Every finding on record at Norton Community Hospital SNF Unit

Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer a 2025-2026 COVID-19 vaccine for three (3) of eight (8) sampled residents (Resident #5, Resident #13, and Resident #12). Resident #5 developed COVID-19 26 days following admission thus resulting in harm for Resident #5. The facility staff also failed to offer 2025-2026 COVID-19 vaccines to the facility staff. The findings included:1. For Resident #5, the facility staff failed to offer the resident a 2025-2026 COVID-19 vaccine following admission to the facility on 1/14/26. The resident tested positive for COVID-19 on 2/09/26 thus resulting in harm to the resident. A facility policy titled, COVID Vaccines, revised 4/04/25, indicated Residents/resident representatives will receive education regarding the benefits, risks and potential side effects associated with the COVID-19 Vaccine. B. Residents will be offered the COVID-19 vaccine unless they have previously immunized, or it is medically contraindicated. The policy also indicated, On admission obtain the residents COVID-19 vaccine status.The resident demographic record indicated the facility admitted Resident #5 on 1/14/26. According to Resident #5's 1/15/26 History and Physical (H&P), the resident had a medical history that included pulmonary fibrosis, chronic obstructive pulmonary disease, mitral valve disease, and persistent atrial fibrillation. An admission minimum data set (MDS) with an assessment reference date (ARD) of 2/09/26, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A review of Resident #5's clinical record revealed an immunization history which indicated the resident had previously received COVID-19 vaccinations on 1/15/21, 2/12/21, 2/02/22, 11/17/22, and 8/29/23. Resident #5's was admitted to the facility on [DATE] and tested negative for SARS-CoV-2 (virus that causes COVID-19) on 1/30/26. However, on 2/09/26, Resident #5 tested positive for SARS-CoV-2. According to the John Hopkins Medicine article, COVID-19 Vaccine: What You Need to Know, dated 9/27/24, It usually takes about two weeks for the vaccine to become effective. The Director provided evidence from the 1/14/26 nursing admission assessment indicating Resident #5 was asked at admission if they had received the COVID-19 vaccine and the resident responded with yes.On 2/12/26 at 11:18 AM, the Director of Nursing (DON) stated the admission assessment does not prompt the nurse to enter the date of their last COVID vaccine. The 1/14/26 admission assessment was completed by Registered Nurse (RN) #3. During an interview on 2/12/26 at 11:57 AM, RN #3 stated she asked if the patient had a COVID vaccine and the patient said yes and no further action was needed. RN #3 further stated if the patient stated they had not received a COVID vaccine; they would offer one. RN #3 confirmed they do not ask for the date of the resident's most recent COVID-19 vaccine to assess if the resident was eligible for an updated vaccine. On 2/11/26 at 4:00 PM, the Director, Quality Officer, and the Director of Nursing were informed of the concern regarding Resident #5 developing COVID-19 after the facility failed to fully assess the resident's COVID-19 vaccine history and offer an updated vaccine following admission. No further information was provided prior to the exit conference on 2/12/26. 2. For Resident #13, the facility staff failed to offer the resident a 2025-2026 COVID-19 vaccine following admission to the facility on 1/27/26. The resident tested positive for COVID-19 on 2/02/26. A facility policy titled, COVID Vaccines, revised 4/04/25, indicated Residents/resident representatives will receive education regarding the benefits, risks and potential side effects associated with the COVID-19 Vaccine. B. Resident will be offered the COVID-19 vaccine unless they have previously immunized, or it is medically contraindicated. The policy also indicated, On admission obtain the residents COVID-19 vaccine status.The resident demographic record indicated the facility admitted Resident #13 on 1/27/26. According to the resident's 1/28/26 History and Physical (H&P), Resident #13 had a medical history that included acute on chronic respiratory failure, congestive heart failure, coronary artery disease, type 2 diabetes mellitus, and chronic kidney disease. Resident #13's clinical record included a Brief Interview for Mental Status (BIMS) assessment dated [DATE] which revealed a score of 15, which indicated the resident had intact cognition. A review of Resident #13's clinical record revealed an immunization history which indicated the resident had previously received COVID-19 vaccinations on 1/15/21, 2/12/21, 11/22/21, and 11/21/22. Resident #13 was admitted to the facility on [DATE] and tested positive for COVID-19 on 2/02/26. A 2/06/26 physician progress note indicated the resident was COVID positive with increased fatigue and cough and COVID specific therapy was not recommended. The Director provided evidence from the 1/27/26 nursing admission assessment indicating Resident #13 was asked at admission if they had the COVID-19 vaccine and the resident responded with yes.On 2/12/26 at 11:18 AM, the Director of Nursing (DON) stated the admission assessment does not prompt the nurse to enter the date of their last COVID vaccine. The 1/27/26 admission assessment was completed by Registered Nurse (RN) #2. During an interview on 2/12/26 at 11:40 AM, RN #2 stated it was mandatory for each admission to ask if the patient had a COVID vaccine and if the patient said yes, no further action was needed. RN #2 further stated if the patient stated they had not received a COVID vaccine, one was offered and an order was placed. RN #2 confirmed they do not ask for the date of the resident's most recent COVID-19 vaccine to assess if the resident was eligible for an updated vaccine. On 2/11/26 at 4:00 PM, the Director, Quality Officer, and the Director of Nursing were informed of the concern regarding Resident #13 developing COVID-19 after the facility failed to fully assess the resident's COVID-19 vaccine history and offer an updated vaccine following admission. No further information was provided prior to the exit conference on 2/12/26. 