Every finding on record at Waddell Nursing And Rehab Center

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide necessary respiratory services in accordance with professional standards of practice for 1 of 4 closed record reviews, Resident #133. For Resident #133, the facility staff failed to ensure supplemental oxygen was available continuously via nasal cannula to the resident as ordered by a medical provider during transportation to a medical appointment on 12/20/23. Resident #133's diagnosis list indicated diagnoses that included, but were not limited to, COPD (chronic obstructive pulmonary disease), Chronic Respiratory Failure with Hypoxia, Anxiety, and Cerebral Infarction affecting Left Nondominant Side. The most recent complete quarterly minimum data set (MDS) with an assessment reference date (ARD) of 7/22/23, assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of the clinical record disclosed the following documentation: A medical provider orders with a start date of 4/15/23 which read in part, .OXYGEN: O2 @ (at) 3 LPM (three liters per minute) via n/c (nasal cannula- a medical device that delivers supplemental oxygen through a lightweight tube with two prongs that are placed in the nostrils) every shift for COPD w/Chronic hypoxic resp (with/respiratory) failure. A progress note dated 12/20/2023 at 11:51(11:51 AM) read in part, .Note.Reason for Departure: Appointment.LOA (leave of absence) with outside transportation. A progress note dated 12/20/2023 at 18:30 (6:30 PM) read in part, .Note.Time of return: 12/20/2023 6:30 PM. A review of the comprehensive person-centered care plan disclosed a focus, goal, and intervention which read in part, .At risk for altered.resp (respiratory) status r/t (related to).copd, chronic resp. failure.Resident will have no preventable crisis thru {sic} next review.O2 as ordered.Date Initiated: 03/29/2023. On 11/17/25, the administrator provided this surveyor with (3) three witness statements regarding Resident #133's transportation to a medical appointment on 12/20/23. A review of the witness statements disclosed a statement from the interim administrator dated 12/27/23, which read in part, .was notified by our van transport scheduler.that the.transport company came to pick up (Resident #133) to take her to the Neurology clinic.I was told this was a longer than normal trip, so our Charge nurse offered for the driver to take an extra O2 tank. The driver called in to his supervisor of which stated for him not to. The charge nurse made sure the resident had a full tank upon leaving which should have been enough to get to the appointment and return. We received a call from an OBGYN (obstetrics and gynecology) clinic and found out the driver actually took the resident to the wrong location and dropped her off.We asked the OBGYN office if we could use one of their O2 tanks being the time was getting more critical. They were fine with it. The transport company was finally notified and they sent someone else to transport the resident to the right office and bring her back. We were later notified the new driver had to contact EMS (emergency medical services) before making it back to our facility due to the second tank running out of 02. A second witness statement dated 12/27/23 written by licensed practical nurse #3 (LPN#3) read in part, .Transportation arrived.for an appointment.in Roanoke, VA.Making sure resident had enough O2 for her departure and return trip to appt (appointment), her portable O2 tank was changed. This nurse asked if another tank could be sent with her in case she needed it, transportation aide stated it was only his 3rd day on the job and he didn't know how to change it, that he would call his supervisor to see if he could take it in the van, after talking with his supervisor, we were notified that the van had nowhere to store a O2 cylinder. Resident left with a full tank O2 cylinder to her appt. Notified by Neurology Clinic that resident was late for her appointment, that the transportation aide dropped her off a the OB dept. (department) and left.In route back to the facility, resident had been picked up by another transportation aide who had stated that resident ran out of O2 on her way back to facility, so she had to pull over on the side of the highway and call EMS for O2, stated that [name of clinic omitted] did not supply her with a full tank as they said they would do. A third witness statement dated 12/27/23 written by licensed practical nurse #4 (LPN#4)-unit manager, read in part, .Resident.was scheduled with transport to neurology, pick up set for 11:40 AM.driver arrived.driver noted that she (Resident #133) had O2 and was afraid she would run out & was uncomfortable taking her. The Charge Nurse.offered to send another E-cylinder with him, he stated that is was his 3rd day on the job and he didn't know how to change it out.called his supervisor who also said he could not take an extra tank. Staff got a new tank and hooked resident up at that time. Resident should have enough O2 for appointment and return to facility.Later in the day, the neurology office called & notified the facility.(Resident #133) had been taken to the wrong office (OB/GYN) and was so late arriving that she missed her appointment and was now running low on O2 and would not have enough to make the return trip. They also stated the driver had not left a call back # (number) for him to be reached.Staff contacted the office to try to secure a e-cylinder for.return trip.contacted her (Resident #133) insurance.to reach out to transport agency.I was on the phone for over 1 1/2 hours while they were trying to reach the driver to establish an ETA (estimated time of arrival). On 11/17/25 at 12:41 PM, this surveyor interviewed other staff #5 (OS#5) and she remembered that transport took Resident #133 to the wrong appointment and then took her to correct appointment. The family called the facility and informed them the resident had run out of oxygen. On 11/17/25 at 3:45 PM, this surveyor interviewed other staff #6 (OS#6) and she stated she set-up transport for the appointment and the resident was scheduled to go to the neurologist in Roanoke. She recalled neurology called the facility and informed them Resident #133 needed to be picked up from the appointment. OS#6 stated it took the transport driver a while to get there and the resident ran out of oxygen, so the driver called 911. OS#6 denied Resident #133 was accidentally taken to the ob-gyn office that day by mistake. OS#6 provided this surveyor with a copy of the appointment page depicting Resident #133's appointments. Resident #133's neurology appointment on 12/20/23 was scheduled for 1:45 PM. On 11/17/25 at 3:52 PM, this surveyor interviewed other staff #10 (OS#10) and she informed surveyor she took the call from neurology on 12/20/23 and stated neurology called to let the facility know Resident #133 was ready to be picked up. OS#10 denied Resident #133 was accidentally taken to the ob-gyn clinic by mistake on that day. On 11/17/25 at 3:56 PM, this surveyor interviewed LPN#4 and she informed surveyor Resident #133 was on oxygen and had a full tank when she left the facility for the appointment. The transport driver stated he was not allowed to take extra tanks of oxygen on the van. LPN#4 recalled neurology switched the tank to her understanding so the resident could get back to the facility. She recalled there was a delay in transport picking the resident up from neurology and the resident was later coming back. LPN#4 stated she was not working by the time the resident returned to the facility, but it had been discussed that the resident ran out of oxygen on the way back and the driver pulled over and called 911 and they (EMS) gave Resident #133 enough oxygen to get back to the facility. On 11/18/25 at 3:04 PM, this surveyor interviewed LPN#3 and she informed surveyor that she was Resident #133's nurse on 12/20/23. She stated she was going to send another oxygen cylinder with the resident and transport told her they could not take an extra oxygen tank on the van and the driver did not know how to change the oxygen tank. This surveyor inquired the process for ensuring there is an adequate supply of oxygen for appointments that are a greater distance away from the facility and LPN#3 stated she believes in times past that the oxygen tank should have lasted, but she believed the transport driver took Resident #133 to the wrong appointment first or was late getting her to the neurology appointment and that's why the resident ran out of oxygen. LPN#3 did not recall speaking with the ob-gyn office or the neurology office. On 11/18/25 at 3:17 PM, this surveyor and LPN#3 observed the oxygen cylinders at the facility. LPN#4 assisted LPN#3 and this surveyor and found information on the internet and the information stated a fully charged e-tank (tanks the facility utilizes) contains 680 (six-hundred eighty) liters of oxygen. The survey team reviewed an internet site at https://pipingtechs.com/oxygen-tank-size-chart-calculating-oxygen-tank-duration/ that calculated a fully charged e-tank at 680 liters divided by the flow rate of 3 liters per minute x 60 = 3.78 hours of supplemental oxygen. Resident #133 departed the facility at approximately 11:40 AM and the neurology appointment was scheduled at 1:45 PM at an approximate distance of 97.48 miles with an uninterrupted drive duration of one hour and thirty-nine minutes one-way. Total time for the appointment trip with an uninterrupted drive was calculated at two hours and eighty minutes, excluding the duration of time Resident #133 would have been at the appointment facility. This concern was discussed on 11/18/25 at 5:10 PM, at the end of day meeting with the administrator, director of nursing, assistant director of nursing, and regional director of clinical services. The director of nursing informed this surveyor her expectation would have been to send a CNA (certified nursing assistant) with Resident #133 to the appointment on 12/20/23. Surveyor requested and received a facility policy titled, Oxygen Administration (all routes) Policy with a revision date of 6/23/25 that read in part, .licensed clinicians with demonstrated competence will administer oxygen.as ordered by the provider. No further information regarding this concern was presented to the survey team prior to the exit conference on 11/19/25.

