordinator stated that she was not aware of the behavior. The concern of not developing a care plan for skin picking behavior was discussed during a meeting with the administrative staff on 12/0 /18 at approximately No further information was provided prior to exit.

Based on observation, staff interview and clinical record review the facility staff failed to provide ADL care for 1 of 26 dependant Residents, Resident #14. The findings included: The facility staff failed to provide nail care for a dependent Resident. Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 09/17/18 coded the Resident as 10 of 15 in section C, cognitive patterns. Section G, functional status, coded the Resident as 3/2 in the area of personal hygiene. This is equivalent to extensive assistance/one person physical assist. This a quarterly MDS. Surveyor observed Resident #14 on 12/04/18 at approximately 1430. Resident was resting in bed. Surveyor observed several scratches to the right side of Resident's face. Surveyor observed that Resident's fingernails were long and ragged. Surveyor observed Resident #14 again on 12/05/18 at approximately. Resident's fingernails were observed to be long and ragged. Resident #14's CCP (comprehensive care plan) was reviewed on 12/0518. It contained a care plan for .requires assist wit ADL's (activities of daily living) r/t (related to) self care deficit . Interventions listed for this care plan included Provide assistance with bathing and hygiene as needed. The concern of not providing nail care was discussed with the administrative team during a meeting on 12/05/18 at approximately 1630. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure respiratory care and services were provided for 2 of 26 (Resident #54 and Resident #74) residents. The findings included: 1. The facility staff failed to ensure the oxygen filters on Resident #54's oxygen concentrator were clean. The clinical record of Resident #54 was reviewed 12/4/18 through 12/6/18. Resident #54 was admitted to the facility 10/10/17 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #54's 14- day minimum data set assessment (MDS) with an assessment reference date (ARD) of 11/29/18 assessed the resident with a BIMS (brief interview for mental status) as 09/15. Resident #54's current comprehensive care plan identified the focus area of respiratory problems r/t (related to) chronic [MEDICAL CONDITION]. Date initiated 8/22/18 Revision on 9/03/18. Interventions read: Administer medications as ordered. Resident #54's (MONTH) (YEAR) physician's orders [REDACTED]. The surveyor observed Resident #54 during the initial tour of the facility on 12/4/18 beginning at 12:54 p.m. Resident #54 was positioned in bed, eyes closed with oxygen at 3 L/M via NC. Oxygen sign on door. Oxygen tubing was dated 12/2/18. The oxygen concentrator filters were observed to have a dust like grey color to both and a fuzzy white appearance on both. The surveyor observed Resident #54 during breakfast on 12/5/18 at 8:54 a.m. Resident #54 was in bed with oxygen at 3 l/m per NC. The oxygen concentrator filters were observed to have a fuzzy white and dusty grey appearance. The surveyor informed the unit manager registered nurse #1 of the above concern on 12/5/18 at 10:32 a.m. R.N. #1 checked both filters and stated the filters need to be changed. The unit manager R.N. #1 was asked when were they changed or cleaned. The unit manager R.N. #1 stated the filters are changed weekly when the oxygen tubing was changed. The surveyor informed the administrative staff of the above concern on 12/5/18 at 4:27 p.m. The surveyor requested the facility policy on the care of oxygen concentrators. The surveyor reviewed the policy on oxygen titled Oxygen Administration on 12/5/18. The policy read in part 8. Change the cannula or mask every week. Date and initial. The cannula or mask must be placed in a plastic bag any time they are not in use. The corporate registered nurse #1 stated the facility contracts with a company to oversee the oxygen equipment; however, the contents of what the contract covered was not provided. No further information was provided prior to the exit conference on 12/6/18. 2. The facility staff failed to clean Resident #74's oxygen concentrator filters or place a sign on the door indicating that oxygen was in use. The clinical record of Resident #74 was reviewed 12/4/18 through 12/6/18. Resident #74 was admitted to the facility 10/6/18 with [DIAGNOSES REDACTED]. Resident #74's 30-day minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/1/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #74's (MONTH) (YEAR) physician's orders [REDACTED]. The surveyor observed Resident #74 on 12/4/18 at 12:44 p.m. The resident was sitting on the side of the bed and eating lunch. Oxygen concentrator was on the left side of the bed and turned to 2 LPM. The oxygen tubing was dated 12/2/18. The surveyor observed both oxygen filters on the concentrator. Both had a layer of grey dust and fuzzy white balls on them. The surveyor did not observe a No Smoking sign at the entrance to the resident's rooms. The surveyor interviewed licensed practical nurse #2 on 12/4/18 