3. For Resident #12, the facility staff failed to offer the resident a 2025-2026 COVID-19 vaccine following admission to the facility.A facility policy titled, COVID Vaccines, revised 4/04/25, indicated Residents/resident representatives will receive education regarding the benefits, risks and potential side effects associated with the COVID-19 Vaccine. B. Resident will be offered the COVID-19 vaccine unless they have previously immunized, or it is medically contraindicated. The policy also indicated, On admission obtain the residents COVID-19 vaccine status.The resident demographic record indicated the facility admitted Resident #12 on 1/29/26. According to the active problem list, Resident #12 had a medical history that included diabetes mellitus type 2, obstructive sleep apnea, hypertension, and obesity. Resident #12's clinical record included a Brief Interview for Mental Status (BIMS) assessment dated [DATE] which revealed a score of 15, which indicated the resident had intact cognition. Resident #12's clinical record included an immunization history which did not include documentation of a previous COVID-19 vaccine. The Director provided evidence from the 1/29/26 nursing admission assessment indicating Resident #12 was asked at admission if they had the COVID-19 vaccine and the resident responded with yes.On 2/12/26 at 11:18 AM, the Director of Nursing (DON) stated the admission assessment does not prompt the nurse to enter the date of their last COVID vaccine. The 1/29/26 admission assessment was completed by Registered Nurse (RN) #2. During an interview on 2/12/26 at 11:40 AM, RN #2 stated it was mandatory for each admission to ask if the patient had a COVID vaccine and if the patient said yes, no further action was needed. RN #2 further stated if the patient stated they had not received a COVID vaccine, one was offered and an order was placed. RN #2 confirmed they do not ask for the date of the resident's most recent COVID-19 vaccine to assess if the resident was eligible for an updated vaccine. On 2/11/26 at 4:00 PM, the Director, Quality Officer, and the Director of Nursing were informed of the concern regarding the facility's failure to assess Resident #12's COVID-19 vaccine history and offer the vaccine. No further information was provided prior to the exit conference on 2/12/26. 4. The facility failed to offer 2025-2026 COVID-19 vaccines to the current facility staff. A facility policy titled, COVID-19 Plan dated 10/18/22, indicated Employees will be provided with reasonable time and paid leave to receive vaccination and if they experience any side effects following vaccination. Employee vaccinations will continue to be offered and reported, consistent with Federal and/or state requirements.During an interview on 2/10/26 at 1:00 PM, Infection Preventionist (IP) #1 stated the facility no longer offered COVID-19 vaccinations for staff since it was no longer mandated. On 2/11/26 at 4:00 PM, the Director, Quality Officer, and the Director of Nursing were informed of the concern regarding the facility no longer offering COVID-19 vaccines to staff.No further information was provided prior to the exit conference on 2/12/26.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to conduct an admission minimum data set (MDS) assessment within 14 calendar days after admission for two (2) of eight (8) sampled residents (Resident #1 and Resident #5).The findings included: 1. For Resident #1, the facility staff failed to conduct an admission MDS assessment within 14 calendar days after admission.A facility policy titled, Care Plan/Comprehensive Assessment revised 4/04/25 indicated The RAI (Resident Assessment Instrument) manual provides instructions for when and how to use the time frames for completing assessments and transmitting data.The resident demographic record indicated the facility admitted Resident #1 on 11/26/25. According to the active problem list, Resident #1 had a medical history that included a fracture of the right ankle, debility, and chronic diastolic heart failure.Resident #1's admission MDS with an assessment reference date (ARD) of 12/11/25 was signed as completed by the Director of Nursing on 12/11/25, 16 days following admission to the facility. During an interview with the Director of Nursing (DON) on 2/10/26 at 8:54 AM, the DON stated Resident #1's ARD should have been 12/09/25 and confirmed the admission MDS was completed late.On 2/11/26 at 4:00 PM, the Director, Quality Officer, and the DON were informed of the concern regarding the late admission MDS assessment for Resident #1. No further information was provided prior to the exit conference on 2/12/26. 2. For Resident #5, the facility staff failed to conduct an admission MDS within 14 calendar days after admission. A facility policy titled, Care Plan/Comprehensive Assessment revised 4/04/25 indicated The RAI (Resident Assessment Instrument) manual provided instructions for when and how to use the time frames for completing assessments and transmitting data.The resident demographic record indicated the facility admitted Resident #5 on 1/14/26. According to Resident #5's physician History and Physical (H&P) dated 1/15/26, the resident had a medical history that included chronic obstructive pulmonary disease, pulmonary fibrosis, debility, cerebral stroke, and persistent atrial fibrillation. Resident #5's admission MDS with an assessment reference date (ARD) of 2/09/26 was signed as completed by the Director of Nursing on 2/09/26, 26 days following admission to the facility. During an interview with the Director of Nursing (DON) on 2/10/26 at 10:31 AM, the DON stated Resident #5's admission MDS was completed late.On 2/11/26 at 4:00 PM, the Director, Quality Officer, and the DON were informed of the concern regarding the late admission MDS assessment for Resident #5. No further information was provided prior to the exit conference on 2/12/26.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer a pneumococcal vaccine in accordance with nationally recognized standards for two (2) of eight (8) sampled residents (Resident #1 and Resident #12). The findings included:1. For Resident #1, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 15 (PCV15), pneumococcal conjugate vaccine 20 (PCV20), or pneumococcal conjugate vaccine 21 (PCV21) following admission to the facility.The resident demographic record indicated the facility admitted Resident #1 on 11/26/25. According to the active problem list, Resident #1 had a medical history that included a fracture of the right ankle, debility, and chronic diastolic heart failure. An admission minimum data set (MDS) with an assessment reference date (ARD) of 12/11/25, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A review of Resident #1's clinical record included an immunization history which indicated the resident received a pneumococcal polysaccharide vaccine (PPSV23) on 8/26/21. Resident #1's immunization history did not include any additional pneumococcal vaccines. The Centers for Disease Control and Prevention (CDC) guideline titled, Pneumococcal Vaccine Timing for Adults dated March 2025 indicated adults [AGE] years of age or older who have had a PPSV23 only at any age should have one dose of PCV15, PCV20, or PCV21 at least one year after the last dose of PPSV23. Resident #1's clinical record failed to include documentation of the facility offering the resident a PCV15, PCV20, or PCV21 vaccine following admission.During an interview on 2/10/26 at approximately 1:30 PM, the Director of Nursing (DON) confirmed there was no documentation of a pneumococcal vaccine being offered to Resident #1 following admission to the facility. A facility policy titled, Influenza and Pneumococcal, revised 1/03/25 specified On admission obtain the residents influenza and pneumococcal immunization history. Provide immunization UNLESS: a. Resident/resident representative declines. b. A Medical contraindication exists. c. Resident has already received the vaccine. The policy also indicated All residents will be screened, recommended, and encouraged based on the up-to-date CDC ACIP (Advisory Committee on Immunization Practices) Vaccine Recommendations and Guidelines.On 2/11/26 at 4:00 PM, the Director, Quality Officer, and the DON were informed of the concern regarding staff failing to offer Resident #1 a pneumococcal vaccine following admission.No further information was provided prior to the exit conference on 2/12/26. 