Every finding on record at Wallace Rehabilitation and Healthcare Center

Based on record review, observations and staff interviews, the facility failed to place signage indicating oxygen was in use outside resident rooms for 2 of 3 residents reviewed for oxygen use (Resident #228 and Resident # 69). Findings included: 1. Resident #69 was admitted to the facility on [DATE], and diagnoses included congestive heart failure. Resident #69 was discharged from the facility on 1/27/2024 to the hospital and was readmitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 was cognitively intact, was not experiencing shortness of breath and was not receiving oxygen therapy. Physician orders dated 1/8/2024 included an order for oxygen at 2 liters per minute via nasal cannula as needed to keep oxygen saturations greater than 90%. On 2/1/2024, Resident #69's re-admission physician orders included oxygen at 2 liters per minute via nasal cannula continuously every shift for congestive heart failure and hypoxia (low oxygen in the blood). A physician note dated 2/2/2024 recorded Resident #69 was still requiring oxygen therapy, and Resident #69 was receiving oxygen via nasal cannula. On 2/5/2024 at 2:40 p.m., Resident #69 was observed wearing oxygen via nasal cannula at 2 liters per minute. There was no warning signage observed indicating oxygen was in use located outside the room or on the door frame. On 2/6/2024 at 8:28 a.m., there was no warning signage observed indicating oxygen was in use located outside the room or on the door frame. On 2/6/2023 at 2:16 p.m. in an interview with Unit Nurse Manager #1 and Unit Nurse Manager #2 (the assigned nurse on re-admission), Unit Nurse Manager #2 stated after reviewing Resident #69's electronic medical record, she could not positively say Resident #69 was using oxygen when readmitted to the facility. Unit Nurse Manager #1 explained based on the hospital's discharge summary it was reported Resident #69 was using oxygen on arrival to the facility, and Resident #69 was to continue the use of oxygen until weaned off oxygen at the facility. Unit Nurse Manager #1 stated the facility used red Oxygen in Use. No Smoking magnetic signage outside the room on the door frames to communicate oxygen was in use in the room. She stated Resident #69 was using oxygen, and nursing staff was responsible for placing and checking that the Oxygen in Use. No Smoking warning signage was outside the room on the door frame. When asked why Resident #69 did not have warning signage indicating oxygen was in use outside the room, she stated the warning signage was magnetic and could have gotten knocked off the door frame. On 2/7/2024 at 8:57 a.m. in an interview with the Director of Nursing, she stated Resident #69 should have an Oxygen in Use. No Smoking warning signage outside the room on the door frame due to receiving oxygen, and nursing staff were responsible for placing the warning signage outside the room on the door frame. She further stated checking the use of oxygen and ensuring placement of the warning signage on the door frame was a task for the nursing staff to observe for compliance when completing daily rounds on residents in the facility. She stated she did not have an explanation why a warning signage was not on Resident #69's door frame when observed on 2/5/2024 and 2/6/2024 and reported there were ambulatory confused residents on the hall where Resident #69 resided that would remove items off the walls and door frames at times. 2. Resident #228 was admitted to the facility on [DATE], and diagnoses included chronic obstructive pulmonary disease (COPD) and pneumonia. Physician orders dated 1/20/2024 included oxygen via nasal cannula at 2 liters per minute to keep oxygen saturation greater than 91% as needed due to pneumonia. Resident #228's care plan dated 1/20/2024 indicated Resident #228 was receiving oxygen therapy for a respiratory illness. Interventions included humified oxygen set at 2 liters per minute via nasal cannula continuously. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #228 was cognitively intact and was receiving oxygen therapy. Nursing documentation dated 2/5/2024 recorded Resident #228 was using oxygen. On 2/5/2024 at 10:45 a.m., Resident #228 was observed receiving oxygen at 2 liters per minute via nasal cannula. There was no warning signage that oxygen was in use observed outside Resident #228's room on the door frame. On 2/6/2024 at 8:30 a.m. there was no warning signage reporting oxygen was in use observed outside Resident #228's room on the door frame. In an interview with Unit Nurse Manager #1 on 2/7/2024, she stated after completing an interview on 2/6/2023 at 2:16 p.m. related to oxygen and the use of warning signage, she asked other unit managers to assist her in conducting rounds to check to ensure residents receiving oxygen had a warning signage, Oxygen in Use. No Smoking, outside the room on the door frame. She stated she recalled at some point Resident #228 having the warning signage, Oxygen in Use. No Smoking outside the room on the door frame and didn't know why the warning signage was not on the door frame on 2/5/2024 and 2/.6/2024. She explained unit nurse managers tried to check that the magnetic warning signage was outside the room on the door frame when completing daily rounds on the residents and explained sometimes unit nurse managers were pulled to complete other tasks which interrupted them from completing rounds on the residents. In an interview with Unit Nurse Manager #3 on 2/7/2024, she stated on 2/6/2024, after an initial interview with Unit Nurse Manager #1 on 2/6/2024 at 2:16 p.m. about oxygen warning signage, she completed rounds on Resident #228 and placed the warning signage, Oxygen in Use. No Smoking outside Resident #228's room on the door frame. On 2/7/2024 at 8:57 a.m. in an interview with the Director of Nursing, she stated Resident #228 should have an Oxygen in Use. No Smoking warning signage outside the room on the door frame due to receiving oxygen, and nursing staff were responsible for placing the warning signage outside the room on the door frame. She further stated checking the use of oxygen and ensuring placement of the warning signage on the door frame was a task for the nursing staff to observe for compliance when completing daily rounds on residents in the facility. She stated she did not have an explanation why a warning signage was not on Resident #69's door frame when observed on 2/5/2024 and 2/6/2024 and reported there were ambulatory confused residents on the hall where Resident #69 resided that would remove items off the walls and door frames at times.

Based on observations, resident and staff interviews, the facility failed to display survey results in a location accessible to residents during 3 of 3 observations of the facility. Findings included: During a tour of the facility on 2/5/24 at 9:45 AM, the survey results were not located in the building. An observation of the front lobby revealed a desk area near the entrance. On the desk there was a visitor sign in book, a red plastic bin that contained facemasks, and written information about infection control. Tours of the facility on 2/5/24 at 2:36 PM and 2/6/24 at 1:00 PM revealed the survey results were not located in the building. A Resident Council group meeting was conducted on 2/6/24 at 2:00 PM. During the meeting, the residents indicated they did not know where the survey results were located. The Resident Council President shared she had been at the facility for a year and did not know the location of the survey results. Resident #60 stated she also did not know the location of the survey results book. An interview was completed with the Receptionist on 2/6/24 at 2:21 PM. He explained the survey results book was located behind his desk. The book was not visible when a resident or visitor faced the front of the receptionist's desk. The Receptionist said the book had been on his desk 2/5/24 and 2/6/24. He thought someone may have updated the survey results book and placed it on the desk instead of on the coffee table in the front lobby area where it was usually kept for residents/visitors. In an interview with the Director of Nursing (DON) on 2/06/24 at 2:43 PM, she explained the survey book was typically on the coffee table in the front lobby. She said there was a sign posted on a cabinet in the activities room/office that identified the location of the survey results. She said the activities room/office was unlocked 24 hours a day. The DON stated there was also a sign on the desk in the front lobby area where visitors signed in that identified the location of the survey results. During the interview, an observation of the desk with the DON revealed the sign had been covered up by a red plastic bin that contained facemasks. On 2/08/24 at 1:09 PM an interview was conducted with the Administrator. She said the survey results book was always on the bottom shelf of the coffee table in the front lobby. The Administrator stated she was unsure if in the hustle and bustle of the survey process, the Receptionist moved it from the coffee table.