Based on staff interview, clinical record review, and facility document review the facility staff failed to administer a medication per the providers orders for 1 of 24 residents Resident #59 and failed to follow a medical provider order for notification of elevated Blood Sugars for 1 of 24 residents, Resident #21. The findings included: 1. For Resident #59, the facility staff failed to ensure they had a prescription for the medication Gabapentin. Resulting in Resident #59 missing 7 doses of this medication. Gabapentin is a controlled medication and requires an updated prescription to be dispensed. Resident #59's diagnoses included low back pain, muscle weakness, migraine, and dementia. Section C (cognitive patterns) of Resident #59's significant change in status minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/06/25 was coded 1/1/3 to indicate Resident #59 had problems with long-and short-term memory and was severely impaired in cognitive skills for daily decision making. Resident #59's comprehensive care plan (CCP) included the problem area of pain. Approaches included Medications as ordered. Resident #59's clinical record included a provider order for Gabapentin 100 mg twice a day. Date of order 10/16/24. The clinical record included a progress note documented on 10/20/25 that read in part. Resident out of prescription gabapentin 100mg. On-call provider.notified; however, unable to refill prescription at this time as the medication requires MD setup due to an alert in the system. On-call provider gave new order to hold HS [bedtime] dose of gabapentin tonight. Pharmacy notified; representative stated they will continue to search for a script but confirmed they did not receive a new script from today. A review of Resident #59's electronic medication administration record (eMAR) revealed that the nursing staff had documented the following. 10/17/25 9:00 p.m. Not administered, unavailable, Pharmacy and MD notified awaiting script. 10/18/25 5:00 p.m. Not administered, waiting for script from MD. 10/18/25 9:00 p.m., Not administered drug/item unavailable waiting on script. 10/19/25 5:00 p.m., Not administered drug/item unavailable waiting on new script. 10/19/25 9:00 pm., Not administered drug/item unavailable waiting script MD aware. 10/20/25 5:00 p.m., Not administered drug/item unavailable. Provider to send script to pharmacy-delayed due to internet connection issues today. 10/20/25 9:00 p.m., Not administered: On hold. A review of the Omnicell list (backup supply of medication) revealed this medication was available for administration. On 11/18/25 at 5:10 p.m., during an end of the day meeting with the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and Regional Nurse the issue with Resident #59 not receiving their medication per the providers orders was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #21, the facility staff failed to follow a medical provider orders for notification of blood sugar levels greater than 400 (four hundred). Resident #21's diagnosis list indicated diagnoses, which included, but not limited to, Type 2 Diabetes Mellitus, Vascular Dementia, Atrial Fibrillation, and Atherosclerotic Heart Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 10/16/25, coded the resident in Section C (Cognitive Patterns) as rarely/never understood with short and long-term memory problems and severe impairment in cognitive skills for daily decision making. A review of a medical provider orders with a start date of 8/20/25 read in part, .insulin lispro.special instructions.blood sugar.Call provider if over 400. This order had a discontinued date of 9/7/25. A review of a medical provider orders with a start date of 9/11/25 read in part, .insulin lispro.special instructions.Call MD (medical doctor) if <400 (greater than 400). This order had a discontinued date of 10/16/25. This surveyor reviewed Resident #21's August 2025 and October 2025 MARs (medication administration records) and observed documentation of the resident's BS (blood sugar) being elevated over 400 on (2) two occasions. No evidence could be located in the clinical record that a medical provider was notified as indicated in the medical provider orders on the following dates: 8/29/25-BS 402 10/1/25-BS 532 A review of the comprehensive person-centered care plan disclosed a focus and intervention which read in part, .The resident has Diabetes Mellitus with CKD (chronic kidney disease).Assess/document/report to MD.for.hyperglycemia (high blood sugar-a condition where there is an abnormally high level of glucose in the bloodstream). This surveyor requested evidence that the medical provider was notified of Resident #21's elevated blood sugars on 8/29/25 and 10/1/25. On 11/18/25 at 11:00 AM, the director of nursing (DON) provided this surveyor with a copy of a page from a medical provider communication book which read in part, .8-29-25.(Resident #21).FBS (fasting blood sugar)-402 this AM (morning). The NP (nurse practitioner) had initialed the concern as acknowledged. On 11/18/25 at 1:20 PM, the DON agreed her expectation would be for the nurse to call the provider as ordered at the time the blood sugar was taken. This concern was discussed on 11/18/25 at 5:10 PM at the end of day meeting with the administrator, director of nursing, assistant director of nursing, and regional nurse consultant. No further information regarding this concern was presented to the survey team prior to the exit conference on 11/19/25.

Based on staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan (CCP) for 1of 24 residents, Resident #9.The findings included. The findings included.The facility staff failed to review and revise Resident #9's CCP when the resident elected to sign a Do Not Resuscitate (DNR) order. The CCP included the focus area of full code. Resident #9's diagnoses included gastro-esophageal reflux disease, anemia, dysphagia, and weakness. Section C (cognitive patterns) of Resident #9's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/17/25 included a brief interview for mental status (BIMS) score of 10 out of a possible 15 points. Per the MDS manual a 10=moderately impaired in cognitive skills for daily decision making. Resident #9's clinical record included the following orders. 1. Full code order dated 08/08/25 and a discontinued order date of 09/03/25.2. DNR order dated 09/03/25. Resident #9's current CCP included the problem area Advanced Directives/Code Status resident has chosen to be a full code. Interventions included if resident/responsible party chooses to change code status, necessary items will be completed, new order, update documentation/care plan, face sheet. The face sheet in the clinical record included the information DNR. On 10/01/2025 at 10:10 a.m., the surveyor notified the Social Worker that Resident #9's CCP included the problem area of full code when they had a DNR order in place. The facility staff provided the surveyor with a copy of a signed Durable Do Not Resuscitate Order from the Virginia Department of Health dated 09/13/25. During an end of the day meeting on 11/18/25 at 5:10 p.m., with the Administrator, Director of Nursing, Assistant Director of Nursing, and Regional Nurse the issue with Resident #9's CCP not being reviewed and revised to reflect their current DNR status was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference on 11/19/25.

Based on staff interview and clinical record review, the facility staff failed to ensure 5 of 26 residents were free of significant medication errors involving insulin. Residents #3, #92, #58, #2, and #20. The findings included: 06/24/2021 the (DON) director of nursing provided the survey team with a copy of a policy titled, Facilities Receiving Pharmacy Products and Services from Pharmacy. This policy read in part, .Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following .Verify each time a medication is administered that it is the correct medication at the correct dose . 1. For Resident #3, the facility staff failed to follow the physician ordered parameters in regards to insulin administration. Resulting in resident #3 not receiving their insulin on 05/07/2021 for a (BS) blood sugar of 180 and receiving insulin on 05/25/2021 for a BS of 159. Resident #3's facesheet in the (EHR) electronic health record included the diagnoses, diabetes, [CONDITION(S)], hypertension, and major depressive disorder. Section C (cognitive patterns) of Resident #3's annual (MDS) minimum data set assessment with an (ARD) assessment reference date of 06/15/2021 included a (BIMS) brief interview for mental status summary score of 8 out of a possible 15 points. Resident #3's EHR included a physicians order for Novolog insulin inject 12 unit subcutaneously before meals for diabetes. Hold if BS less than 180. The order date was documented as 11/02/2020. A review of Resident #3's (EMARs) electronic medication administration records revealed the following 05/07/2021 the nursing staff documented a 16. Per the preprinted code on the EMAR a 16=Hold/See Nurses Note. This nurse documented Resident #3's BS as 180 and documented in the medication administration note that the insulin was held. Per the physicians order the insulin should have been administered. 05/25/2021 the nursing staff documented a BS of 159 and that the insulin was administered in the right lower quadrant of Resident #3's abdomen. Per the physicians order the insulin should have been held. 06/23/2021 4:05 p.m., the administrator, DON, regional nurse, regional vice president of operations and assistant administrator/ADON (assistant director of nursing) were made aware of the issue regarding Resident #3's insulin. This issue was again reviewed on 06/24/2021 at 4:00 p.m. with these same staff. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #92, the facility staff failed to follow the physician ordered parameters in regards to insulin administration. Resulting in resident #92 not receiving their insulin on 06/13/2021 for a (BS) blood sugar of 210. Resident #92's facesheet in the (EHR) electronic health record included the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Section C (cognitive patterns) of the residents quarterly (MDS) minimum data set assessment with an (ARD) assessment reference date of 06/03/2021 included a (BIMS) brief interview for mental status summary score of 9 out of a possible 15 points. Resident #92's EHR included a physicians order dated 05/21/2021 for Novolog insulin inject 10 units subcutaneously two times a day for diabetes. Hold for (BG) blood glucose less 180. Give before lunch and supper. A review of Resident #92's (EMARs) electronic medication administration records revealed that the nursing staff documented a 3 on 06/13/2021 at 5:00 p.m. Per the preprinted code on this form a 3=No insulin required. The blood sugar was documented as 210. Indicating the resident should have received insulin per the physician ordered parameters. 06/23/2021 4:05 p.m., the administrator, DON, regional nurse, regional vice president of operations and assistant administrator/ADON (assistant director of nursing) was made aware of the issue regarding Resident #92's insulin. This issue was again reviewed on 06/24/2021 at 4:00 p.m. with these same staff. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #58, the facility staff failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #58's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent significant change MDS (minimum data set) with an ARD (assessment reference date) of 6/07/21 assigned the resident a BIMS (brief interview for mental status) score of 13 out of 15 in section C, Cognitive Patterns. In section I, Active Diagnoses, Resident #58 was coded for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #58's active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] **Hold for BG (blood glucose) less than 200**. A review of Resident #58's June 2021 MAR (medication administration record) revealed the resident received Novolog 4 units on 6/15/21 at 5:41 am in the right arm with a documented blood sugar of 104. On 6/16/21 at 5:46 am, the resident received Novolog 4 units in the right lower abdominal quadrant with a documented blood sugar of 117. On 6/24/21 at 4:00 pm during a meeting with the facility administrative team, surveyor discussed the concern of Resident #58 receiving Novolog on 6/15/21 and 6/16/21 with documented blood sugars below 200. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/24/21. 4. For Resident #2 the facility staff administered insulin outside the physician ordered parameters. Resident #2's face sheet listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 06/17/21 assigned the resident a BIMS (brief interview for mental status) of 14 of 15 in section C, cognitive patterns. This indicated the resident is cognitively intact. Resident #2's comprehensive care plan was reviewed and contained a care plan for Resident is at risk for hypo/[CONDITION(S)] episodes R/T (related to): dx (diagnosis) IDDM (insulin dependent diabetes mellitus); [CONDITION(S)] with recent ER visit. Interventions for this care plan included medication as ordered; hold as needed per ordered parameters. Resident #2's clinical record was reviewed and contained a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Inject 10 unit subcutaneously before meals for DM (diabetes mellitus). Hold if <180 (less than). Resident #2's eMARs (electronic medication administration record) for the month of June was reviewed and contained an entry as above. The entry for 06/01/21 at 11:30 am recorded the resident's blood glucose level as 163 and was initialed as insulin given. The notes section of the eMAR indicated the resident had been administered insulin subcutaneously in the right lower abdomen. The concern of administering insulin outside physician ordered parameters was discussed with the administrative team (administrator, director of nursing, regional nurse consultant, regional vice president of operations, assistant administrator) during a meeting on 06/24/2021 at approximately 4:00 pm No further information was provided prior to exit. 5. For Resident #20 the facility failed to hold the resident's Novolog (insulin) according to the provider's written order. The resident's electronic clinical record was reviewed and the facesheet listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #20's MDS (minimum data set) with an ARD (assessment reference date) of 04/04/2021 noted in Section C (cognitive patterns) the resident had a BIMS (brief interview for mental status) score of 11 out of 15. One of the resident's medication orders, with a 04/03/2021 start date, read NovoLOG [MEDICATION(S)] Solution Pen-Injector 100 UNIT/ML (Insulin [MEDICATION(S)]) Inject 6 unit [sic] subcutaneously before meals related to TYPE 2 DIABETES MELLITUS WITH [CONDITION(S)] (E11.65) Hold for BG [blood glucose] less than 180. Resident #20's MAR (medication administration record) was reviewed and for the month of June 2021, there were three (3) times facility staff documented the medication was administered when the resident's blood glucose was noted less than 180; on 06/01/2021 at 4:30 p.m. the resident's blood glucose was 177, on 06/03/2021 at 4:30 p.m., the resident's blood glucose was 178, and on 06/06/2021 at 6:30 a.m. the resident's blood glucose was 138. On 06/24/21 at 11:30 a.m. the director of nursing (DON) was interviewed about the facility's staff documenting they administered insulin to Resident #20 when the resident's blood glucose was less than the ordered parameter of 180. The DON acknowledged Resident #20's June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reported becoming aware of this concern while recently completing an insulin audit and reported discussing the concern with the medical director. The DON, administrator, assistant administrator, regional director of clinical services, and regional vice president of operations were informed of the medication findings described above on 06/24/2021 at 4:00 p.m. No further information was provided 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 during wound care observations for 2 of 26 residents. Residents #74 and #58. The findings included: 06/24/2021 the (DON) director of nursing provided the survey team with a copy of a policy titled, Hand Hygiene/Handwashing Policy date of revision 01/31/2020. This policy read in part, Hand washing is the most important component for preventing the spread of infection. Use of gloves does not replace the need for hand cleaning by either hand rubbing or hand washing .Perform hand hygiene .Before and after having direct contact with residents .After removing gloves .After contact with body fluids or excretions, mucous membranes, non-intact skin and/or wound dressings .If moving from a contaminated body site to a clean body site during resident care . 1. For Resident #74, the facility staff failed to complete hand hygiene during a wound care observation. Resident #74 had three stage IV pressure ulcers and an excoriated area to their sacrum. Resident #74's facesheet in the (EHR) electronic health record included the diagnoses, adult failure to thrive, (MS) [CONDITION(S)], nutritional deficiency, and major depressive disorder. Section C (cognitive patterns) of Resident #74's quarterly (MDS) minimum data set assessment with an (ARD) assessment reference date of 05/23/2021 included a (BIMS) brief interview for mental status summary score of 6 out of a possible 15 points. Section G (functional status) was coded (4/3) for bed mobility, transfers, locomotion of unit, dressing, and toilet use to indicate the resident required total assistance of two people for these tasks. Section M (skin conditions) was coded to indicate the resident was at risk for pressure ulcers and had three stage IV pressure ulcers. Resident #74's (CCP) comprehensive care plan included the focus areas at risk for infection related to history of recurrent infections pneumonia, urinary tract infections, [CONDITION(S)], and wound. Total assistance for all activities of daily living, [CONDITION(S)]. Risk for skin breakdown related to decreased mobility, function and weakness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #74's EHR included physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 06/23/21 2:00 p.m., wound care observation with (LPN) licensed practical nurse #3 and the (IP) infection preventionist. These staff were observed to wear a protective mask, gown, and gloves due to Resident #74's contact isolation status. LPN #3 was observed to remove the old dressings from the excoriated area and two stage IV pressure ulcers. LPN #3 changed their gloves and then cleaned these three areas with (DWC) dermal wound cleanser, applied skin prep to the sacral area X2 and a protective dressing, opened kerlix, changed gloves, poured the dakins solution onto the kerlix, applied the dakins soaked kerlix to two stage IV pressure ulcers, applied a protective dressing to the left hip wound, and then changed their gloves. LPN #3 was unable to cover wound #2 with a protective dressing due to the residents position. LPN #3 and the IP repositioned Resident #74 to their left side, removed the dakins gauze from wound #2, placed new dakins soaked kerlix into the wound bed, and applied a protective dressing. LPN #3 changed their gloves, cleaned wound #3 with DWC, applied dakins soaked kerlix to the wound bed, and then applied a protective dressing. 06/24/21 10:09 a.m., interview with IP. This nurse stated LPN #3 washed their hands before starting the treatments and after completion of the treatments but did not complete any hand hygiene during wound care. The IP stated LPN #3 should have washed her hands during wound care and they had discussed it after the observation. 06/24/21 4:00 p.m., the administrator, DON, nurse consultant, assistant administrator, and regional vice president of operations were made aware that LPN #3 did not complete hand hygiene during a treatment observation of three stage IV wounds. No other information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #58, the facility staff failed to perform hand hygiene while performing treatments to multiple pressure areas. Resident #58's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent significant change MDS (minimum data set) with an ARD (assessment reference date) of 6/07/21 assigned the resident a BIMS (brief interview for mental status) score of 13 out of 15 in section C, Cognitive Patterns. In section M, Skin Conditions, Resident #58 was coded for the presence of two (2) unstageable pressure ulcers with slough and/or eschar and five (5) unstageable pressure areas presenting as deep tissue injury. Resident #58's active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Apply sure prep to right heel and right 5th metatarsal and cover with bordered gauze every day shift 2. Apply sure prep to left heel, left lateral malleolus, and left mid foot, cover with bordered gauze every day shift 3. Cleanse wound to left lower extremity lateral aspect with normal saline, apply santyl to wound bed, cover with bordered gauze every day shift 4. Cleanse wound to right buttock with wound cleanser, apply santyl and calcium AG to wound bed and cover with bordered gauze, change every day and as needed On 6/23/21 at 4:58 pm, surveyor entered Resident #58's room to observe wound treatments. LPN (licensed practical nurse) #1 had already prepared the over bed table with dressings, treatment solutions had been poured into clear medication cups and ointment was also placed in a clear medication cup. Surveyor was unable to verify the solutions in each medication cup. LPN #1, with the assistance of RN (registered nurse) #1 turned the resident on their left side and discovered the resident had recently had a bowel movement. With gloved hands, LPN #1 cleaned the bowel movement from the resident's skin and placed a new pad under the resident and immediately proceeded to treatment the pressure area to the right buttock and apply the clean dressing without removing gloves and performing hand hygiene. LPN #1 removed gloves but did not wash hands or use hand sanitizer and obtained two clean gloves and carried them out of the resident's room. LPN #1 returned to the room with two gloves and a wash cloth in their hands. LPN #1 donned the gloves and cleaned the pressure areas to the resident's right lateral foot, left heel, left mid foot, and applied the treatment to the left mid foot and left lateral malleolus without performing hand hygiene or changing gloves. There was a knock at the resident's door and LPN #1 touched the door handle and opened the door with the same gloved hands. With the same gloved hands, LPN #1 returned to the resident and applied a dressing to right heel. LPN #1 then removed gloves and left the room without performing hand hygiene. LPN #1 returned to the room and donned clean gloves and cleaned the area to the resident's left lower extremity and applied the treatment. With the same gloved hands, LPN #1 pulled an ink pen from their hair and dated a clean dressing and applied it to the left lower extremity. With the same gloved hands, LPN #1 applied a dressing to the right lateral foot. On 6/24/21 at 10:12 am, surveyor discussed treatment observations with the infection control nurse who stated the nurse should have done hand hygiene and changed gloves during the treatments. On 6/24/21 at 10:25 am, surveyor spoke with LPN #1 and asked about their hand hygiene during the treatment observation. LPN #1 immediately replied I didn't do it like I was supposed to. LPN #1 further stated that they should have washed their hands and changed gloves after cleaning the resident's bowel movement and between each wound, LPN #1 stated they did use hand sanitizer between one. On 6/24/21 at 4:00 pm during a meeting with the facility management staff, surveyor discussed the concerns of the lack of hand hygiene identified during the observation of treatment administrations performed by LPN #1. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/24/21.