2. For Resident #12, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 20 (PCV20) or pneumococcal conjugate vaccine 21 (PCV21) following admission to the facility.The resident demographic record indicated the facility admitted Resident #12 on 1/29/26. According to the active problem list, Resident #12 had a medical history that included type 2 diabetes mellitus, obstructive sleep apnea, and obesity. Resident #12's clinical record included a Brief Interview for Mental Status (BIMS) assessment dated [DATE] which revealed a score of 15 which indicated the resident had intact cognition. Resident #12's clinical record included an immunization history which indicated the resident received a pneumococcal conjugate 13 (PCV13) vaccine on 3/24/15 and a pneumococcal polysaccharide 23 (PPSV23) vaccine on 10/06/16. The Centers for Disease Control and Prevention (CDC) guideline titled, Pneumococcal Vaccine Timing for Adults dated March 2025 indicated adults [AGE] years of age or older who have had a PCV13 at any age and a PPSV23 before age [AGE] should have a PCV20 or PCV21 at least five (5) years after the last pneumococcal vaccine dose. Resident #12's clinical record failed to include documentation of the facility offering the resident a PCV20 or PCV21 vaccine following admission.During an interview on 2/10/26 at approximately 1:30 PM, the Director of Nursing (DON) confirmed there was no documentation of a pneumococcal vaccine being offered to Resident #12 following admission to the facility. A facility policy titled, Immunizations Influenza and Pneumococcal, revised 1/03/25 specified On admission obtain the residents influenza and pneumococcal immunization history. Provide immunization UNLESS: a. Resident/resident representative declines. b. A Medical contraindication exists. c. Resident has already received the vaccine. The policy also indicated All residents will be screened, recommended, and encouraged based on the up-to-date CDC ACIP (Advisory Committee on Immunization Practices) Vaccine Recommendations and Guidelines.On 2/11/26 at 4:00 PM, the Director, Quality Officer, and the DON were informed of the concern regarding staff failing to offer Resident #12 a pneumococcal vaccine following admission.No further information was provided prior to the exit conference on 2/12/26.

Based on observation and facility document review, the facility staff failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of infections as evidenced by failure to use appropriate hand hygiene during medication administration. The findings included:During an observation of medication administration on 2/10/26 at 9:45 AM, Registered Nurse (RN) #1 performed hand hygiene, donned gloves, scanned Resident #11's identification band with the medication cart's handheld scanner. RN #1 returned to the medication cart and returned the scanner. RN #1 then obtained and applied ointment to Resident #11's nares using a cotton applicator and returned to the cart. While wearing the same gloves, RN #1 then opened the resident's oral medications, placed a tablet into her gloved hand and then into the medication cup with additional oral tablets. RN #1 then proceeded to administer the oral medications to Resident #11. After administration, RN #1 removed her gloves and performed hand hygiene. 2/10/26 at 9:55 AM, RN #1 again donned gloves, scanned Resident #13's identification band with the medication cart's handheld scanner, returned the scanner, opened each medication from their individual packets and placed them in a medication cup. While wearing the same gloves, RN #1 then placed two potassium tablets into her gloved hand before placing them in a medication cup and administering them to the resident. The facility policy titled, Hand Hygiene, revised 12/05/25 indicated, Hands must be washed with soap and water or alcohol hand gel used.Before handling medications.Gloves should never be used as a substitute for Hand Hygiene.On 2/11/26 at 4:00 PM, the Director, Quality Officer, and the Director of Nursing were informed of the concerns regarding RN #1's hand hygiene observations. No further information was provided prior to the exit on 2/12/26.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure the drug regimen review of each resident was reviewed at least monthly by a licensed pharmacist for one (1) of eight (8) sampled residents (Resident #1). The findings included:A facility policy titled, Medication Reconciliation/Drug Regimen revised 3/07/25 indicated, Residents drug regimen will be reviewed on admission prior to midnight the second day of admission, monthly and prn (as needed) as determined by the medical condition of the resident and risk of adverse consequences of medications.According to Resident #1's active problem list, the resident has a medical history that included a fracture of the right ankle, debility, chronic diastolic heart failure, and depression. An admission minimum data set (MDS) with an assessment reference date (ARD) of 12/11/25, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. On 2/10/26, a review of Resident #1's clinical record revealed the most recent drug regimen review was completed on 12/19/25. During an interview with the Director on 2/11/26 at 8:45 AM, she confirmed that a drug regimen review was not completed in January and added a current review had now been performed. On 2/11/26 at 4:00 PM, the Director, Quality Officer, and the Director of Nursing were informed of the concern regarding the lack of a January drug regimen review for Resident #1. No further information was provided prior to the exit conference on 2/12/26.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to electronically transmit an admission minimum data set (MDS) assessment within 14 days following completion for one (1) of eight (8) sampled residents (Resident #1).The findings included: A facility policy titled Care Plan/Comprehensive Assessment revised 4/04/25 indicated The RAI (Resident Assessment Instrument) manual provides instructions for when and how to use the time frames for completing assessments and transmitting data.The Resident demographic record indicated the facility admitted Resident #1 on 11/26/25. According to the active problem list, Resident #1 had a medical history that included a fracture of the right ankle, debility, and chronic diastolic heart failure.Resident #1's admission MDS with an assessment reference date (ARD) of 12/11/25 was signed as completed by the Director of Nursing (DON) on 12/11/25. The 12/11/25 admission MDS was transmitted on 1/06/26, 26 days following completion. During an interview on 2/10/26 at 8:54 AM, the DON stated Resident #1's admission MDS was completed on 12/11/25 and transmitted on 1/06/26. The DON stated her goal was to transmit MDS assessments within seven to 10 days of completion. On 2/11/26 at 4:00 PM the Director, Quality Officer, and the DON were informed of the concern regarding the late transmission of Resident #1's admission MDS assessment.No further information was provided prior to the exit conference on 2/12/26.