Based on observations and resident and staff interviews, the facility failed to maintain walls in good repair in 4 of 8 rooms (Rooms 203-2, 207-1, 207-2, 214-1, and 215-1) on the 200 hallway. Findings included: a. During tours of room [ROOM NUMBER]-2 on 2/5/24 at 11:30 AM and 2/7/24 at 1:30 PM, an observation revealed scratches on the wall and missing paint behind the resident's bed. An interview was conducted with the resident in room [ROOM NUMBER]-2 on 2/8/24 at 10:48 AM. She stated she had resided in her room for 1 1/2 years and the wall behind her bed had always been scratched with missing paint. She shared she would like for the wall to be patched and repainted. b. During tours of room [ROOM NUMBER]-1 on 2/5/24 at 11:11 AM and 2/7/24 at 1:33 PM, an observation revealed scratches on the wall and missing paint behind the resident's bed. An interview was conducted with the resident in room [ROOM NUMBER]-1 on 2/5/24 at 11:12 AM. He acknowledged there were scratches on the wall behind his bed and said, Every room has them. c. During tours of room [ROOM NUMBER]-2 on 2/5/24 at 11:02 AM and 2/7/24 at 1:34 PM, an observation revealed scratches on the wall and missing paint behind the resident's bed. An interview was conducted with the resident in room [ROOM NUMBER]-2 on 2/5/24 at 11:03 AM. He stated the scratches on the wall had been there since he resided in the room (about 3 years). He said he had not told any of the facility staff about the scratches on the wall. d. During tours of room [ROOM NUMBER]-1 on 2/5/24 at 11:23 AM and 2/7/24 at 1:34 PM, an observation revealed gouges in the wall and exposed sheetrock behind the resident's bed. e. During tours of room [ROOM NUMBER]-1 on 2/5/24 at 3:02 PM and 2/7/24 at 1:35 PM, an observation revealed scratches on the wall and missing paint behind the resident's bed. The Maintenance Director was interviewed on 2/08/24 at 10:20 AM. He explained there was a clipboard at the nurse's station where staff wrote down repair issues that needed to be addressed and he checked the clipboard throughout the day. He added staff also called or texted him with repair needs. The Maintenance Director shared he walked through the building daily and if he saw something that needed to be repaired, he took care of it. He stated he had not routinely audited rooms for repairs. He said he was currently working on installing wall boards behind residents' beds. He did not have a specific schedule for when the wall boards would be installed, rather, he did them as he got to them. He said he was the only maintenance employee and had worked on installing the wall boards for the past six months. A tour of rooms 203-2, 207-1, 207-2, 214-1 and 215-1 was conducted with the Maintenance Director and Administrator on 2/8/24 at 10:30 AM. The Maintenance Director explained the scratches/gouges in the walls were from the beds hitting the walls which then removed the paint from the walls. The Administrator verified the walls should be repaired so that each resident's room maintained a homelike environment. In an interview with the [NAME] President of Clinical Operations on 2/08/24 at 11:00 AM, she explained that on 1/3/24 rooms 203, 207, 214 and 215 had been noted in the computer system that repairs were needed. She added some of the walls were chronic issues where the bed was moved so staff could operate a mechanical lift and subsequently scratched the wall. On 2/08/24 at 11:40 AM, observations of rooms 203, 207, 214 and 215 were conducted with Medication Aide #1. In an interview with Medication Aide #1 on 2/8/24 at 11:42, she shared the scratches on the wall behind the bed of room [ROOM NUMBER]-2 been there for at least the last few months. She further stated the walls in rooms [ROOM NUMBER] had been scratched/gouged for at least the last two months. She said the scratches on the wall came from the bed being pushed up against the wall. A follow up interview was conducted with the [NAME] President of Clinical Operations and the Maintenance Director on 2/08/24 at 11:46 AM. The [NAME] President said the facility had sent environmental room audits weekly to the corporate office. She explained each time the audit was completed, the facility reiterated to the corporate office that a work order needed to be approved for an outside contractor to come in and repair the walls. She said the facility had sent 4-6 work order notices to the corporate office regarding wall repair. The Maintenance Director added if it were just paint issues, he could install a wall board, but if there were gouges, the wall needed to be repaired first before it could be painted.

Based on staff interview and record review, the facility Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor these interventions the committee put into place following the 04/14/2021 recertification survey. This was for a recited deficiency in the area of infection control. This deficiency was cited again on the current recertification survey. The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F880 - Based on record review, observation and staff interviews, the facility failed to ensure staff followed the facility's infection control procedures by not performing hand hygiene when donning and doffing Personal Protective Equipment (gloves) during wound care for 1 of 1 resident observed for pressure ulcer wound care (Resident #60). During the recertification survey of 04/14/21, the facility was cited F880 Infection Control for failure to ensure staff wore Personal Protective Equipment (face masks) correctly while working in the facility. During an interview with the Administrator on 09/23/22 at 2:26 p.m., the Administrator indicated the QAA Committee meets on the last Friday of every month and the Director of Nursing and the Infection Control are included in attendance.

Based on record review, observation and staff interviews, the facility failed to ensure staff followed the facility's infection control procedures by not performing hand hygiene when donning and doffing Personal Protective Equipment (gloves) during wound care for 1 of 1 resident observed for pressure ulcer wound care (Resident #60). The findings included: Review of the facility's Infection Control: Hand Hygiene policy, released January 2022, read in part, Effective hand hygiene reduces the incidence of healthcare associated infections . B. Indications for Hand Hygiene Using Alcohol-based Hand Sanitizer include: #7 Before donning gloves; #8 After removing gloves . An observation of Resident #60's wound care was conducted on 09/22/22 at 9:42 a.m. Nurse #1 administered the wound care to the resident's left buttock area, assisted by Nursing Assistant (NA) #1; also in attendance was the facility's wound care medical doctor who assessed Resident #60s wound once the soiled dressing had been removed. Upon the start of the wound care, Nurse #1 washed her hands and donned gloves and set up wound care supplies on the covered overbed table. Nurse #1 removed the soiled dressing from the resident and disposed the soiled dressing. Nurse #1 then doffed her gloves and donned clean gloves. Nurse #1 then cleansed the wound. At 9:46 a.m., Nurse #1 doffed her gloves and donned clean gloves and did not wash her hands in between the glove change. Nurse #1 applied a petroleum dressing over wound. At 9:47 a.m., doffed her gloves and donned clean gloves, did not washing her hands and applied additional petroleum dressings to the wound bed. At 9:48 a.m., Nurse #1 doffed her gloves and donned clean gloves and did not wash her hands. At 9:51 a.m., Nurse #1 doffed her gloves and donned clean gloves, did not wash her hands, and cleared the overbed table of wound care supplies, sanitized her bandage scissors with an alcohol wipe, doffed her gloves and then went into the bathroom located in the resident's room and washed her hands. During an interview with Nurse #1 on 09/22/22 at 10:05 a.m., Nurse #1 was asked what she should do after doffing and before donning gloves and she did not answer. After prompting if she should have washed her hands after doffing and before donning clean gloves during the wound care procedure, Nurse #1 stated no and explained she had followed the new company's policy which she kept on a clipboard located on her treatment cart and proceeded to show this surveyor the policy. The worksheet Nurse #1 produced was a piece of paper with a check-list on it which was titled 16. Wound Dressing Change Observation. There was no author listed and no created/revised date noted on this worksheet. Nurse #1 referred to the third column on the worksheet which heading read as Hand Hygiene before and after dressing change and to the fourth column which heading read as Clean gloves donned before and doffed after dressing change. Nurse #1 further explained because of these instructions, she only had washed her hands before beginning the wound care and after the wound care was completed. A second interview with Nurse #1 was conducted on 09/22/22 at 10:20 a.m., at her request. Nurse #1 stated she knew she was supposed to wash her hands before donning and after doffing gloves and had become distracted while she provided wound care and had forgotten to do so. An interview was conducted with the Administrator on 09/22/22 at 1:27 p.m. When asked why she thought Nurse #1 did not wash her hands after doffing the soiled gloves and before donning the clean gloves, the Administrator thought Nurse #1 had become distracted during the wound care observation secondary to being observed by a surveyor, a medical doctor, a nursing assistant and the resident. The Administrator explained staff education regarding hand hygiene had already begun and stated the following week a public health nurse from the North Carolina Department of Health & Human Services, Division of Public Health, would be in the facility to monitor handwashing techniques by the staff. The Administrator stated it was her expectation the staff follow facility policy and procedure for handwashing when donning and doffing gloves.