Based on observation, staff interview, and facility document review, the facility staff failed to keep a controlled medication in a separately locked, permanently affixed compartment on 1 of 3 units, Unit 2. The findings included: The facility staff failed to secure the medication, [MEDICATION(S)] (a schedule V controlled substance under Virginia state law used to treat seizures and nerve pain) in a separately locked, permanently affixed compartment in the medication cart. On 6/24/21 at 11:40 am, the surveyor accompanied by LPN (licensed practical nurse) #2, observed two separate bubble pack cards of [MEDICATION(S)] in an open area of the medication cart drawer beside the separately locked, permanently affixed, metal compartment containing controlled medications. One bubble pack card was labeled [MEDICATION(S)] 300 mg and contained 13 capsules and had the Controlled Substance Sheet folded around the card, the sheet indicated there were 13 capsules remaining. The second bubble pack card was labeled [MEDICATION(S)] 300 mg and contained 21 capsules and also had a Controlled Substance Sheet folded around the card, the sheet indicated there were 21 capsules remaining. LPN #2 stated the resident went home yesterday and the unit manager comes around and picks up the medications. At 11:55 am, LPN #2 stated I just pulled them this morning to prevent an error. The director of nursing was also present and stated they have called the pharmacy to bring a new cart with a single locking door with two compartments for the narcotics drawer. Surveyor requested and received the facility policy entitled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles which states in part: Procedure 3. General Storage Procedures: 3.1 Facility should store Schedule II - V Controlled Substances, in a separate compartment within the locked medication carts and should have a different key or access device, i.e. 3.1.1 Store all drugs and biologicals in locked compartments, including the storage of Schedule II - V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access On 6/24/21 at 4:00 pm during a meeting with the facility administrative team, surveyor discussed the concern of the facility staff not properly storing the medication [MEDICATION(S)] in the Unit 2 medication cart. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/24/21.

Based on staff interviews, facility document review, and during the course of a complaint investigation, the facility staff failed to obtain a consent for vaccine prior to administering the vaccine for 1 of 6 residents (Resident #1). The findings were: The facility staff failed to obtain a consent for the first of two COVID vaccines prior to administering the COVID vaccine to Resident #1. Resident #1's minimum data set (MDS) assessment had an assessment reference date (ARD) of 12/30/2020. Section AC (cognitive patterns) of the MDS indicated the Brief Interview for Mental Status (BIMS) summary score was 05 out of 15. The resident's diagnoses included, but were not limited to: cerebrovascular disease, dysphagia (difficulty swallowing), aphasia (inability to communicate) following unspecified cerebrovascular disease, COVID-19, failure to thrive, and dehydration. Resident #1's electronic clinical records was reviewed and a progress note dated 01/07/21 read that during a COVID vaccine clinic the same day, the pharmacist from a contracted pharmacy had administered the first of two COVID vaccines to Resident #1. The resident's representatives (two adult children) had not provided consent. One of the resident representatives (RR) was notified of the occurrence and provided consent for Resident #1 to receive the second dose. The resident was monitored for response or reaction to the vaccine. The resident's physician was notified and instructed staff to continue monitoring for adverse reaction to the vaccine. During an interview with the director of nursing (DON) while investigating a complaint onsite on 03/16/21, the DON explained that during the COVID vaccine clinic on 01/07/21, the facility provided a nurse to accompany the contracted pharmacist to each room in order to identify the residents. While in Resident #1's room, the facility's nurse was called away to answer a page related to vaccines and while the nurse was out of the room, the pharmacist administered the vaccine to Resident #1 who's RR had not provided consent. When the error was caught, Resident #1's son (one of two RRs) was notified and provided consent at that time for the second dose when it was due. Resident #1's son (co-RR) was interviewed via phone by this surveyor on 03/17/21 at 10:43 a.m. He acknowledged that he had not provided consent, verbal or otherwise, for the vaccine and explained the family had been on the fence about whether to consent to the vaccine or not since Resident #1 had recently been positive for COVID-19 virus. He acknowledged providing consent for the second dose. The facility conducted an investigation into the occurrence, presented the occurrence to the quality committee and provided education to the unit managers. The facility's administrator was interviewed via phone on 03/18/21 and he explained the unit managers were the ones educated since they were responsible for verifying consents prior to vaccines being scheduled and administered. Six resident records were reviewed for consents and no one else had any problems with consents and vaccines. The quality program investigated all vaccines and consents given and found no other issues. The administrator acknowledged the date for compliance was 03/10/21 which was the end of the investigation. This is a complaint deficiency.