Based on observation, staff interview, and policy review the facility failed to ensure the sanitizing solution was maintained at an acceptable level to sanitize food contact surfaces; and failed to perform hand hygiene after contaminating their gloves and before touching resident food. This had the potential to affect 25 of 25 residents residing in the facility. Findings include: 1.On 04/26/21 at 11:07 AM one of two red containers of sanitizing solution used to sanitize food preparation surfaces and to hold wiping cloths measured at zero parts per million (ppm). The wiping container was located by the three-compartment sink. The Dietary Supervisor and the System Chef both verified the solution was not at the proper sanitizer level to sanitize the food contact surfaces. The Dietary Supervisor stated she made the solution about 8:00 AM that morning. The System Executive Chef tested the sanitizing solution with a test strip and verified it measured zero ppm. The facility policy titled Sanitizing Food Contact Surfaces with a revised date of 01/19 stated the J-512 sanitizer must be between 200 ppm and 400 ppm. The policy stated the sanitizer in the red buckets should be replaced every two hours or more frequently, if visibly dirty. The manufacture's information titled Diversey Final Step J-512 stated the solution should be between 200 ppm and 400 ppm to sanitize food contact surfaces and equipment. 2. On 04/28/21 the noon meal service was observed continuously from 11:54 AM through 12:40 PM. At 11:56 AM a plastic bag containing hot dog buns dropped on the floor from the cart. The Cook picked the bag up with his gloved hands and placed it on a tray with clean soup bowls. Without first washing his hands or changing his gloves he removed bread from a bread bag and made a turkey and cheese sandwich and held the sandwich with the same gloved hands to cut it in half. He served two additional trays touching the handles of the serving utensils with the contaminated gloves and at 12:03 PM, with the same gloves on, he obtained a bowl off the tray and poured potato soup into it. He touched the handle of the ladle with the same gloves on. At 12:04 PM he removed his gloves, washed his hands, and put on clean gloves. During the same continuous observation of the cook on 04/28/21 at 12:25 PM he pushed his eyeglasses up with his gloved hands. At 12:27 PM he stuck his hands in a quart size bag of parmesan cheese and obtained the cheese with his gloved hands without first changing his gloves. The Executive Chef was present in the kitchenette area and verbally prompted him to use a spoon to serve the parmesan cheese. At 12:29 PM the cook picked up the bag containing the hot dog buns that had been dropped on the floor touching the portion of the bag (bottom) that had landed on the floor. He removed two hot dog buns with the same gloves on. He put the hot dogs on the bun using tongues. At 12:32 PM he again obtained bread from the bread bag with the same gloves on. At that time, the Executive Chef was made aware of the situation and he prompted the cook to change his gloves and wash his hands and stated he was going to replace the resident's hot dogs. At 12:43 PM the Cook was interviewed. He verified that he did pick the bread up and verified he had not changed his gloves or washed his hands after picking it up off the floor and confirmed he touched the bag and served the hot dog buns that were in the bag. The facility policy titled Hand Hygiene with a revised date of 01/19 stated hands should be washed with soap and water after any activity that may contaminate the hands. The facility policy titled Food Handling Guidelines with a revised date of 01/19 stated gloves should be changed between task and hands should be washed after removing gloves.

Based on observation, menu review, and staff interview the facility failed to follow the menu selected for the residents. This affected three (Resident (R) 2, R20, R23) of 25 residents in the facility. Findings include: The lunch meal was observed in the kitchenette on the nursing unit on 04/28/21 continuously from 11:54 AM through 12:40 PM. At 12:36 PM the Cook ran out of spaghetti (pasta). As a result, Resident (R) 2, R22, and R23 did not receive any pasta. The pasta was served as a side dish with chicken parmesan and the last three residents served were not offered or provided a substitiute of equal nutritive value when there was not enough spaghetti prepared. Review of the orders tab in each of the resident's electronic medical records revealed R2 had an order for a regular, dysphagia mechanically altered texture; R20 had an order for a Regular diet; and R23 an order for a Regular, dysphagia mechanically altered, regular consistency diet. Review of the menu revealed R20 was supposed to receive pasta and R2 and R23 mechanically altered diets were supposed to receive chopped pasta. Following the observations on 04/28/21 at 12:43 PM the Cook was interviewed. He stated he was the person who cooked the meal. He stated he did not cook enough pasta and he verified he did not give the last three residents he served pasta or a substitute for the pasta. The System Chef was present in the dining room on the nursing unit when the cook ran out of pasta. At 1:00 PM he confirmed the cook ran out of the pasta and should have cooked enough for all the residents.

Based on observation, interview and facility policy review the facility failed to ensure expired medications were removed from the medication cart and the medication storage room. This deficient practice occurred in one of one med rooms and two of two med carts; and could potentially lead to administering ineffective, outdated medications to the residents. Findings include: On 04/29/21 at 12:12 PM, in the medication cart for resident rooms 4-11 and 29-32, two individual Tylenol 325 milligram (mg) packets were found with an expiration date of 03/04/21. On 04/29/21 at 12:12 PM, Licensed Practical Nurse (LPN)3 verified the Tylenol packets were outdated and confirmed the medication should have been removed from the cart and not available for administration. On 04/29/21 at 12:43 PM, three 10 cubic centimeters (cc) [MEDICATION(S)] flush syringes were found in the medication storage room with an expiration date of 2/2021. On 04/29/21 at 12:43 PM, LPN2 verified the [MEDICATION(S)] syringes were outdated and confirmed the syringes should be sent back to the pharmacy and not available for resident use. On 04/29/21 at 12:46 PM, the Charge Nurse confirmed the syringes were outdated and should have been discarded. The Charge Nurse verified the pharmacy sent 30 cc and since there were three 10 cc syringes in the bag, concluded none of the expired [MEDICATION(S)] syringes were used for resident port flushes. Review of the facility policy titled Storage of Medication - LTC - Ballad Health, dated 09/25/20, revealed, No discontinued, outdated or deteriorated medications are available for use in the facility. All such medications are destroyed. Any unused, expired, damaged, returned, and/or contaminated medications are removed from medication cart.