Based on observation, staff interviews, and record reviews, the facility staff failed to ensure one of one staff members (Dietary Aide #2) wore their facial covering over their mouth and nose while working in the facility and one of one staff members (Dietary Aide #1) wore a cloth mask not authorized by the facility. The failures occurred during a COVID-19 pandemic. Findings included: 1. Facility records indicated an in-service was conducted on 03/09/21. The in-service was provided to all staff members/departments and educated staff on use of Personal Protective Equipment (PPE). Another in-service was also conducted on 03/31/21 on the use of N95 and face shields. During the initial tour of the kitchen on 04/05/21, Dietary Aide #1 (DA#1) was observed wearing a cloth mask. During an interview with Dietary Aide #1 on 04/05/21 at 8:02 AM, she explained she could wear the mask and would disinfect it at home and bring it back. She stated she only used it at work. On 04/05/21 at 9:00 AM during re-entry to the kitchen, Dietary Aide #1 had changed to a N95 face mask. During an interview with the Dietary Manager (DM) on 04/05/21 at 9:01 AM, the Dietary Manager stated he monitored his employees daily for proper personal protection equipment. He explained he corrected DA#1 when he arrived because the cloth mask was not acceptable for staff working in the facility. She now had on a N95 face mask. He stated he would review mask coverings with all his staff again. During an interview with the Director of Nursing (DON) on 04/06/21 at 1:52 PM, she explained the facility was allowing the surgical mask for all staff throughout the building unless you were on the quarantine hall. The quarantine hall staff would use a N95 mask and a face shield for care of those residents. She explained cloth masks were not permitted or allowed for any staff in the facility. She explained they receive their guidance from their corporate office, the Center for Disease Control, and the County Public Health Department. During an interview with the Infection Control Nurse (ICN) on 04/06/21 at 4:01 PM she stated all staff were trained on how to don and doff Personal Protective Equipment (PPE), including placing the facemask over their mouth and nose. She stated all staff in the facility should have on the surgical mask at a minimal. She stated the cloth mask worn by the Dietary Aide was not acceptable. She continued and stated the staff assigned to the quarantine unit would be wearing a N95 and a face shield along with their full PPEs. She added staff were monitored daily regarding PPE usage. The ICN expressed the facility were following the guidelines and recommendations of the Center for Disease Control for Nursing Homes and the county public health guidance. During an interview with the Administrator on 04/06/21 at 4:21 PM, the Administrator stated they take the infection control protocols seriously and she knew all staff were trained and knew the importance of wearing PPE properly. 2. During an observation in the hallway by the conference room on 04/05/21 at 8:10 AM, Dietary Aide #2 (DA#2) was observed pushing the dietary cart to the resident hall with her surgical face mask covering only her mouth - her nose was not covered. During an interview with DA#2 on 04/05/21 at 8:24 AM she explained the mask slips down sometimes and she forgets to pull it back up. She stated she was trained to make sure it covers her mouth and nose but had forgot to pull it up. During an interview with the Dietary Manager (DM) on 04/05/21 at 9:01 AM, the Dietary Manager stated he monitored his employees daily for proper personal protection equipment and DA#2 knew she was supposed to wear her facemask over her nose and her mouth at all the times. He stated he would review mask coverings with all his staff again. During an interview with the Director of Nursing (DON) on 04/06/21 at 1:52 PM, she explained the facility was allowing the surgical mask for all staff throughout the building unless you were on the quarantine hall. The quarantine hall staff would use a N95 mask and a face shield for care of those residents. She explained cloth masks were not permitted or allowed for any staff in the facility. She explained they receive their guidance from their corporate office, the Center for Disease Control, and the County Public Health Department. During an interview with the Infection Control Nurse (ICN) on 04/06/21 at 4:01 PM she stated all staff were trained on how to don and doff Personal Protective Equipment (PPE), including placing the facemask over their noses. She stated all staff in the facility should have on the surgical mask at a minimal. She continued and stated the staff assigned to the quarantine unit would be wearing a N95 and a face shield along with their full PPEs. She added staff were monitored daily regarding PPE usage. The ICN expressed the facility were following the guidelines and recommendations of the Center for Disease Control for Nursing Homes and the county public health guidance. During an interview with the Administrator on 04/06/21 at 4:21 PM, the Administrator stated they take the infection control protocols seriously and she knew all staff were trained and knew the importance of wearing PPE properly.