Based on observation, staff interview and clinical record review the facility staff failed to ensure that residents receive treatment and care by following physician's orders [REDACTED].#25, #40 and #110. The findings included: 1. For Resident #25 the facility staff failed to follow physician's orders [REDACTED]. Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/24/19 assigned the resident a BIMS (brief interview for mental status) score of 6 out 15 in section C, cognitive status. Resident #25's comprehensive care plan was reviewed and contained a care plan for Resident is at risk for hypo/[MEDICAL CONDITION] episodes R/T (related to): IDDM (insulin dependent diabetes mellitus). Interventions for this care plan include medication as ordered. Resident #25's clinical record was reviewed on 08/07/19. It contained a signed physician's orders [REDACTED].units/ml. Inject 10 units subcutaneously two times a day for DM (diabetes mellitus). Hold if BS (blood sugar) < (less than) 140. Resident #25's eMAR (electronic medication administration record) for the months of (MONTH) and (MONTH) 2019 were reviewed. The eMAR's contained an entry, which read in part, Humalog Kwickpen 3 ml 100 units/1 ml Unit. Inject 10 unit subcutaneously two times a day for DM. Hold if BS <140. The blood sugar for 07/04/19 at 9:00 AM was recorded as 122, and the entry was signed as administered. The blood sugar for 07/09/19 at 9:00 AM was recorded as 126 and the entry was signed as administered. The blood sugar for 08/05/19 was recorded as 126 and the entry was signed as administered. The blood sugar for 08/07/19 was recorded as 128, and the entry was signed as administered. The surveyor spoke with RN #1 on 08/08/19 at approximately 3:35 PM regarding Resident #25's insulin. Surveyor asked RN #1 what a check and initials indicated on the eMAR, and she stated that it meant the medication was administered as ordered. Surveyor then asked RN #1 to look at Resident #25's eMAR for the dates indicated above. RN #1 stated that the resident's insulin should not have been administered on these dates. The concern of not following the physician's orders [REDACTED]. No further information was provided prior to exit. 2. For Resident #40 the facility staff failed to follow physician's orders [REDACTED]. Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/31/19 assigned the resident a BIMS (brief interview for mental status) score of 12 out of 15 in section C, cognitive status. Surveyor observed Resident #40 on 08/07/19 at approximately 8:45. The resident did not have skin-sleeves on either arms or legs at this time. Resident #40's clinical record was reviewed on 08/08/19. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Resident #40's comprehensive care plan was reviewed and contained a care plan for at risk for skin breakdown related to: decreased mobility, weakness, med use, wears geri-legs (skin sleeves) per Resident request. Interventions for this care plan included geri-legs and geri-sleeves to all extremities for protection of skin from bumping into objects. Surveyor observed Resident #40 again on 08/08/19 at approximately 1:40. The resident did not have skin-sleeves on either arms or legs at this time. Surveyor observed a bandage to left elbow and two bandages to left lower leg. Surveyor spoke with LPN #1 on 08/08/19 at approximately 1:50 PM. Surveyor asked LPN #1 if Resident #40 was supposed to be wearing skin sleeves on his legs and LPN #1 stated, He has them for his arms but not his legs, he doesn't have an order for [REDACTED].#1 to pull Resident #40's physician's orders [REDACTED].#1 read the order summary, and stated I guess he is supposed to be wearing them on his legs. The concern of not following the physician's orders [REDACTED]. No further information was provided prior to exit. 3. For Resident #92, the facility staff failed to administer the residents 9:00 a.m. medication until the resident verbalized a concern to the surveyor during a group meeting and had awoken the resident at 1:00 a.m. to administer aspirin. The clinical record review revealed that Resident #92 had been admitted to the facility 08/21/17. [DIAGNOSES REDACTED]. Section C of the resident's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 01/03/19 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. The resident's EHR (electronic health record) was reviewed on 08/07/19 after a concern brought up in the group meeting regarding not receiving her morning insulin and being awoken at 1:00 a.m. to be administered an aspirin. On 08/07/19 at 11:21 a.m., Resident #92 verbalized to the surveyor that she had not received her morning insulin. Resident #92 stated the nursing staff had checked her BS (blood sugar) but she did not get her insulin. When asked if she felt okay, Resident #92 stated she did. Resident #92 also stated the facility nursing staff had awoken her at 1:00 a.m. to administer an aspirin. The surveyor immediately spoke with the administrator and LPN (licensed practical nurse) #1. LPN #1 verbalized to the surveyor that the resident had not received her insulin as she had not been in her room and she was unable to find her. LPN #1 stated the resident's insulin was due to be administered at 10:00 a.m. On 08/07/19 at 11:32 a.m., LPN #1 verbalized to the surveyor that she had not administered any of the resident's morning medications that the computer system was new to her, and she was just trying to figure it out. During this interview, LPN #6 verbalized to the surveyor that she had just administered the resident's medications. A review of the resident's eMARs (electronic medication administration records) revealed that the resident was due to receive [MEDICATION NAME] 20 mg for [MEDICAL CONDITION], [MEDICATION NAME] 20 mg for hypertension, [MEDICATION NAME] 10 mg for hypertension, therems tablet (multivitamin), 18 units of [MEDICATION NAME] for diabetes, and [MEDICATION NAME] 500 mg for diabetes. LPN #1 had signed for all of these medications as if they had been administered. In regards to the resident's aspirin the resident's physicians orders revealed that the resident had a new order for aspirin 81 mg to be given in the morning for [MEDICATION NAME] the order date was documented as 08/05/19 and the start date was documented as 08/06/19. A review of the resident's eMAR revealed that the facility nursing staff had placed a check mark beside the time of 12:00 a.m. on 08/07/19 indicating the aspirin had been administered. The facility nursing staff had also placed a check mark beside the timeframe of 8:00 a.m. on 08/06/19 indicating the aspirin had been administered. There was no medication scheduled for 10:00 a.m. as LPN #1 stated. 08/07/19 at 2:52 p.m., LPN #1, who was an agency nurse, verbalized to the surveyor that it was her third day in the building and her first day on that unit. When asked if she had received any orientation LPN #1 stated A little. On the first day, they kind of showed me around the facility, ins and outs of the computer. If I have an issue, I just grab whom I see and they direct me to whomever. LPN #1 stated she had been a nurse [AGE] years and that the resident's BS was obtained on 3rd shift and when she was completing the medication pass the Resident was there and after she had set up the Residents medications, she was gone. LPN #1 stated the Resident was in therapy and therapy stated she would be up there for 45 minutes. LPN #1 stated she called back to therapy and therapy said she was down here. I could not find her. LPN #1 stated she was still familiarizing herself with the system. When asked why she had signed as if the medication had been administered LPN #1 stated you can check yes, you can hit lock, or save and apparently I hit the save button instead of the lock button. LPN #1 stated she had relieved an agency nurse when she took report and there was not a whole lot the previous nurse could tell me about the unit. On 08/07/19 at approximately 4:08 p.m., the administrator, DON (director of nursing), regional vice president of operations, and regional director of clinical services were notified of the issue regarding Resident #92's medications. The facility policy/procedure titled, General Dose Preparation and Medication Administration read in part, .Verify each time a medication is administered that it is the correct medication, at the correct time .Confirm that the MAR indicated [REDACTED].Administer medication within timeframes specified by facility policy . On 08/08/19 at approximately 4:04 p.m., during a meeting with the administrator, DON, regional vice president of operations, and regional director of clinical services the DON verbalized to the surveyor that the medication guidelines were that a medication could been administered one hour before or one hour after their scheduled time. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure 2 of 27 residents were free of significant medication errors involving insulin. Residents #92 and #25. The findings included: 1. For Resident #92, the facility staff failed to administer the resident's insulin until the resident verbalized a concern to the surveyor during a group interview. The clinical record review revealed that Resident #92 had been admitted to the facility 08/21/17. [DIAGNOSES REDACTED]. Section C of the resident's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 01/03/19 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. The resident's EHR (electronic health record) was reviewed on 08/07/19 after a concern brought up in the group meeting regarding not receiving her morning insulin. On 08/07/19 at 11:21 a.m., Resident #92 verbalized to the surveyor that she had not received her morning insulin. Resident #92 stated the nursing staff had checked her BS (blood sugar) but she did not get her insulin. When asked if she felt okay, Resident #92 stated she did and stated her BS was 227. The surveyor immediately spoke with the administrator and LPN (licensed practical nurse) #1. LPN #1 verbalized to the surveyor that the resident had not received her insulin as she had not been in her room and she was unable to find her. LPN #1 stated the resident's insulin was due to be administered at 10:00 a.m. On 08/07/19 at 11:32 a.m., LPN #6 verbalized to the surveyor that she had just administered the resident's medications to included insulin. A review of the resident's eMARs (electronic medication administration records) revealed that the resident was due to receive18 units of [MEDICATION NAME] for diabetes at 9:00 a.m.; the resident's BS had been obtained at 6:30 a.m. and had been documented as being 226. LPN #1 had signed for the insulin at 9:00 a.m. as if it had been administered. There was no medication scheduled for 10:00 a.m. as LPN #1 stated. 