Based on record review and staff interview the facility failed to ensure residents who received antipsychotic medications had a gradual dose reduction attempt at least annually. This failure affected 1 resident (R)esident 23) of 5 residents reviewed for unnecessary medications. Findings include: The diagnosis tab in the electronic medical record (EMR) revealed Resident (R) 23's diagnosis included Alzheimer's Disease, Unspecified Dementia with behavioral disturbance, restlessness and agitation, and repeated falls. Review of physician's orders under the orders tab in the EMR revealed R23 had an order for [MEDICATION(S)] Tablet 25 MG give 0.5 tablet by mouth in the morning related to unspecified dementia with behavioral disturbance and an order for [MEDICATION(S)] tablet 25 MG give 1 tablet by mouth at bedtime related to unspecified dementia with behavioral disturbance. Both orders had a start date of 04/22/19. [MEDICATION(S)] is an antipsychotic medication. Antipsychotics are a class of [CONDITION(S)] medications primarily used to manage [CONDITION(S)] (including delusions hallucinations, or disordered thought), particularly in [CONDITION(S)] and [CONDITION(S)]. Review of R23's care plan revealed she had a care plan focus area stating she receives [CONDITION(S)] medications due to behavior management (agitation), general anxiety disorder, Depression and Disease process (dementia) and appetite stimulation. The care plan had a revision date of 03/15/21. The interventions included to consult with the pharmacy, MD to consider dosage reduction when clinically appropriate but at least quarterly. There were no documented behaviors present in the record review for R23. The drug regimen reviews printed on forms titled MV Pharmacy Drug Regimen Review were reviewed. The pharmacist documented no recommendations or irregularities were noted on the drug regimen review forms dated 04/14/20, 06/15/20, 07/14/20, 08/18/20, 10/23/20, 11/16/20, 12/21/20, 1/19/21, 02/16/21, 03/16/21, and 04/20/21. On 04/28/21 at 1:00 PM an interview was conducted with the Director of Nursing (DON) related to dose reduction attempts for the [MEDICATION(S)]. She provided two Medication Regimen Review forms titled Professional Networks Services dated 04/15/19 and 11/18/19. Review of the Medication Review forms revealed the following: On 04/15/19 the pharmacist wrote R23 was receiving [MEDICATION(S)] 25mg two times a day since 10/21/18 and requested the physician consider reducing [MEDICATION(S)] to 25mg once a day. On the bottom of the form the physician wrote to reduce the [MEDICATION(S)] to 12.5mg in the morning and 25mg in the evening. He signed and dated the form 04/22/19. Review of the physician's orders under the orders tab in the EMR revealed the order was changed on 04/22/19. On 11/22/19 the pharmacist recommended reducing the [MEDICATION(S)] to 12.5mg twice a day. On the bottom of the form the physician checked the Do not change box and wrote, Pt failed GDR repeatedly in the past. He did not include any additional information or include the dates Gradual Dose Reductions (GDR) had been attempted and failed. The paper chart and EMR were reviewed in its entirety and were silent to any notes related to attempted dose reductions other than the reduction on 04/22/19. Review of the physician progress notes under the miscellaneous tab of the EMR revealed the physician wrote progress notes on 10/16/20, 12/04/20, 02/26/21, and 04/13/21 and each of the notes was silent to the use of the [MEDICATION(S)] for the resident. The facility policy titled Medication Reconciliation/Drug Review with a last reviewed date of 12/18/21 stated, Gradual dose reductions will be completed at a minimum frequency of annually for any resident receiving [CONDITION(S)] medications. On 04/29/21 at 11:02 AM the Director of Nursing and the MDS Coordinator were interviewed. The DON and the MDS Coordinator verified the physician failed to attempt gradual dose reductions quarterly and failed to document the attempted dose reductions. On 04/29/21 at 1:26 PM the MDS Coordinator stated she looked through all of R23's medical record in attempt to find physician documentation related to the reason for using the [MEDICATION(S)] and any gradual dose reduction attempts. She stated she could not find any progress notes addressing gradual dose reductions and the only notes she found related to why R23 was on [MEDICATION(S)] were dated 11/18/16 and 12/13/16. There were no more recent behaviors documented for R23.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the correct physician's order was followed for wound care for one of 12 sampled residents (Resident (R)11). The failure to follow current physician's orders for wound care could impede healing of the sacral pressure ulcer being treated, and increase the health risks associated with a wound, such as infection and [CONDITION(S)]. Findings include: Review of the Face Sheet in the Electronic Medical Record (EMR) revealed R11 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Orders tab in the EMR for R11, a new physician's order dated 04/18/21 revealed Wound Care-Sacrum: Clean with normal saline (NS), pat dry, cover with Allevyn daily and as needed (PRN). On 04/28/21 at 6:22 AM, in R11's room, the pressure ulcer dressing was changed by Licensed Practical Nurse (LPN)1. The resident was positioned on her side and the previous dressing of Allevyn and [MEDICATION(S)] AG was removed. Skin and wound were cleaned with normal saline and gauze. The [MEDICATION(S)] AG dressing needed to be cut to the size of the opening of the pressure ulcer. Once the [MEDICATION(S)] AG dressing was in place the Allevyn dressing was applied over the wound. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Assessments tab in the EMR the documents titled My Wound Flowsheet-V2 revealed the description of the wound order of the dressing changes for R11 from 04/18/21 to 04/27/21 was clean sacral wound with NS, pat dry, apply [MEDICATION(S)] AG and cover with Allevyn daily and PRN. The application of the [MEDICATION(S)] AG was not included on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/28/21 at 6:45 AM, LPN1 stated she did not review the physician's order before performing the dressing change and did not realize the [MEDICATION(S)] AG dressing was not ordered for the wound care for R11. On 04/28/21 at 8:36 AM, the Charge Nurse confirmed the physician's order was changed on 04/18/21 and [MEDICATION(S)] AG was no longer being applied to the wound during the dressing change. The Charge Nurse confirmed her expectation that staff would review the physician's orders prior to doing a dressing change and to follow the current physician's orders. Review of the facility policy titled Wound Cleansing, Dressing and Irrigation - LTC - Ballad Health, revised 09/25/21, revealed Residents will receive appropriate wound care and dressing changes per providers orders.