Based on observations, record review, staff and Pharmacy Consultants interviews the facility failed to ensure it was free of medication error rates greater than 5% as evidenced by 2 medication errors out of 31 opportunities, resulting in a medication error rate of 6.45% for 2 of 5 sampled residents observed during medication administration. (Resident #47 and Resident #6) Findings included: 1. Resident #47 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] had Resident #47 coded as moderately cognitively impaired needing limited assistance with her activities of daily living (ADL). The care plan dated 01/27/2021 had focus' of ADL self-care performance deficit related to (r/t) Confusion, Fatigue, sometimes, she did not want to bathe, go to activities, take medications, or change clothes, has impaired cognitive function or impaired thought processes r/t Dementia. The facility's medication administration procedures dated June 2008 read in part: Observe that the resident swallows' oral drugs. Do not leave medications with the resident to self-administer unless the resident is approved for self-administration of the medication. The April 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of a medication administration for Resident #47 on 04/07/2021 at 8:26 AM, Resident #47 was in her room sitting in her chair by her bed. Nurse #1 entered the resident's room to administer morning medications which included [MEDICATION(S)] in 8 ounces of water. She explained what medications she was administering and informed Resident #47 there was [MEDICATION(S)] in the cup on her table. Resident #47 took the medication in the small cup and reached for her [MEDICATION(S)]. Resident #47 took several sips and put the cup down with ¾ of the medication left in the cup. Nurse #1 also told Resident #47 she did not have to finish the whole thing now and left the room. During an interview with Nurse #1 on 04/07/2021 at 8:28 AM, Nurse #1 stated Resident #47 likes to sip on her [MEDICATION(S)] and moved on to another resident to begin another medication administration. During a telephone interview with the Pharmacy Consultant (PC) on 04/08/2021 at 9:39 AM, the PC stated medication was supposed to be completely administered before the nurse left the room and should never be left with the resident. During a telephone interview with the Director of Nursing (DON) on 04/08/2021 at 11:14 AM, the DON stated Resident #47 had not been assessed to self-administer medications. The DON also stated she expected that all medications are administered before leaving a resident's room and they are not to be left with the resident to finish on their own. During a telephone interview with the Administrator on 04/08/2021 at 3:15 PM, the Administrator stated her expectations were for staff to follow all policies and procedures related to medication administration. 2. Resident #6 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6 was coded as severely cognitively impaired and needed extensive assistance with his activities of daily living (ADL). He was also coded for [MEDICATION(S)]/IV feeding and Feeding tube - nasogastric or abdominal (PEG). The care plan dated 01/14/2021 had focus' of ADL self-care performance deficit related to (r/t) Stroke and Immobility. He has Altered Gastrointestinal (GI) function r/t Dysphagia as evidenced by nothing by mouth status with enteral feeding to meet nutrition nutrition/hydration needs. The facilities procedures for enteral tube drug instillation with revised date of May 15, 2020 read in part: Discuss any unresolved concerns with the resident's practitioner. Consult the pharmacist to determine the safest dosage form of the drug to administer, if needed. Crush simple compressed tablets to a fine powder using a mortar and pestle or other pill-crushing device and mixing with purified water. The 03/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of a percutaneous endoscopic gastrostomy (PEG) tube medication administration for Resident #6 on 04/07/2021 at 9:41 AM, Nurse #1 was observed crushing Resident #6's medications individually. Nurse #1 put a Calcium (600 MG)/Vitamin D3 (10 MCG/ 400 IU) tablet in a plastic envelope and crushed the medication using a pill crusher. The medication was not fully crushed, and pieces of the pill were sticking out of the crushed medication. Nurse #1 took a spoon and scooped out medication that was not crushed and decarded it in the trash. Nurse #1 finished preparing all the medications and administered them to Resident #6. During an interview with Nurse #1 on 04/07/2021 at 9:44 AM, Nurse #1 stated she knows that may have been a mistake, but she scoops out the pieces of medication that did not crush and throws it out because she didn't want to clog Resident #6's tubing. Nurse #1 also stated she could have also put it in warm water to dissolve it but didn't. Nurse #1 further stated she did not report that the medication is hard to crush to anyone. During a telephone interview with the Pharmacy Consultant (PC) on 04/08/2021 at 9:39 AM, the PC stated if the medication was difficult to crush and if she knew about it, she could have changed the order to a liquid form. The medication could have been dissolved in warm water and it would have been able to be administered without clogging the tubing. The PC also stated she would expect a call regarding the medication, and it should have been reported, but parts of a residents medication should never be discarded because they are expected to receive the full dosage of a medication. During a telephone interview with the Director of Nursing (DON) on 04/08/2021 at 11:14 AM, the DON stated she did not expect any amount of medication to be discarded because it was hard to crush. Residents are expected to receive their full dosages of medication. The medication should have been dissolved in warm water and the issue should have been reported. During a telephone interview with the Administrator 04/08/2021 at 3:15 PM, the Administrator stated her expectations were for staff to follow all policies and procedures related to medication administration.

Based on observation, record review, staff and resident interviews the facility failed to provide dressing changes according physician's order for a bilateral lower extremity (BLE) and a left lower extremity (LLE) Venous Ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident #50). Findings included: Resident #50 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] had Resident #50 coded as cognitively intact needed limited assistance with activities of daily living (ADL). The MDS also showed Resident #50 had a venous ulcer. The care plan dated 03/11/2021 had focus' of a venous stasis ulcer of the left lower extremity (LLE) related to (r/t) CHF and PVD with interventions to include documentation of the location of wound, amount of drainage, peri-wound area, pain, [CONDITION(S)], and circumference measurements weekly, evaluate wound for: size, depth, margins, peri-wound skin, sinuses, undermining, exudates, [CONDITION(S)], granulation, infection, necrosis, eschar and gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated, give medications as ordered for pain, observe/document/report as needed (PRN) for signs and symptoms (s/s) of infection: green drainage, foul odor, redness and swelling, red lines coming from the wound, excessive pain, fever, refer to therapy prn and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. The Treatment Administration Record (TAR) dated 01/2020 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was dated 01/03/2020 and there were missed dates on 01/17/2020, 01/24/2020 and 01/27/2020. The order was discontinued 01/30/2020. The TAR dated 02/2020 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was dated 02/10/2020 and there was a missed date on 02/14/2020. The order was discontinued 03/03/2020. The TAR dated 03/2020 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was dated 03/03/2020 and there were missed dates on 03/16/2020, 03/23/2020 and 03/30/2020. The order was discontinued 05/12/2020. The TAR dated 04/2020 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was dated 03/03/2020 and there were missed dates on 04/06/2020, 04/13/2020 and 04/20/2020. The order was discontinued 05/12/2020. The TAR dated 05/2020 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was dated 03/03/2020 and there was a missed date on 05/04/2020. The order was discontinued 05/12/2020. The TAR dated 05/2020 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was dated 05/12/2020 and there was missed dates on 05/15/2020, 05/18/2020, 05/22/2020 and 05/27/2020. The TAR dated 06/2020 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was dated 05/12/2020 and there was missed dates on 06/01/2020, 06/03/2020, 06/05/2020, 06/10/2020, 06/12/2020, 06/15/2020 and 06/29/2020. The TAR dated 07/2020 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was dated 05/12/2020 and there was missed dates on 07/03/2020 and 07/17/2020. The TAR dated 08/2020 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was dated 05/12/2020 and there was missed dates on 08/10/2020 and 08/28/2020. The order was discontinued 08/28/2020. The TAR dated 09/2020 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was dated 08/31/2020 and there was a missed date on 09/04/2020. The TAR dated 11/2020 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a missed date on 11/30/2020. The TAR dated 12/2020 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a missed date on 12/23/2020. The TAR dated 01/2021 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There were missed dates on 01/01/2021, and 01/11/2021. During an observation of Resident #50 on 04/05/2021 at 8:38 AM, Resident #50 was sitting in his wheelchair and his BLE were not wrapped. During an observation of Resident #50 on 04/05/2021 at 4:48 PM, resident did not have Una boot applied to his LLE. During an observation of Resident #50 on 04/06/2021 at 9:27 AM, resident was in wheelchair and had Unna boot to LLE he stated it was done at 7:00 PM 04/05/2021 on 3-11 shift. During an interview with Resident #50 on 04/05/2021 at 8:38 AM, Resident #50 stated his Unna boot was removed with his morning bath and would be replaced soon. Resident #50 also stated there had been times when the facility had missed his treatments and he did not mention it to staff because he knew they were busy and he figured they will get to it when they get to it. Resident #50 further stated the areas to his lower legs have gotten better over time. During an interview with the Treatment Nurse (TN) on 04/06/2021 at 3:44 PM, the TN stated if she was called to the floor and she was working the floor the nurses were supposed to do the treatments but she did her treatments when she worked as a treatment nurse. During an interview with Nurse #1 on 04/06/2021 at 8:19 AM, Nurse #1 stated she had Resident #50 on 01/01 and 01/11/2021 and she did do his treatments but didn't document it because she was used to the treatment nurse doing them. During an interview with the Administrator on 04/06/2021 at 4:20 PM, the Administrator stated she expects nursing staff to follow the orders from the Physicians. During a telephone interview with the Director of Nursing (DON) on 04/07/2021 at 3:07 PM, the DON stated Nurse #1 stated she did do the treatments that were missing for Resident #50 on 01/1/2021 and 01/11/2021. The DON also stated she was not aware of the other missing treatments and her expectations are for the nursing staff to administer treatments and document them when they are done as ordered on the TAR.