at 12:50 p.m. about oxygen signs. L.P.N. #2 stated signs are supposed to be put on the door if the resident uses oxygen. The surveyor observed and interviewed Resident #74 on 12/5/18 at 10:18 a.m. Both oxygen filters were dirty with a layer of gray dirt/dust and those fuzzy white balls. The surveyor asked licensed practical nurse #3 on 12/05/18 10:24 a.m. to check the oxygen concentrator filters. L.P.N. #3 stated, They need to be cleaned. L.P.N. #3 stated she had only been here a month and didn't know if cleaning the filter comes with changing the tubing. The surveyor informed and showed the unit manager registered nurse #1 on 12/5/18 at 10:30 a.m. the oxygen concentrator filters. R.N. #1 stated the filters are changed out and will do that as soon as she gets them. The surveyor informed the administrative staff of the above concern on 12/5/18 at 4:27 p.m. The surveyor requested the facility policy on the care of oxygen concentrators. The surveyor reviewed the policy on oxygen titled Oxygen Administration on 12/5/18. The policy read in part 8. Change the cannula or mask every week. Date and initial. The cannula or mask must be placed in a plastic bag any time they are not in use. The corporate registered nurse #1 stated the facility contracts with a company to oversee the oxygen equipment; however, the contents of what the contract covered was not provided. No further information was provided prior to the exit conference on 12/6/18.

Based on observation, staff interview, and clinical record review the facility staff failed to collaborate with the contracting pharmacy and identify that a medication was still being administered after being discontinued for 1 of 26 Residents, #70. The findings included: The consulting pharmacy failed to identify that Resident #70 was receiving the medication [MEDICATION NAME][MEDICATION NAME] 4 mg. This medication had been discontinued by the physician in (MONTH) (YEAR). The clinical record review revealed that Resident #70 had been admitted to the facility 07/31/2014. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 10/31/2018 included a BIMS (brief interview for mental status) summary score of 14 out of a possible 15 points. The Residents CCP (comprehensive care plan) included the intervention give medications as ordered. The facility used a Paxit system for administering medications. This system packaged the Residents tablets/capsules inside of a plastic bag that included the Residents name, room number, time of medication administration, date, name of facility, and the name of the Residents medications listed in alphabetical order. The bottom of the bag included the statement Refer to MAR (medication administration record) for medication administration times and instructions . Inside of the paxit, the medications were individually packaged in blister packs making each medication easily identifiable. On 12/05/2018 at 9:34 AM, the surveyor observed LPN (licensed practical nurse) #1 prepare and administer Resident #70's morning medications. During this observation, LPN #1 prepared and administered the Residents morning medications using the paxit system. The paxit bag included 1 tablet of [MEDICATION NAME][MEDICATION NAME] 4 mg along with the Residents other morning medications. LPN #1 removed all the medications from the paxit bag, removed them from the blister packs, and placed them in a medication cup to administer to Resident #70. After preparing all of the Residents morning medications LPN #1 entered the Residents room and administered the medications to Resident #70. After the medication observations the surveyor reconciled the Residents medications using the Residents EHR (electronic health record). The surveyor was unable to locate an active order for the [MEDICATION NAME][MEDICATION NAME]. The EHR included a physician order [REDACTED]. On 12/05/2018 at 10:45 AM, the surveyor and LPN #1 reviewed the Residents physician orders. After reviewing the orders, LPN #1 verbalized to the surveyor that the [MEDICATION NAME][MEDICATION NAME] looked as if it had been discontinued. The monthly medication regimen reviews completed by the pharmacist did not include any information to indicate the pharmacy had identified that the medication [MEDICATION NAME][MEDICATION NAME] was continuing to be packaged, sent, and administered to the Resident. On 12/06/18 at 3:03 PM, LPN #1 stated she had called the pharmacy on 12/05/18 to ensure the medication would be discontinued. After this interview the surveyor and LPN #1 checked the paxit medication pack that had delivered to the facility after LPN #1 had contacted the pharmacy. This paxit still contained the medication [MEDICATION NAME][MEDICATION NAME]. The administrative staff were notified of the issues regarding the [MEDICATION NAME][MEDICATION NAME] during a meeting with the survey team on 12/06/2018 at 4:14 PM. Prior to the exit conference the DON (director of nursing) stated she had contacted the pharmacy and the issue with the [MEDICATION NAME][MEDICATION NAME] appeared to be a linking problem. No further information regarding these issues were provided to the survey team prior to the exit conference.