Based on interview, record review and facility policy/procedure review the facility failed to ensure a resident's Port-A-Cath (also known as an intravenous vascular access port -IVAP) was flushed with [MEDICATION(S)] by a Registered Nurse (RN) and not by a Licensed Practical Nurse (LPN). Per accepted standards of practice, these flushes are outside an LPN's scope of practice. The deficient practice affected one sampled resident (R)21 and one unsampled resident R22; and had the potential for poor quality of care for all residents, if staff operated outside their accepted scope of practice. Findings include: Review of the facility procedure titled Implanted Venous Access Port: Flushing, dated February 9, 2018, revealed RNs, physicians, nurse practitioners and physician assistants can flush IVAPs. RNs are generally responsible for monitoring the effects of injected medications or fluids for administering appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 1.) Review of the Face Sheet in the Electronic Medical Record (EMR) revealed R21 was admitted to the facility on [DATE] and readmitted on [DATE]. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Orders tab in the EMR for R21 revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Use 5 ml intravenously every night shift starting on the 23rd and ending on the 23rd every month for management of a Port-A-Cath access port a cath and flush with 10 ml of normal saline flush and then flush with 5 ml of [MEDICATION(S)]. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Notes tab in the EMR dated 07/22/20, revealed LPN4 documented a comment in the Progress Notes on the e-MAR Administration Note addressing the [MEDICATION(S)] flush: flushed per charge nurse. LPN4 was the charge nurse. 2.) Review of the Face Sheet in the EMR revealed R22 was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Orders tab in the EMR for R21 revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Use 5 ml intravenously every night shift starting on the 15th and ending on the 15th every month for management of a Port-A-Cath access port a cath and flush with 10 ml of normal saline flush and then flush with 5 ml of [MEDICATION(S)]. Review of the MAR from July 2020 to April 2021 revealed the flushing of the Port-A-Cath was performed by a LPN, nine times, on 07/15/20, 8/15/20, 9/15/20, 10/15/20, 11/15/20, 12/15/20, 2/15/21 3/15/21, and 4/15/21. Review of the Progress Notes tab in the EMR dated 04/15/21, revealed LPN4 documented a comment in the Progress Notes for the e-MAR Administration Note for the [MEDICATION(S)] flush no RN avail at this time. On 04/28/21 at 12:30 PM, the Director of Nursing (DON) verbalized only RNs can do flushing of Port-a-Cath. LPNs are not to flush the ports. The DON verbalized she was aware LPNs were doing the flush of the Port-a-Cath and it was not an acceptable practice and only RNs are to perform the [MEDICATION(S)] flush for R#21 and R#22. On 04/29/21 at 12:20 PM, LPN3 confirmed only RNs should do the [MEDICATION(S)] flush.

Based on record review and staff interviews the facility failed to ensure Resident (R)23's assessment accurately reflected gradual dose reduction attempts for an antipsychotic. This failure affected one of five residents reviewed for unnecessary medications. Findings include: Review of the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Both orders had a start date of 04/22/19. Review of R23's Minimum Data set (MDS) assessments for the past year revealed each of the assessments was inaccurately coded at Section N0450 Antipsychotic Medication Review to indicate a gradual dose reduction had been attempted during that quarter and included an inaccurate GDR date. Review of the MDS assessments revealed the following: The Quarterly MDS Assessment with an assessment reference date of 12/10/20 was marked that a Gradual Dose Reduction (GDR) of [MEDICATION(S)] was attempted on 02/25/20. The EMR was reviewed in its entirety and was silent for a dose reduction on the date listed. The Quarterly MDS Assessment with an assessment reference date of 12/10/20 was marked that a GDR of [MEDICATION(S)] was attempted on 02/25/20. The EMR was reviewed in its entirety and was silent for a dose reduction on the date listed. The Annual MDS assessment with an assessment reference date of 06/11/20 was marked that a GDR of the [MEDICATION(S)] was attempted on 02/18/20. The EMR was reviewed in its entirety and was silent for a dose reduction on the date listed. On 04/29/21 at 11:02 AM the above MDS assessments were reviewed with the MDS Coordinator. On 04/29/21 at 1:26 PM the MDS Coordinator stated she completed a thorough review of R23's record and the only GDR she could find was on 04/22/19. She verified the MDS assessments were inaccurate.

Based on observation, interview, record review, and facility policy review the facility failed to ensure the scissors, used by the nurse, to cut dressings for a pressure ulcer were cleaned prior to use on the dressing for one of 12 sampled residents (Resident (R) 11). The failure to follow accepted standards of practice related to infection control with wound care could potentially introduce bacteria into the wound causing an infection. Findings include: Review of the Face Sheet in the Electronic Medical Record (EMR) revealed R11 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Orders tab in the EMR for R11, a physician's order dated 04/18/21 revealed Wound Care-Sacrum: Clean with normal saline (NS), pat dry, cover with Allevyn daily and as needed (PRN). On 04/28/21 at 6:22 AM, in R11's room, the pressure ulcer dressing was changed by Licensed Practical Nurse (LPN)1. The resident was positioned on her side, and the previous dressings were removed. R11's skin and wound were cleaned with normal saline and gauze. The dressing needed to be cut to the size of the opening of the pressure ulcer. LPN1 removed her scissors from the pocket of her uniform and, without cleaning the blades of the scissors, cut the dressing to the size of the opening of the pressure ulcer. Once the dressing was in place the Allevyn dressing was applied over the wound. On 04/28/21 at 6:45 AM, LPN1 acknowledged she knew to clean the scissors prior to cutting the dressing to the size of the pressure ulcer opening. She admitted that she did not bringing alcohol pads with her into the room for the dressing change, and so she did not clean the blades of the scissors prior to using them to cut the dressing. LPN1 explained by not cleaning the blades of the scissors, bacteria could potentially be introduced into the pressure ulcer creating an infection. Additionally, LPN1 stated she did not review the physician's order before performing the dressing change and did not realize the wound care order had changed for R11's dressings. On 04/28/21 at 8:46 AM, the Charge Nurse confirmed the importance of following infection control practices for dressing changes and the use of aseptic technique; and by not cleaning the scissor blades prior to cutting the dressing created an increased potential for infection in the pressure ulcer for R11. Review of the facility policy titled Infection Control Program-Long Term Care-Ballad Health, revised January 21. 2021, revealed There is consistent use of aseptic technique for dressing changes.