Based on staff interviews and record review, the facility failed to provide written responses to grievances for 1 (Resident #20) of 3 residents reviewed for grievances. Findings included: Record review revealed Resident #20 was last admitted [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #20 was cognitively intact and required extensive assistance for her activities of daily living (ADLs). Record review of grievances indicated Resident #20's family member filed a written grievance on 10/29/20. The grievance was investigated by the Receptionist. The Administrator completed the follow up on 11/03/20. The grievance form listed the grievance as resolved on 10/29/2020 and indicated the investigation findings were reported to the family member on 10/29/20. There was no evidence of a written response/summary provided to the family member who filed the grievance. Record review of grievances indicated Resident #20's family member filed a written grievance on 12/23/20. The grievance was investigated by the Director of Nursing. The Administrator completed the follow up on 12/24/20. The grievance form listed the grievance as resolved on 12/24/2020 and indicated the investigation findings were reported to the family member on 12/24/20. There was no evidence of a written response/summary provided to the family member who filed the grievance. Record review of grievances indicated Resident #20's family member filed a written grievance on 01/18/21. The grievance was investigated on 01/20/21 by the Administrator. The grievance form listed the grievance as resolved on 01/20/2021 and indicated the investigation findings were reported to the family member on 01/20/21. There was no evidence of a written response/summary provided to the family member who filed the grievance. Record review of grievances indicated Resident #20's family member filed a written grievance on 04/01/2021. The grievance was investigated by the Administrator on 04/01/2021. The grievance form listed the grievance as resolved on 04/01/2021 and indicated the investigation findings were reported to the family member on 04/01/21. The documentation revealed the grievance was completed by the Administrator. There was no evidence of a written response/summary provided to the family member who filed the grievance. An interview was conducted with the Administrator and the District Director of Clinical Services on 04/07/2021 at 11:38 AM. The Administrator revealed the grievances were resolved and indicated the investigation findings were reported to the family member verbally, but no written summary/documentation had been provided. The Administrator revealed it had been brought to her attention by her corporate official that there needed to be written documentation to the family members who initiated the grievance. In an interview on 04/07/2021 at 2:17 PM, the Administrator stated the added comments at the bottom of all the forms was updated. She explained she annotated the updates after calling each of the family members. She explained she would provide written letters to the family in the future and maintain a copy in the records. In a telephone interview on 04/07/21 at 2:26 PM with Family Member #1, she revealed she had not received a written summary from the facility regarding grievances submitted on 10/29/20, 01/20/21, and 04/01/21. She stated a woman from the facility had called her earlier the morning of 04/07/21 to ask if she wanted a copy of the written summary for her grievances.

Based on observation, record review, staff and resident interviews the facility failed to maintain dignity by failing to knock on doors or ask permission to enter for 3 of 6 residents (Resident #32, Resident #26 and Resident #33). Findings included: 1. Resident #32 was admitted to the facility on [DATE]. The most recent quarterly Minimum Data Set (MDS) dated [DATE] had Resident #32 coded as moderately cognitively impaired with the ability to express his ideas and wants. During an observation of the 300 Hall breakfast pass on 04/05/2021 at 8:19 AM, NA #1 was seen walking into Resident #32's room with a food tray without knocking and waiting to enter. During an interview with NA #1 on 04/06/2021 at 8:36 AM, NA #1 stated she knows she was supposed to knock on the resident's doors and wait to be told to come in before entering their rooms. NA #1 also stated she didn't know why she did not do it. During an interview with Resident #32 on 04/06/2021 at 8:39 AM, the Resident stated that he would expect staff to knock on the door before coming into his room. During an interview with the Administrator on 04/06/2021 at 4:20 PM, the Administrator stated she expects the staff to knock and wait to get permission to enter all resident's rooms. During a telephone interview with the Director of Nursing (DON) on 04/08/2021 at 10:33 AM, the DON stated she had a meeting with the 3-11 shift staff on 04/07/2021 and asked, What should you do before entering a residents room and everyone stated, Knock on the door before entering, so they all know that it is expected of them to knock before entering a residents room. 2. Resident #26 was admitted to the facility on [DATE]. The most recent annual Minimum Data Set (MDS) dated [DATE] had Resident #26 coded as cognitively intact. During an observation of the 300 Hall breakfast pass on 04/05/2021 at 8:23 AM, NA #1 was seen walking into Resident #26's room with a food tray without knocking and waiting to be invited in. During an interview with NA #1 on 04/06/2021 at 8:36 AM, NA #1 stated she knows she was supposed to knock on the resident's doors and wait to be told to come in before entering their rooms. NA #1 also stated she didn't know why she did not do it. During an interview with Resident #26 on 04/06/2021 at 8:39 AM, the Resident stated that he would expect staff to knock on the door before entering his room. During an interview with the Administrator on 04/06/2021 at 4:20 PM, the Administrator stated she expects the staff to knock and wait to get permission to enter all resident's rooms. During a telephone interview with the Director of Nursing (DON) on 04/08/2021 at 10:33 AM, the DON stated she had a meeting with the 3-11 shift staff on 04/07/2021 and asked, What should you do before entering a residents room and everyone stated, knock on the door before entering, so they know that it is expected of them to knock before entering a residents room. 3. Resident #33 was admitted to the facility on [DATE]. The most recent quarterly Minimum Data Set (MDS) dated [DATE] had Resident #33 coded as severely cognitively impaired. During an observation of the 300 Hall breakfast pass on 04/05/2021 at 8:25 AM, NA#1 was seen walking into Resident #33's room with a food tray without knocking and waiting to be invited in. During an interview with NA #1 on 04/06/2021 at 8:36 AM, NA #1 stated she knew she was supposed to knock on the resident's doors and wait to be told to come in before entering their rooms. NA #1 also stated she didn't know why she did not do it. During an interview with the Administrator on 04/06/2021 at 4:20 PM, the Administrator stated she expects the staff to knock and wait to get permission to enter all resident's rooms. During a telephone interview with the Director of Nursing (DON) on 04/0/2021 at 10:33 AM, the DON stated she had a meeting with the 3-11 shift staff on 04/07/2021 and asked, What should you do before entering a residents room and everyone stated, knock on the door before entering, so they know that it is expected of them to knock before entering a residents room.