08/07/19 at 2:52 p.m., when asked why she had signed for the resident's medications as if they had been administered LPN #1 stated you can check yes, you can hit lock, or save and apparently I hit the save button instead of the lock button. LPN #1 stated she had relieved an agency nurse when she took report and there was not a whole lot the previous nurse could tell me about the unit. On 08/07/19 at approximately 4:08 p.m., the administrator, DON (director of nursing), regional vice president of operations, and regional director of clinical services were notified of the issue regarding Resident #92's medications. The facility policy/procedure titled, General Dose Preparation and Medication Administration read in part, .Verify each time a medication is administered that it is the correct medication, at the correct time .Confirm that the MAR indicated [REDACTED].Administer medication within timeframes specified by facility policy . On 08/08/19 at approximately 4:04 p.m., during a meeting with the administrator, DON, regional vice president of operations, and regional director of clinical services the DON verbalized to the surveyor that the medication guidelines were that a medication could been administered one hour before or one hour after their scheduled time. The facility nursing staff had documented the resident's BS at 4:30 p.m. as being 221. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #25 the facility staff failed to ensure the resident was free of a significant medication error. Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/24/19 assigned the resident a BIMS (brief interview for mental status) score of 6 out 15 in section C, cognitive status. Resident #25's comprehensive care plan was reviewed and contained a care plan for Resident is at risk for hypo/[MEDICAL CONDITION] episodes R/T (related to): IDDM (insulin dependent diabetes mellitus). Interventions for this care plan include medication as ordered. Resident #25's clinical record was reviewed on 08/07/19. It contained a signed physician's orders [REDACTED].units/ml. Inject 10 units subcutaneously two times a day for DM (diabetes mellitus). Hold if BS (blood sugar) < (less than) 140. Resident #25's eMAR (electronic medication administration record) for the months of (MONTH) and (MONTH) 2019 were reviewed. The eMAR's contained an entry, which read in part, Humalog Kwickpen 3 ml 100 units/1 ml Unit. Inject 10 unit subcutaneously two times a day for DM. Hold if BS <140. The blood sugar for 07/04/19 at 9:00 AM was recorded as 122, and the entry was signed as administered. The blood sugar for 07/09/19 at 9:00 AM was recorded as 126 and the entry was signed as administered. The blood sugar for 08/05/19 was recorded as 126 and the entry was signed as administered. The blood sugar for 08/07/19 was recorded as 128, and the entry was signed as administered. The surveyor spoke with RN #1 on 08/08/19 at approximately 3:35 PM regarding Resident #25's insulin. Surveyor asked RN #1 what a check and initials indicated on the eMAR, and she stated that it meant the medication was administered as ordered. Surveyor then asked RN #1 to look at Resident #25's eMAR for the dates indicated above. RN #1 stated that the resident's insulin should not have been administered on these dates. The concern of not ensuring Resident #25 was free of a significant medication error was discussed with the administrative staff (administrator, director of nursing, regional nurse consultant, and regional vice-president of operations) during a meeting on 08/08/19 at approximately 4:00 PM. No further information was provided prior to exit.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure that this resident who is continent of bladder received services and assistance to maintain continence by following physician's orders [REDACTED].#66. The findings included: The facility staff failed to anchor Resident #66's foley catheter per the physicians order. The clinical record review revealed that Resident #66 had been admitted to the facility 02/28/17. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the resident's significant change in status MDS (minimum data set) assessment included a BIMS (brief interview for mental status) summary score of 13 out of a possible 15 points. Section H (bladder and bowel) was coded to indicate the resident has a catheter. Attempts to interview the resident were unsuccessful. The resident's EHR (electronic health record) included a physicians order to anchor catheter tubing and check placement every shift. The resident's comprehensive care plan included the focus area risk for complication in urinary system related to foley catheter use. Interventions included, but were not limited to, anchor catheter tubing and check placement every shift. On 08/08/19 at 7:40 a.m., the surveyor and CNA (certified nursing assistant) #5 checked the resident's foley catheter. This foley catheter was not anchored. On 08/08/19 at 2:26 p.m., the surveyor and LPN (licensed practical nurse) #2 again checked this foley catheter. The foley catheter was now anchored. LPN #2 verbalized to the surveyor that one of the CNA's had put the strap in place. On 08/08/19 at 3:35 p.m., CNA #4 stated she thought CNA #5 had put the strap in place. On 08/08/19 at approximately 4:04 p.m., the administrator, DON, regional vice president of operations, and regional director of clinical services were notified of the issue regarding Resident #66's foley catheter not being anchored. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and clinical record review, the facility staff failed to implement the resident's comprehensive care plan in regards to a foley catheter for 1 of 27 residents, Resident #66. The findings included: The facility staff failed to implement the resident's comprehensive care plan in regards to anchoring the resident's foley catheter. The clinical record review revealed that Resident #66 had been admitted to the facility 02/28/17. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the resident's significant change in status MDS (minimum data set) assessment included a BIMS (brief interview for mental status) summary score of 13 out of a possible 15 points. Section H (bladder and bowel) was coded to indicate the resident had a catheter. The resident's EHR (electronic health record) included the following physician's orders [REDACTED].>Anchor catheter tubing and check placement every shift. Foley catheter for [MEDICAL CONDITION]. The resident's comprehensive care plan included the focus area risk for complication in urinary system related to foley catheter use. Interventions included, but were not limited to, anchor catheter tubing and check placement every shift. On 08/08/19 at 7:40 a.m., the surveyor and CNA (certified nursing assistant) #5 checked the resident's foley catheter. This foley catheter was not anchored. On 08/08/19 at 2:26 p.m., the surveyor and LPN (licensed practical nurse) #2 again checked this foley catheter. The foley catheter was now anchored. LPN #2 verbalized to the surveyor that one of the CNA's had put the strap in place. On 08/08/19 at 3:35 p.m., CNA #4 stated she thought CNA #5 had put the strap in place. Attempts to interview this resident were unsuccessful. On 08/08/19 at approximately 4:04 p.m., the administrator, DON, regional vice president of operations, and regional director of clinical services were notified of the issue regarding Resident #66's foley catheter not being anchored. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to accurately complete MDS (minimum data set) assessments for 2 of 27 residents, Residents #34 and #92. The findings included: 1. For Resident #34, the facility staff failed to completed sections C (cognitive patterns) and D (mood) of the resident's quarterly MDS assessment with an ARD (assessment reference date) of 05/24/19. The clinical record review revealed that Resident #34 had been admitted to the facility 02/14/19. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the resident's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/21/19 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. The EHR (electronic health record) was reviewed on 08/06/19. During a review of the resident's MDS assessment with an ARD of 05/24/19, it was noted that sections C and D had been marked with dashes (-). On 08/06/19 at 4:05 p.m., the surveyor reviewed the MDS with the DON (director of nursing). On 08/07/19 at 9:07 a.m., the surveyor interviewed the SW (social worker), the SW verbalized to the surveyor that she really did not know the reason why it had dashes. .typically we get them all done timely . This SW stated she was responsible for sections C, D, E, and Q. The MDS coordinator that had signed this MDS as being complete was no longer employed at the facility. On 08/08/19 at approximately 4:04 p.m., the administrator, DON, regional vice president of operations, and regional director of clinical services were notified of the issue regarding Resident #34's MDS assessment being inaccurate. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #92, the facility staff failed to complete sections C (cognitive patterns) and D (mood) of 2 MDS (minimum data set) assessments. The clinical record review revealed that Resident #92 had been admitted to the facility 08/21/17. [DIAGNOSES REDACTED]. Section C of the resident's quarterly MDS assessment with an ARD (assessment reference date) of 01/03/19 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. The resident's EHR (electronic health record) was reviewed on 08/07/19 after a concern brought up in the group meeting. This review revealed that the facility staff had marked sections C and D of the resident's quarterly MDS assessment with an ARD (assessment reference date) of 04/05/19 and the resident's annual MDS assessment with an ARD of 07/06/19 with dashes (-). For the MDS with an ARD of 04/05/19 LPN #2 had signed the MDS as being responsible for sections C and D. The RN (registered nurse) that had signed the assessment as complete was no longer employed at the facility. On 08/07/19 at 3:10 p.m., LPN (licensed practical nurse) #2 verbalized to the surveyor that she had dashed the sections, as she had no information from social services. LPN #2 then added we have asked and emailed. For the MDS with an ARD of 07/06/19 the RN that had signed for sections C and D to be completed and for the assessment to be complete was no longer employed at the facility. On 08/08/19 at approximately 4:04 p.m., the administrator, DON, regional vice president of operations, and regional director of clinical services were notified of the issue regarding Resident #92's MDS assessments being incomplete. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, employee record review, facility document review, the facility staff failed to implement their policy/procedure in regards to new hires and criminal background checks for 3 of 25 new hires (New hire #6, #13, and #17). The findings included: The facility staff failed to obtain criminal background checks upon hire per their facility policy/procedure. Facility policy titled Employee Background Screening read in part, .Each facility shall conduct a criminal background check of all employees, as required by law, upon hire . The surveyor reviewed 25 new hire employee record on 08/07 and 08/08/19. Employee #6 was an LPN (licensed practical nurse). Documented DOH (date of hire) 10/08/18 criminal background check completed 12/20/18. Employee #13 was a cook. Documented DOH (08/30/18) criminal background check completed 10/09/18. Employee #17 was an activity staff. Documented DOH (10/26/18) criminal background check completed 12/19/18. On 08/08/19 at 10:00 a.m. human resource employee #1 was asked if they had any further information regarding background checks for these three employees. On 08/08/19 at 1:21 p.m., the surveyor reviewed the hire dates and criminal background dates with human resource employee #1. After this review, this employee verbalized to the surveyor that she had not completed the paperwork for employees #6 and #17. For employee #13 human resource employee #1 stated they must have missed it. On 08/08/19 at approximately 4:04 p.m., the administrator, DON, regional vice president of operations, and regional director of clinical services were notified of the issue regarding employee records. On 08/09/18 at 8:32 a.m., during the QA (quality assurance) task with the administrator, the administrator verbalized to the surveyor that by the end of (MONTH) they had realized they had placed too much on one person and made some internal changes in regards to job duties. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on interviews, clinical record review, and facility document review, it was determined the facility staff failed to correctly address residents' advance directives for three (3) of 25 sampled residents (Resident #57, Resident #34, and Resident #123). The findings included: 1. The facility staff failed to correctly address Resident #57's advance directive decisions. Resident #57 was admitted on [DATE]. Resident #57's [DIAGNOSES REDACTED]. Resident #57's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] assessed the resident with a BIMS (brief interview for mental status) score of 15 out of 15; this assessment also documented the resident as being able to express ideas and wants and as being able to make himself/herself understood. During the review of Resident #57's clinical record on [DATE] at approximately 4:00 p.m., a document titled POLICY ON CPR (CARDIOPULMONARY RESUSCITATION) was noted. This document was completed on [DATE]; it was signed by Resident #57's responsible party. This document had the following statement selected: I do not wish CPR be performed. On [DATE] at 04:13 p.m., Licensed Practical Nurse (LPN) #16 was interviewed about Resident #57's code status; LPN #16 reported the resident was a full code. LPN #16 showed the surveyor a 'unit report form' which had a heart-shaped symbol beside Resident #57's name. LPN #16 stated the heart-shaped symbol indicated the patient was a full code. On the afternoon of [DATE], it was also noted that Resident #57's clinical record included a care plan which included the Focus of Resident/Responsible party has chosen Full Code. On [DATE] at 9:25 a.m., LPN #14 provided the surveyor with the following documents: - a revised care plan for Resident #57, dated [DATE], indicating the patient was now DNR (do not resuscitate), - a provider order for Resident #57, dated [DATE] and timed 4:45 p.m., indicating the patient was DNR, and - a Durable Do Not Resuscitate (DDNR) Order form completed for Resident #57 on [DATE]. The issue of Resident #57 being a full code when documentation in the resident's clinical record indicated the resident was not to receive CPR was discussed during a survey team meeting with the facility's administrative team on [DATE] at 4:25 p.m.; the facility's administrative team at this meeting included the Administrator, the Director of Nursing (DON), the Regional Director of Clinical Services, and the Regional Vice-President of Operations. On [DATE] at 1:30 p.m., LPN #12 provided the survey team with a policy titled Code Status Audit Policy (this policy had an effective date of (MONTH) (YEAR) and a reviewed date of (MONTH) 2019). This policy included the following statement: The Facility will ensure resident's (sic) code status is accurate and current throughout the residents stay and the clinical record represent the accurate code status. 2. For Resident #123 the facility staff failed to ensure the DDNR (durable do not resuscitate) form was complete. Resident #123 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The admission MDS (minimum data set) with an ARD (assessment reference date) of [DATE] assigned the Resident a BIMS (brief interview for mental status) score of 13 out of 15 in section C, cognitive patterns. The advance directives section of the Resident's clinical record was reviewed on [DATE]. It contained a Virginia Department of Health DDNR form, 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) () 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: () [NAME] 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) Sections I and II of the DDNR form had not been checked as directed. Surveyor spoke with the ADON (assistant director of nursing) on [DATE] at approximately 2:45 PM regarding the incomplete DDNR form. ADON stated that the form should have been completed. The concern of the incomplete DDNR form was discussed with the administrative team (administrator, director of nourishing, regional nurse consultant, and regional vice-president of operations) on [DATE] at approximately 4:20 PM. No further information was provided prior to exit. 3. For Resident #34, the facility staff failed to complete a DDNR (durable do not resuscitate). All the boxes on this form had been left blank (unchecked). The clinical record review revealed that Resident #34 had been admitted to the facility [DATE]. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents admission MDS (minimum data set) assessment with an ARD (assessment reference date) of [DATE] included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. Section O (special treatments/procedures/programs) had been coded to indicate the Resident was receiving hospice services. The EHR (electronic health record) was reviewed on [DATE]. The EHR included a DDNR order form dated [DATE]. The physician and Resident #34 had signed this DDNR This DDNR 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. On [DATE] at 3:45 p.m., this DDNR was shared with the DON (director of nursing). The DON acknowledged the DDNR was incomplete. On [DATE] at approximately 4:04 p.m., the administrator, DON, regional vice president of operations, and regional director of clinical services were notified of the issue regarding Resident #34's DDNR being incomplete. Prior to the exit conference on [DATE], the facility provided the surveyor with an updated copy of the Residents DDNR dated [DATE]. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation and staff interview, the facility staff failed to provide a dignified existance by ensuring that privacy was maintained for residents during a group meeting. The findings included: During the group meeting, a facility staff entered the meeting, disturbing the group meeting, and proceeded to heat their food in the microwave. On 08/07/19 at 11:00 a.m., a group meeting wasas held with nine alert and orientated Residents of the facility. This meeting was held in the resident dining area. Prior to leaving the room, the activity staff shut the door. The staff had previously posted a notice on the entrance door that would alert anyone who wished to enter that a group meeting was being conducted. At 11:09 a.m., CNA (certified nursing assistant) #1 entered the group meeting, placed her food into the microwave, and proceeded to heat her food. After heating her food, CNA #1 left the dining area. At the conclusion of this meeting, the surveyor checked the outside door of the meeting room to ensure the sign was still posted. This sign was still in place. On 08/07/19 at approximately 4:08 p.m., the administrator, director of nursing, regional vice president of operations, and regional director of clinical services were notified of the issue regarding CNA #1 disturbing the group meeting. On 08/08/19 at 7:44 a.m., CNA #1 stated she saw the sign on the outside of the door for group but did not realize it meant she should not enter. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation and staff interview, the facility staff failed to ensure that a resident who needs respiratory care is provided such care storing oxygen equipment appropriately for 2 of 27 residents in the sample survey (Resident #32 and # 82). The findings included: 1. The facility staff failed to store a nebulizer mask appropriately when not in use for Resident #32. Resident #32 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/24/19, the resident was coded as requiring extensive assistance of 2 staff members for dressing, personal hygiene and bathing. On 8/7/19 at 8:21 am, the surveyor accompanied LPN (licensed practical nurse) #2 into Resident #32's room to observe the medication pass. Upon entering the room, the surveyor observed the nebulizer mask laying on the bedside table and was not stored in a plastic bag. The surveyor asked LPN #2 how the nebulizer mask was to be stored when not in use by the resident. LPN #2 stated, The mask of the nebulizer is to be stored in a plastic bag. At 9:30 am, the surveyor notified the DON (director of nursing) and the regional nurse consultant of the above documented findings. On 8/8/19 at 4:22 pm, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 8/9/19. 2. The facility staff failed to ensure Resident #82's respiratory treatment mask and oral suction catheters were appropriately stored. Resident #82 was admitted on [DATE]. Resident #82's [DIAGNOSES REDACTED]. Resident #82's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 7/16/19 assessed the resident being unable to obtain a BIMS (brief interview for mental status) score due to the resident is rarely/never understood; this assessment also documented the resident as being dependent on facility staff for bed mobility, dressing, eating, toileting, and personal hygiene. On 8/6/19 at 2:52 p.m., the following was observed: - the suction canister at Patient #82's bed side had been used but was not dated, - a [MEDICATION NAME] suction catheter was lying uncovered on a towel on Patient #82's beside table, - a flexible suction catheter was lying uncovered on a towel on Patient #82's bedside table, - a mask for providing breathing treatments was lying uncovered on a towel on Patient #82's beside table, and - a plastic bag was in floor beside Patient #82's bed side table. The failure of facility staff to ensure Resident #82's respiratory treatment/suction equipment was correctly stored was discussed on 8/8/19 at 4:05 p.m. during a survey team meeting with the facility's Administrator, Director of Nursing (DON), Regional Director of Clinical Services (RDCS), and Regional Vice-President of Operations. The RDCS reported there was not a written policy and procedure to guide the storage of the aforementioned respiratory equipment. The DON reported the respiratory treatment mask should be changed weekly and kept stored in a bag, the [MEDICATION NAME] suction catheter should be changed daily, and the flexible suction catheter should be discarded after use. During a survey team meeting with the facility's Administrator, Director of Nursing (DON), Regional Director of Clinical Services (RDCS), and Regional Vice-President of Operations on 8/9/19 at 9:45 a.m., the DON reported Resident #82's daughter suctions the patient and had been previously been provided education about the use/storage of the respiratory equipment. The surveyor asked for documentation of education provided to the resident's daughter. The following information, found in Patient #82's care plan, was provided to the surveyor: Daughter observed suctioning resident . Daughter education to ask nursing for suctioning PRN (as needed). No further information was provided to the surveyor prior to the exit conference on 8/8/19.