Based on observation, staff interview, and clinical record review, the facility staff failed to protect the private health care information for 1 of 15 Residents, Resident #192. The findings included: For Resident #192, the facility staff failed to close the computer screen during a medication administration observation. This computer screen included Resident #192's personal healthcare information and was visible to any person(s) in the hallway. Resident #192 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #192 did not have a MDS (minimum data set) assessment completed at this time due to being a new admission. Resident # 192 is alert and oriented. On 09/05/18 at approximately 8:19 a.m., surveyor #1 observed RN (registered nurse) #1 during a medication administration observation. RN #1 was observed preparing and administering medications to Resident # 192. RN #1 used the Resident's eMAR's (electronic medication administration records) from the facility's computer program to prepare Resident's medications. This computer was located on the top of the medication cart. After preparing the medications RN #1 left the computer open and in full view of any person(s) in the hallway and entered the Resident's rooms to administer the medications. The computer screen and medication cart were out of the view of RN #1 when she entered the Resident's room. The computer screen contained the private healthcare information of the Resident #192 and was visible to any person(s) in the immediate area. Surveyor #2 observed housekeeping personnel, dietary personnel and one resident in the hallway during this observation. After the medication administration surveyor #1 approached RN #1 and interviewed her regarding the computer screen being open. RN #1 verbalized to the surveyor that she leaves the computer open if it is facing the room. The DON (director of nursing) was notified of the above on 09/05/18 at approximately 4:30p.m., during an end of the day meeting. On 09/06/18 the DON provided the surveyor with a copy of a policy/procedure titled Medication Pass Quick Guide page 1 of this document read under Reminders: #2 of guide Cover or close MAR/TAR when unattended. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and facility document review, the facility staff failed properly store medications in one of one medication rooms and on one of two halls, the skilled hall. The findings included. 1. The refrigerator in the medication room included a narcotic box that was not permanently affixed. The surveyor was able to remove the box from the refrigerator. This box contained 20 tablets of dronabinol ([MEDICATION NAME]). Per the national institute of health Dronabinol is an orally active cannabinoid which has complex effects on the CNS, including central sympathomimetic activity. On 09/05/18 at 7:50 a.m., the surveyor entered the medication room with the nursing staff. Inside the refrigerator in this medication room, the surveyor observed a small plastic clear through box. This box was not permanently affixed and the surveyor was able to remove the box from the refrigerator. The box contained 20 tablets of dronabinol. On 09/05/18 09:28 a.m., the DON (director of nursing) was notified that the narcotic box in the medication room was not permanently affixed and that this narcotic box contained 20 tablets of dronabinol. On 09/05/18, the DON provided the surveyor with their policy regarding medication storage. This policy read in part .Any controlled drugs will be stored securely .in an affixed container . The administrative staff were notified of the issues regarding the narcotic box not being permanently affixed on 09/05/18 at 3:00 p.m. Prior to the exit conference, the DON verbalized to the surveyor that the pharmacy had affixed the narcotic box to the refrigerator. No further information regarding the [MEDICATION NAME] was provided to the survey team prior to the exit conference. 2. The facility staff failed to ensure the medication cart was locked when unattended. On 09/05/18 at approximately 8:19 a.m., surveyor #1 observed RN ( registered nurse) #1 during a medication administration observation. During this observation RN #1 was observed preparing and administering medications. After preparing the medications RN #1 entered a Resident's rooms to administer the medications leaving medication draw open and medication cart unlocked in hallway. The medication cart was out of RN#1's view. Surveyor #2 observed housekeeping personnel, dietary personnel and one resident in the hallway during this observation. After the medication administration surveyor #1 approached RN #1 and interviewed her regarding the medication cart being open. RN #1 verbalized to the surveyor that she leaves the cart open if it is facing the room. The DON (director of nursing) was notified of the above on 09/05/18 at approximately 4:30p.m., during an end of the day meeting. On 09/06/18 the DON provided the surveyor with a copy of a policy/procedure titled Storage of Medications page 1 of this document read under Guidelines: #6 of policy Compartments containing medications are locked when not in use. Trays or carts used to transport such items are not left unattended. (Compartments include, but are not limited to drawers, cabinets, rooms, refrigerators, carts and boxes.) 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 two of 15 Residents, were free of significant medication errors, Residents #14 and #30. The findings included. 1. For Resident #14, the facility failed to administer the Residents physician ordered [MEDICATION NAME]. The Resident had a stat (immediate) order for [MEDICATION NAME]. The facility was unable to provide any proof that this medication had been administered. The clinical record review revealed that Resident #14 had been admitted to the facility 12/03/15. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents annual MDS (minimum data set) assessment with an ARD (assessment reference date) of 07/12/18 included a BIMS (brief interview for mental status) summary score of five out of a possible 15 points. The EHR (electronic health record) included a physicians order dated 08/26/18 for [MEDICATION NAME] Tablet 20 MG ([MEDICATION NAME]) Give 3 tablet by mouth STAT for [MEDICAL CONDITIONS] one time dose. The surveyor was unable to locate any information in the clinical record to indicate that this medication had been administered as ordered. The clinical record did not include any information to indicate the Resident suffered any effects from not receiving the medications. The surveyor observed the Resident throughout the survey process and no issues regarding the [MEDICATION NAME] not being administered were observed. The administrative staff were notified of the issues regarding the Residents [MEDICATION NAME] on 09/05/18 at 3:00 p.m. No further information regarding the [MEDICATION NAME] was provided to the survey team prior to the exit conference. 2. For Resident #30, the facility administered the Residents [MEDICATION NAME] for a pulse less than 60. The Resident had a physicians order to hold the [MEDICATION NAME] for a pulse less than 60. The clinical record review revealed that Resident #30 had been admitted to the facility 11/01/17. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 08/02/18 was coded 1/1/3 to indicate the Resident had problems with long and short term memory was severely impaired in cognitive skills for daily decision making. The Residents EHR included the order [MEDICATION NAME] give 0.125 mg one time a day for heart check pulse, hold for HR (heart rate) less than 60. A review of the Residents eMARs (electronic medication administration records) revealed that the nursing staff had documented the Residents pulse as being 59 on 08/11, 56 on 08/28, and 55 on 09/01. This medication had been checked as being administered by LPN (licensed practical nurse) #1. The DON (director of nursing) was notified of the issue regarding the Residents [MEDICATION NAME] on 09/05/18 at 9:28 a.m. The administrative staff were notified of the issues regarding the Residents [MEDICATION NAME] on 09/05/18 at 3:00 p.m. The surveyor attempted to interview LPN #1 on 09/06/18. However, the surveyor was notified that LPN #1 was not working. No further information regarding the [MEDICATION NAME] was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to coordinate care with [MEDICAL TREATMENT] center for 1 of 15 Residents, Resident #41. The findings included: For Resident #41 the facility staff failed to coordinate care with [MEDICAL TREATMENT] center. Resident #41 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 08/23/18 coded the Resident as 15 of 15 in section C, cognitive patterns. This is a quarterly MDS. Resident #41's CCP (comprehensive care plan) was reviewed and contained a care plan for receives [MEDICAL TREATMENT] r/t (related to) end stage [MEDICAL CONDITION]. Resident #41's clinical record was reviewed on 09/04/18. The surveyor could not locate any communications between the facility and the [MEDICAL TREATMENT] center regarding the status of Resident prior to or after [MEDICAL TREATMENT] treatments. Surveyor spoke with DON (director of nursing) on 09/05/18 at approximately 1140. DON stated that the facility did not keep any copies of written communications from the [MEDICAL TREATMENT] center regarding Resident #41. Surveyor spoke with LPN (licensed practical nurse) #1 on 09/06/18 at approximately 0955 regarding Resident #41. LPN #1 stated that the facility communicated with the [MEDICAL TREATMENT] center via telephone of fax only when there were changes to the Residents condition or orders, but not each time Resident goes for [MEDICAL TREATMENT]. Surveyor reviewed the facility agreement with the [MEDICAL TREATMENT] center on 09/06/18. This agreement read in part, The nursing facility shall ensure that all appropriate medical and administrative information accompanies all Residents at the time of transfer to the [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) [MEDICAL TREATMENT] Unit and 5.the Company agrees to provide [MEDICAL TREATMENT] services at the [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit as follows: D. To provide the nursing facility information on all aspects of the management of the Resident care related to the provision of [MEDICAL TREATMENT] services . The concern of the facility not coordinating care with the [MEDICAL TREATMENT] was discussed with the administrative team during a meeting on 09/06/18 at approximately 1040. 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 1 of 15 Residents, Resident #12. The findings included: For Resident #12 the facility staff failed to assess Resident and document that Resident had been admitted to the hospital. Resident #12 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 07/05/18 coded the Resident as 5 out of 15 in section C, cognitive patterns. This is an annual MDS. Resident #12's clinical record was reviewed on 09/04/18. It contained progress note dated 08/29/18 at 03:37, which read in part, Bed alarm went off when walked into room [ROOM NUMBER] Patient was laying in the floor beside of bed. Patient stated that she was trying to put herself in the bed. no complaints of pain or injury noted. (name omitted) was on the floor and she checked the patient. gave verbal order to just watch Patient. The clinical record also contained a progress note dated 08/31/18 at 13:49, which read in part, Resident readmitted to ICF (intermediate care facility) room [ROOM NUMBER]-A from acute care . The surveyor could not locate any progress notes regarding any assessment of the Resident or that the Resident had been discharged to the hospital. Surveyor spoke with DON (director of nursing) on 09/05/18 at approximately 1145 regarding Resident #12. DON stated that Resident #12 had recently been in the hospital. Surveyor asked the DON if there should have been progress notes related to Resident #12 being hospitalized and the DON stated that there should have been. Surveyor requested the facility standard of practice regarding charting and was provided with a copy of policy entitled Nursing Documentation Guidelines which read in part, Care and/or services provided to a Resident or any change in a Resident's physical or mental condition shall be documented in the medical record. 13. Incidents, accidents, changes in the Resident's condition, supporting documentation for therapy and clinician's orders as well as family and physician notification shall be recorded in the clinical record. 14. Nurse documents in the clinical record indicating communication with physician and/or nurse practitioner changes in Resident's status and document follow-up in Resident's status. The DON also provided the surveyor with a copy of Documentation in Nursing Practice which she stated was the facility standard for documentation. This standard read in part, Documentation in Nursing Practice is anything written or electronically generated that describes the status of client on the care or services given to that client. The purpose of documentation in nursing practice is to facilitate communication, to promote good nursing care and to meet professional and legal standards. The concern of the facility failing to follow professional standards of practice was discussed with the administrative team during a meeting on 09/06/18 at approximately 1040. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to ensure one of 15 Residents were free from unnecessary medications, Resident #30. The findings included. The facility nursing staff administered the Residents [MEDICATION NAME] when the Residents pulse was documented in the EHR (electronic health record) as being less than 60. Resident #30 had a physician's orders [REDACTED]. The clinical record review revealed that Resident #30 had been admitted to the facility 11/01/17. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 08/02/18 was coded 1/1/3 to indicate the Resident had problems with long and short term memory was severely impaired in cognitive skills for daily decision making. The Residents EHR included the order [MEDICATION NAME] give 0.125 mg one time a day for heart check pulse, hold for HR (heart rate) less than 60. A review of the Residents eMARs (electronic medication administration records) revealed that the nursing staff had documented the Residents pulse as being 59 on 08/11, 56 on 08/28, and 55 on 09/01. This medication had been checked as being administered by LPN (licensed practical nurse) #1. The DON (director of nursing) was notified of the issue regarding the Residents [MEDICATION NAME] on 09/05/18 at 9:28 a.m. The administrative staff were notified of the issues regarding the Residents [MEDICATION NAME] on 09/05/18 at 3:00 p.m. The surveyor attempted to interview LPN #1 on 09/06/18. However, the surveyor was notified that LPN #1 was not working. No further information regarding the [MEDICATION NAME] was provided to the survey team prior to the exit conference.