Based on record reviews, observations, Nurse Practitioner interview, staff interviews and contracted van transportation staff interviews, the facility failed to ensure the lift platform of the contracted transportation company's van was in the elevated position before unloading a resident from the van for 1 of 3 sampled residents reviewed for accidents (Resident #2). When unloading Resident #2, who was seated in a wheelchair and on anticoagulant medication, from the transportation van the van driver failed to raise the van's lift platform to the level of the van floor which resulted in Resident #2 falling backwards from the van onto the ground. Resident #2 was transported to the hospital for evaluation and treatment and sustained a contusion to her scalp, abrasions to bilateral knees and skin tears on her bilateral upper extremities. The findings include: The manufacturer's operation notes and details for operation of the van's lift include, in part, it is the responsibility of the lift operator (attendant) to properly open, secure and close the vehicle lift door(s), to activate the vehicle interlock(s), to load and unload the wheelchair passenger on and off the lift platform, and to properly activate all lift functions. The operation notes indicated, the platform must be fully raised at floor level (the position (height) the platform assembly reaches for the wheelchair passenger to enter and exit the vehicle) and the bridge plate must be properly positioned when loading or unloading passengers in or out of the vehicle. It is the responsibility of the lift attendant to ensure the platform and the bridge plate are properly positioned at floor level with loading and unloading passengers. Resident #2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent quarterly Minimum Data Set ((MDS) dated [DATE], Resident #2's cognition was intact. The resident needed extensive assistance with transfers and required physical assistance of 2 persons. Resident #2 required the use of a wheelchair as a mobility device and received [MEDICAL TREATMENT] services and anticoagulant medication. Resident #2's Care Plan, reviewed by staff on 01/14/20, revealed the following: --Limited physical mobility related to deconditioning. Interventions included Resident #2 being totally dependent on 1 staff for locomotion using a wheelchair, initiated on 07/01/19. --High risk for falls related to previous falls. Interventions included staff to anticipate and meet Resident #2's needs, initiated on 11/04/19. --Anticoagulant therapy (blood thinning medication) related to [DIAGNOSES REDACTED]. An incident report completed by Nurse #1 on 01/15/20 at 3:45 p.m. revealed the nurse responded immediately to a report of Resident #2 having fallen outside of the facility, from a transportation van, upon returning from a doctor's appointment. The nurse documented the position of the resident on the ground and assessed her for injuries and range of motion. The incident report indicated the nurse provided treatment to the resident's bleeding abrasions and skin tears and applied an ice pack to the head injury. Nurse #1 explained the Nurse Practitioner (NP) was on scene and assessed the resident and ordered to send the resident to emergency room (ER) for further evaluation and treatment. The nurse documented notifications were made and 911 was called. Nurse #1 noted she and the NP stayed with resident until Emergency Medical Services (EMS) arrived. Nurse #1 documented the injuries observed at the time of incident and noted Resident #2 sustained a hematoma with open lesion to left temporal area, left cheek abrasion, left elbow skin tear, right hand and forearm skin tear, 2 abrasions on left knee and 1 abrasion on right knee. Nurse #1 also documented Resident #2 was alert and oriented, wheelchair-bound and rated her pain an 8 out of 10. During a telephone interview with Van Driver #1, on 03/12/20 at 9:41 a.m., she stated she worked for the facility's contracted transportation company and confirmed she was driver responsible for Resident #2's accident on 01/15/20. Van Driver #1 explained she arrived at the nursing home on 1/15/20 at around 3:25 p.m. and indicated she got out of the van, opened the van doors and opened the lift gait and then walked back into the van. Van Driver #1 explained when the liftgates are opened, they open to the floor level of the van and for the liftgate to be lowered to the ground a button would have to be pushed. She stated the only thing she remembered is opening the liftgate but for it to be in the down position she may have accidentally pushed the button to lower the liftgate. She further explained when she returned inside the van and while facing the resident in her wheelchair, she unhooked all the straps and belts from the resident's wheelchair and pushed the resident in her wheelchair backwards toward the van's liftgate, Van Driver #1 acknowledged by the time she realized what was happening, it was too late as the resident's wheelchair wheels had already started falling backwards off the van. She explained she grabbed the arm of the wheelchair in an attempt to stop it from falling but was unable to stop the resident from falling from the back of the van. She indicated she did not let go of the wheelchair and ended up being pulled out of the van as well by the weight of the resident and chair and landed another part of the lift gate. Van Driver #1 stated she did not know how the resident ended up falling on her face, but she assumed the wheelchair flipped during the fall. She confirmed she received retraining from her company after the accident which included safety, transporting and correctly loading and unloading passengers. During an interview with the facility's NP on 03/11/20 at 3:58 p.m., she explained she was informed by the Administrator Resident #2 had fallen off the transportation van on 01/15/20 and she and the treatment nurse went running outside to assess the resident. The NP stated upon arriving at the scene of the accident, Resident #2 had been lying face down on the ground and she immediately began assessing her and the resident was conscious with complaints of pain in her knees with noted bleeding on her arm and knees. She further explained Resident #2 had chronic ascites (the accumulation of fluid which causes abdominal swelling) which made it difficult for her to breathe and they needed to reposition the resident so further assessment could be performed. The NP acknowledged she assessed the resident's cervical spine to rule out any injury, stabilized her neck and rolled her onto her back to complete the assessment which revealed no areas of profuse bleeding. She indicated the resident had a goose egg on her head which appeared to be getting bigger and this concerned her because the resident was on anticoagulant therapy. She stated the resident was understandably anxious although spoke normally. The NP stated a call was placed to 911 for transport to the hospital ED and while awaiting the arrival of EMS, treatment was provided for the resident's bleeding areas, The NP confirmed she saw the resident a few times after her return from the hospital on the same date as the accident and the resident complained of continued pain in her knees. Knowing no x-rays had been taken of the resident's lower extremities while in the ED on 01/15/20, she said she ordered x-rays of both knees and hips on 01/22/20 and they were negative for fracture. During an interview with Nurse #1 on 03/11/20 at 4:25 p.m., Nurse #1 stated she was the treatment nurse for the facility and she and the NP were informed Resident #2 had fallen from the transport van on 01/15/20. The nurse explained she and the NP immediately ran outside to assess the resident and noted Resident #2 lying on her left side, face down with her right arm underneath her. Nurse #1 indicated they assessed her the best they could at that point. She documented the resident's injuries which included bilateral abrasions to her knees and arms and an abrasion to her right hand in addition to one small abrasion to the side of her head and thought a hematoma was starting. She indicated the resident's her head wound was not open or bleeding. Nurse #1 stated she continued to provide cervical spine support and applied an ice pack to the left side of the resident's face. She affirmed after the NP completed her assessment, 911 was called and stated they both stayed with the resident until EMS arrived. Resident #2's hospital emergency department (ED) notes, dated 01/15/20, revealed Resident #2 presented to the ED with complaints associated with an accidental fall with contusion to the forehead and superficial abrasions to bilateral knees. Resident #2's physical exam in the ED indicated she had been alert and oriented with no cranial nerve deficit. A head computed tomography (CT) scan was performed with no acute intracranial abnormality noted. A medical doctor's clinical impression indicated Resident #2 had an accidental fall, contusion of scalp and acute pain in both knees. The doctor noted Resident #2 was stable and discharged her back to the facility with instructions to follow-up with her primary care provider in two to three days. During a telephone interview with the owner of the facility's contracted van transportation company on 03/12/20 at 8:45 a.m., the owner stated after Resident #2's accident, he immediately suspended Van Driver #1 pending a complete investigation of the incident. The owner stated they immediately retrained 100% of their van drivers and emergency medical technicians. The owner stated the retraining included safety videos and return demonstrations of loading and unloading a wheelchair passenger. The owner of the transportation company stated his conclusion for the accident was total operator error as no mechanical issues with the van were found during their investigation. When asked the height of the fall, the owner stated it was 24 inches from the van's lift to the ground plus the height of the wheelchair. During an interview with the District Director of Clinical Services (DDCS) on 03/12/20 at 3:00 p.m., the DDCS stated the therapy department measured the height of a wheelchair at 17 inches. During an observation on 03/12/20 at 10:28 a.m., Van Driver #2 assisted a wheelchair-bound resident onto the contracted transportation company's van to go to an appointment. Van Driver #2 placed the resident in position on the liftgate and raised the liftgate to floor level. Van Driver #2 went inside the van and secured the wheelchair front and back to the floor anchors and placed a shoulder harness and seatbelt securely on the resident. During an observation on 03/12/20 at 11:37 a.m., Van Driver #3 assisted a wheelchair-bound resident off the contracted transportation company's van. Van Driver #3 got off the van, opened the doors and liftgate. The liftgate opened at floor level of the van. Van Driver #3 went inside the van and released anchor straps and seatbelt from the wheelchair and positioned the resident onto the liftgate. Van Driver #3 got off the van and using the lift controls, lowered the resident safely to the ground. During an interview with the Administrator on 03/11/20 at 3:36 p.m., the Administrator stated she was walking towards the front office on 01/15/20 when she happened to look outside and saw Resident #2 had fallen from the transport van. She explained she immediately ran to the Physical Therapy Department and informed the NP and the treatment nurse of the accident and said they all immediately ran outside to care for Resident #2. On 03/12/20 at 12:19 p.m., the Administrator indicated she immediately began an investigation of the accident and had suspended all transportation with the contracted transportation company and after speaking with the owner of the contracted transportation company a plan of correction was put into place. The Administrator stated the facility's van driver was re-trained, out of an abundance of caution, in addition to the re-training of all the contracted transportation company's drivers and confirmed there were no transportations by van drivers who did not complete the re-training. The Administrator acknowledged Resident #2's fall from the van was because Van Driver #1 failed to realize the liftgate was not raised when she was assisting Resident #2 off the van. On 03/13/20, the facility provided an acceptable plan of correction with a correction date of 01/20/20. The plan of correction included: Resident #1 sustained a fall on 1/15/20 in the facility parking lot at approximately 3:30 pm. The resident was being unloaded from a van driven by the contracted transportation company. The resident received immediate assessment onsite by the Nurse Practitioner and she was transported by EMS for a complete exam at the hospital. The resident returned to the facility the same night without significant injury, but she did sustain some skin tears. The Responsible Party (RP) and the Medical Doctor were informed about the situation and the resident received monitoring. It was determined that the transportation company employee failed to raise the van lift to the height of the van before pushing the resident out of the van onto the lift. The facility Administrator notified the owner of the van transportation company on 1/15/20 that the facility will not use the transportation company until an acceptable plan of correction is provided by the transportation company. All residents that require transportation with the transportation company have the potential to be affected. The Administrator and Director of Nursing (DON) completed a review of the incidents since the facility reopened June 12, 2019 and there were no other residents identified with this deficient practice. This transportation company will ensure that all their personnel have received re-education and demonstrated understanding on the proper operation of the wheelchair unit prior to resuming transportation of the residents of the facility. Their retraining included safety videos and return demonstrations. 100% completion of his staff was achieved. This plan was presented and accepted on 1/20/2020 by the Administrator and Quality Assurance Performance Improvement (QAPI) committee. The facility will utilize a monitoring tool to observe safe practices are utilized by transport companies and facility transport at least four times monthly for the next two months. This was presented at an ad hoc QAPI on 01/20/20 and the results reviewed and revised if indicated at a QAPI meeting for the next two months. The facility alleges full compliance with this plan of correction effective 01/20/20. As part of the validation process on 03/13/20, the entire plan of correction was reviewed including the re-education of van drivers and observations and interventions put into place to ensure the correct loading and unloading of wheelchair passengers from the transportation vans. Interviews with transportation drivers revealed they were re-trained in safely loading and unloading wheelchair passengers from the transport van. A review of the contracted transportation company's plan of correction revealed 100% of staff were trained on safe wheelchair operations using a wheelchair lift and return demonstration which showed competency in the use of the wheelchair lift. The facility had initiated a QAPI meeting on 01/20/20 which included the medical director, Administrator, Director of Nursing, social services, treatment nurse and other administrative personnel. A review of the facility's monitoring tool for transportation revealed they completed the audits as planned. The facility's correction date of 01/20/20 was validated.