Based on staff interview and clinical record review, the facility staff failed to report any irregularities to ensure that drug regiment review recommendations were reported to the attending physician, facility medical director, and/or the director of nursing for 1 of 27 residents, Resident #3. The findings included: The facility staff failed to ensure the attending physician, facility medical director, and DON (director of nursing) reviewed and/or acted on a pharmacy recommendation for (MONTH) 2019. The clinical record review revealed that Resident #3 had been admitted to the facility 06/23/15. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the resident's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 07/30/19 included a BIMS (brief interview for mental status) summary score of 9 out of a possible 15 points. The resident's EHR (electronic health record) was reviewed on 08/06-08/08/19. The EHR included a Pharmacy Review Note dated 04/16/19. The pharmacist had documented See report for any noted irregularities and/or recommendations. On 08/08/19 at 12:13 p.m., the DON (director of nursing) was made aware that the surveyor needed to review the pharmacy recommendations for 04/16/19. On 08/08/19 at 1:46 p.m., the DON verbalized to the surveyor that she had reviewed her reports and she did not have anything for the date of 04/16/19. On 08/08/19 at approximately 4:04 p.m., the administrator, DON, regional vice president of operations, and regional director of clinical services were notified of the missing pharmacy recommendation. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview and clinical record review, the facility staff failed to ensure 1 of 27 resident was free of unnecessary medications. The findings included: 1. For Resident #25 the facility staff failed to ensure the resident was free of an unnecessary administration of insulin. Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/24/19 assigned the resident a BIMS (brief interview for mental status) score of 6 out 15 in section C, cognitive status. Resident #25's comprehensive care plan was reviewed and contained a care plan for Resident is at risk for hypo/[MEDICAL CONDITION] episodes R/T (related to): IDDM (insulin dependent diabetes mellitus). Interventions for this care plan include medication as ordered. Resident #25's clinical record was reviewed on 08/07/19. It contained a signed physician's orders [REDACTED].units/ml. Inject 10 units subcutaneously two times a day for DM (diabetes mellitus). Hold if BS (blood sugar) < (less than) 140. Resident #25's eMAR (electronic medication administration record) for the months of (MONTH) and (MONTH) 2019 were reviewed. The eMAR's contained an entry, which read in part, Humalog Kwickpen 3 ml 100 units/1 ml Unit. Inject 10 unit subcutaneously two times a day for DM. Hold if BS <140. The blood sugar for 07/04/19 at 9:00 AM was recorded as 122, and the entry was signed as insulin administered. The blood sugar for 07/09/19 at 9:00 AM was recorded as 126 and the entry was signed as insulin administered. The blood sugar for 08/05/19 was recorded as 126 and the entry was signed as insulin administered. The blood sugar for 08/07/19 was recorded as 128, and the entry was signed as insulin administered. The surveyor spoke with RN #1 on 08/08/19 at approximately 3:35 PM regarding Resident #25's insulin. Surveyor asked RN #1 what a check and initials indicated on the eMAR, and she stated that it meant the medication was administered as ordered. Surveyor then asked RN #1 to look at Resident #25's eMAR for the dates indicated above. RN #1 stated that the resident's insulin should not have been administered on these dates. The concern of unnecessarily administering the resident's insulin was discussed with the administrative staff (administrator, director of nursing, regional nurse consultant, and regional vice-president of operations) during a meeting on 08/08/19 at approximately 4:00 PM. No further information was provided prior to exit.

Based on observation, staff interview and clinical record review, the facility staff failed to ensure a medication error rate was less than 5% for 3 of 27 residents in the survey sample. There were 29 opportunities for error with 3 medication errors noted by the surveyors that made the medication error rate of 10.34% (Resident #32, #9 and #50). The findings included: 1. The surveyor observed LPN (licensed practical nurse) #2 crush a [MEDICATION NAME] DM and administer this to Resident #32. Resident #32 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/24/19, the resident was coded as requiring extensive assistance of 2 staff members for dressing, personal hygiene and bathing. On 8/7/19 at 8:21 am, the surveyor was observing LPN #2 administrating medication to Resident #32. During this observation, LPN #2 crushed the medication [MEDICATION NAME] DM and administrated it to the resident. At 9:35 am, the surveyor spoke to the pharmacist on the phone. The pharmacist stated that the Mucincex DM was not to be crushed because it is an extended release tablet that cannot be crushed. At 10:30 am, the surveyor notified the DON (director of nursing) and the regional nurse of the above documented observations. The DON stated, I don't believe that you can crush that. The surveyor requested the Do Not Crush list that the facility staff is to use. The surveyor reviewed the clinical record for Resident #32 at 1 pm. The resident did have a physician order, which stated, .[MEDICATION NAME] DM 1 tablet every BID (twice a day) po (by mouth) . The surveyor received a copy of the Do Not Crush medication list at 1:30 pm from the DON. On this list, the surveyor noted that [MEDICATION NAME] DM was included as one of the medications that is not to be crushed. The surveyor notified the administrative team of the above documented findings on 8/8/19 at 4:22 pm. No further information was provided to the surveyor prior to the exit conference on 8/9/19. 2. The surveyor observed LPN #1 administrating [MEDICATION NAME] nasal spray to Resident #9. LPN #1 did not have Resident #9 to blow her nose before the administration of this medication. Resident #9 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/8/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 11 out of a possible score of 15. Resident #9 was also coded as requiring supervision of 1 staff member for dressing and personal hygiene and extensive assistance of 1 staff member for bathing. During the medication pass and pour observation on 8/7/19 at 8:43 am, the surveyor observed LPN (licensed practical nurse) #1 administrating [MEDICATION NAME] nasal spray to Resident #9. The medication was given as ordered by the physician but LPN did not have the resident blow her nose before administrating this nasal spray to the resident. At 8:55 am, the surveyor asked LPN #1 if the resident was to blow her nose before she was given the nasal spray, [MEDICATION NAME]. LPN #1 stated, I thought I did that. The surveyor stated, No I didn't observe you asking or instructing the resident to do this before you gave the resident the [MEDICATION NAME]. At 11 am, the surveyor notified the DON (director of nursing) of the above documented observations. The surveyor requested a copy of the package insert for the medication [MEDICATION NAME]. At 11:30 am, the DON gave the surveyor the package insert for [MEDICATION NAME]. The surveyor noted the following on the package insert which stated, .Blow your nose to clear your nostrils . The surveyor notified the administrative team of the above documented findings on 8/8/19 at 4:22 pm. No further information was provided to the surveyor prior to the exit conference on 8/9/19. 3. Resident #50 was administered a crushed medication that should not have been crushed. Resident #50 was admitted to the facility on [DATE]. Resident #50's [DIAGNOSES REDACTED]. Resident #50's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 6/15/19 assessed the resident with a BIMS (brief interview for mental status) score of 7 out of 15; this assessment also documented the resident's urinary continence as always incontinent. On 8/8/19 at 7:45 a.m., LPN (licensed practical nurse) #11 was observed administering Resident #50's medication. One of the medications that was crushed before it was administered to Resident #50 was [MEDICATION NAME] 5mg. Resident #50's clinical record included the following medication order: [MEDICATION NAME] Chloride ER Tablet Extended Release 24 hours 5 MG Give 5 mg by mouth one time a day for Bladder Spasms DO NOT CRUSH. On 8/8/19 at 8:25 a.m., LPN #11 was interviewed about which of Resident #50's medication he/she had crushed. LPN #11 reported he/she had crushed all the observed medications except the potassium. On 8/8/19 at 8:35 a.m., the facility's Director of Nursing (DON) was interviewed about Resident #50 having his/her [MEDICATION NAME] crushed prior to administration. The DON reviewed Resident #50's orders then confirmed the [MEDICATION NAME] should not have been crushed. The observation of Resident #50 being administered a crushed medication that should not have been crushed was discussed during a survey team meeting with the facility's administrative team on 8/8/19 at 4:05 p.m.; the facility's administrative team at this meeting included the Administrator, the DON, the Regional Director of Clinical Services, and the Regional Vice-President of Operations.

Based on observation, staff interview and clinical record review the facility staff failed to review and revise a comprehensive care plan for 1 of 27 residents, Resident #40. The findings included: For Resident # 40 the facility staff failed to revise a care plan for skin breakdown. Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/31/19 assigned the resident a BIMS (brief interview for mental status) score of 12 out of 15 in section C, cognitive status. Surveyor observed Resident #40 on 08/07/19 at approximately 8:45. The resident did not have skin-sleeves on either arms or legs at this time. Resident #40's clinical record was reviewed on 08/08/19. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Resident #40's comprehensive care plan was reviewed and contained a care plan for at risk for skin breakdown related to: decreased mobility, weakness, med use, wears geri-legs (skin sleeves) per Resident request. Interventions for this care plan included geri-legs and geri-sleeves to all extremities for protection of skin from bumping into objects. Surveyor observed Resident #40 again on 08/08/19 at approximately 1:40. The resident did not have skin-sleeves on either arms or legs at this time. Surveyor observed a bandage to left elbow and two bandages to left lower leg.the Surveyor spoke with LPN #2 on 08/08/19 at approximately 3:35 PM regarding Resident #40's comprehensive care plan. Surveyor asked LPN #2 if the intervention for geri-sleeves should be on the care plan, and LPN #2 stated that it should have been removed when the care plan was updated. The concern of not reviewing/revising the resident's care plan was discussed with the administrative team (administrator, director of nursing, regional nurse consultant, and regional vice-president of operations) during a meeting on 08/08/19 at approximately 4:00 PM. No further information was provided prior to exit.