Based on record reviews and staff interviews, the facility failed to provide management and oversight to ensure residents were provided incontinent supplies for 1 of 1 resident (Resident #1) reviewed for Administration. Findings included: Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the Resident #1 was cognitively intact. Resident was always incontinent of urine and bowels and required use of briefs. Review of facility Grievances revealed a grievance filed on 10/1/19 by Resident #1's family regarding wipes not provided to the resident. A review of the Facility's Response to the Grievance dated 10/10/19, revealed that the Administrator spoke with the Central Supply Clerk, who stated when she went to pass out wipes, she noticed that the family had brought wipes in for the resident and assumed that the family was going to provide wipes for Resident #1. Resident #1 was given wipes upon request on the date the concern was voiced. During an interview with Resident #1, on 03/12/19 at 9:00 am, she stated that the facility seems to always runs out of wipes and briefs in all sizes but especially in her size of Large and Extra Large. They have to stop her care and go borrow them from another resident and that is not right During an interview with the Central Supply Manager (CSM) on 03/11/19 at 4:30 pm, she stated the supply delivery truck comes on Monday and Wednesday; if an item is ordered by 1pm, it would be available on the next truck delivery. Every Monday, Wednesday and Friday, the CSM looks in each resident's room to assess the needs of the resident then asks the resident/staff as well to see what supplies are needed. The CSM then goes to the shed to pull each item requested and delivers them to the appropriate room. The CSM stated that she also pulls extra supplies in the central supply room that is accessible to the Nursing Assistants (NA) by keypad; There was a shortage of wipes and XL and XXL briefs due to not ordering enough around the end of last year because it took a little time to coordinate the ordering of supplies with the needs of the facility. Since then this has not been a problem. On 3/12/2020 at 1545 During an interview with NA #1, a first shift NA, she stated there is always a shortage of briefs because the individual responsible for ordering supplies has too many responsibilities. The Central supply person, who is also over Transportation department, is the only person with a key to the shed where the supplies are kept. About 6 months ago, when she went on vacation, we had no one to order supplies or access the shed where the supplies were kept so we had to search the facility and borrow wipes and briefs from other residents. When we addressed this with Administration, we were told that they were going to hire someone to fill the Central supply position, but they have not hired anyone. During an observation of the facility's supply room on 03/13/19 at 3:55 pm, there were no briefs in small or medium sizes. There were 2 packages of large briefs, 1 package of extra-large and there were 2 packets of wipes. 03/13/19 at 5:32 pm, NA #2, a second shift NA, she stated the facility runs out of supplies often, mainly briefs. There is only one staff member, the central supply person, who has the key to the shed where the supplies are. When we run out of briefs, we have to search the facility to locate other residents who may have briefs in the same size and borrow and replace briefs and wipes as we use them. During an interview with the Director of Nursing (DON), she stated that around end of last year, we did have a problem with getting supplies timely, but since then we have been able to get the supplies ordered and to the residents without any problem. The DON further stated that it was her expectation that residents have the supplies that are needed.

Based on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor these interventions that the committee put into place in November 2016. This was for 3 deficiencies which were originally cited in November 2016 on a recertification and complaint investigation survey and were cited again on the current complaint investigation survey. The deficiencies were in the areas of infection control, posted nursing staffing information and QAA. The continued failure of the facility during two federal surveys of record show a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: 1) F 356 Based on observation and staff interviews, the facility failed to post accurate nurse staffing information for 1 of 1 days reviewed (02/05/17). 2) F 441 Based on observation, record review and staff interviews, the facility staff failed to handle linens and an adult brief soiled with urine in a sanitary manner by placing the items on the floor of a semi-private resident room and failed to do hand hygiene after providing incontinence care to 1 of 7 residents observed to receive care (Resident #5). During an interview with the Administrator on 02/07/17 at 5:15 p.m., the Administrator stated the facility QAA committee consisted of the department heads, the medical director and the consultant pharmacist. The Administrator stated the QAA committee met monthly and had met after the November 2016 recertification and complaint investigation survey and a Plan of Correction (POC) had been put into place for the nursing staffing posting; the area of infection control had been in another area. The Administrator stated limited access to the part of their computer system which contained the nursing staffing information was causing them to re-evaluate their process.

Based on observation, record review and staff interviews, the facility staff failed to handle linens and an adult brief soiled with urine in a sanitary manner by placing the items on the floor of a semi-private resident room and failed to do hand hygiene after providing incontinence care to 1 of 7 residents observed to receive care (Resident #5). The findings included: A review of the facility's Hand Hygiene policy, taken from the Infection Prevention Manual for Long Term Care 2012, indicated hand washing and hand hygiene was considered the most important single procedure for preventing healthcare associated infections. The policy, in part, indicated staff should wash their hands before performing a procedure and after providing care to a resident. A review of the facility's Soiled Linen Collection & Transfer policy, taken from the Department Operations manual released/revised March 2009, indicated soiled linen was to be placed in containers labeled Soiled Linen and staff are to wash their hands immediately after handling soiled laundry and removing gloves. During an observation on 02/05/17 at 6:10 p.m., Nursing Assistant (NA) #1 was observed to provide incontinent care to Resident #5. NA #1 placed a urine soiled adult brief and a urine soiled pad on the floor near the foot of the resident's bed. NA #1 then slid these two urine soiled items away from the bed to the middle of the room near the divider curtain. NA #1 removed a urine soiled fitted bed sheet from the resident's bed and placed it on the floor in front of the resident's nightstand. NA #1 then wiped Resident #5's perineal area with a wet wipe and placed the soiled wipe on top of the sheet on the floor. NA #1 took the trash bag out of the trash can near the sink and gathered the soiled linen and soiled wipe from the floor. Without removing her soiled gloves, NA #1 replaced the lid on the tub of barrier cream and placed the tub of cream in a drawer. NA #1 placed the palm of her gloved hand on top of the resident's over bed table and pushed the table closer to the resident. NA #1 opened the door to the resident's room, stopped in the threshold and removed her gloves and placed the gloves in the trash bag she was holding. NA #1 walked out of the resident's room and entered the beauty shop located near the nurses' station and disposed of the trash bag in one of three 3-bin soiled linen/trash containers being stored in the beauty shop. NA #1 exited the beauty shop, held up her hands and stated now I have to wash my hands and opened a door to another room by the nurses' station. During an interview with NA #1 on 02/05/17 at 6:50 p.m. NA #1 stated she knew she should wash her hands in between resident care and before and after wearing gloves. When asked why she did not wash her hands after providing incontinent care, NA #1 stated she had been in a rush. When asked why she threw the soiled items on the floor, NA #1 asked if she was in trouble. During an interview with the Director of Nursing (DON) on 02/07/17 at 2:03 p.m., the DON stated it was her expectation the nursing staff follow the hand hygiene policy. The DON stated it was her expectation the nursing staff appropriately bag soiled linen and carry it out of a room in a manner to prevent the transmission of infection. During an interview with the Administrator on 02/05/17 at 4:15 p.m., the Administrator stated it was his expectation facility staff wash their hands and handle soiled linen according to policy.

Based on record reviews and staff interviews, the facility failed to have (1)of (1) sampled resident access her personal funds on ongoing basis and arrange for access to larger funds.(Resident # 1) The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] indicated the resident's cognitively was severely impaired. Review of the Resident's Statement Landscape report revealed the facility received the resident's liability money for the amount of $ 368 per month for December 2016 and January 2017. The statement also revealed the facility deducted $180 from the resident's personal funds account to pay for the resident's care cost at the facility. Interview with the Business Manager on 2/7/2017 at 11:00 AM, revealed the resident liability money paid to the facility when the resident was first admitted on [DATE] was $408 per month and then it was reduced to $368 per month on September 2015. She further reported resident's personal funds was used to pay the care cost at the facility. The Business manager also admitted she should not have used the resident's personal funds to pay the resident's care cost. She added she was going to reimburse the resident's estate the money that the facility had used to pay the care cost. Interview with the Administrator on 2/7/2017 at 10:52 AM, revealed he was not aware that Resident # 1 did not have access to her personal funds in December 2017 and January 2017. He stated his expectation was for the residents at the facility to have access to their personal funds and the money was not to be used for paying the resident's care cost at the facility. The Administrator also added the facility was going to reimburse the resident the money that was used to pay the care cost.

Based on observation and staff interviews, the facility failed to post accurate nurse staffing information for 1 of 3 days reviewed (02/05/17). The Findings Included: Accompanied by the facility's Director of Nursing (DON), an observation made on 02/05/17 at 4:05 p.m. revealed a daily nursing staff posting dated 01/30/17 posted in the administrative hallway. During an interview with the DON on 02/05/17 at 4:05 p.m., the DON stated the posting was not accurate because the nurse who was assigned to complete the task had gone on vacation and no one had updated it during her absence. During an interview with the Administrator on 02/07/17 at 5:15 p.m., the Administrator stated the daily nursing staff information had been being checked daily as part of their ongoing Plan of Correction which had been put into place after their November 2016 recertification and complaint investigation survey. The Administrator stated he could not provide documentation of this daily check. The Administrator stated due to limited access to the part of their computer system that contained the nursing staffing information, the posting had not been updated since the designee had gone on vacation. The Administrator stated it was his expectation the nursing staffing information be posted daily.

Based on physician interview, staff interview, and record review the facility's administration failed to prepare staff for and implement the conversion from paper medication administration records (MARs) to electronic medication administration records (e-MARs) which resulted in physician orders [REDACTED].#16) on [MEDICATION NAME] (anti-platelet medication) not getting transcribed into the e-MAR system, in restarting magnesium supplementation without a physician's orders [REDACTED].#50) reviewed for unnecessary medications, and in nurses being unable to accurately document the administration of medications for 1 of 5 residents (Resident #129) reviewed for unnecessary medications. Findings included: This tag is cross-referenced to: F281: Based on observation, staff interview, and record review the facility failed to obtain clarification regarding 1 of 1 sampled residents (Resident #16) with a bubble pack of [MEDICATION NAME] (medication used to prevent blood clots) on the medication cart but without an order to administer it in the electronic medication administration system which was needed to guarantee the resident was receiving [MEDICATION NAME] daily as ordered by the physician. F329: Unnecessary medications: [REDACTED]. F514: Complete and Accurate Medical Records: Based on staff interview and record review the facility failed to accurately audit orders transcribed from a paper Medication Administration Record [REDACTED]. This resulted in incomplete and inaccurate medical records for 1 of 1 sampled resident (Resident #16) whose order for [MEDICATION NAME] was not carried forward from the paper MAR indicated [REDACTED]#129) reviewed for unnecessary medications who was not having the administration of his PM doses of Ambien, [MEDICATION NAME], and calcium/vitamin D documented on the e-MAR. At 12:20 PM on 11/10/16 the director of nursing (DON) stated since the first or second week in October 2016 there were problems with in-putting orders, documenting the administration of medications, glitches in the e-MAR system, and transcribing orders from the paper system to the electronic system . She explained the e-MAR system went live on 10/01/16. The DON reported two nurses came to her in the past week and a half with concerns about documenting the administration of their medications correctly. She commented she attempted to provide 1:1 education to these two nurses, but was not sure it was effective. At 12:10 PM on 11/15/16, during a telephone interview, the medical director stated the facility held a few training sessions before use of the e-MAR system began on 10/01/16. However, she reported she felt this training was inadequate, and the staff were not well prepared for the transition between paper MARs and the e-MAR system because there were daily problems with transcription of orders and documentation of medication administration. According to the medical director, she still felt there were problems in the e-MAR system which had yet to be worked out.

Based on consultant pharmacy interview, staff interview, and record review consultant pharmacists failed to alert the facility to problems with medication issues in the electronic medication administration (e-MAR system) for 3 of 6 residents (Resident #16, #50, and #129) whose medications were reviewed. The pharmacists failed to alert the facility that while Resident #16 had a punch card for Plavix medication there was no order in the e-MAR system for the medication. The pharmacists failed to alert the facility that magnesium supplementation was resumed for Resident #50 without a physician order to do so. The pharmacist failed to alert the facility that medications were not being initialed as being given electronically for Resident #129. Findings included: 1. Record review revealed Resident #16 was admitted to the facility on [DATE] with a physician order for [REDACTED]. Review of Resident #16's electronic Medication Administration Record [REDACTED]. An observation on 11/10/16 at 10:06 AM revealed that resident #16 had a bubble pack of Plavix 75mg in the medication cart with six missing. The bubble pack was received from the pharmacy on 10/28/16. In an interview conducted on 11/10/2016 at 10:40 AM Nurse #2 was unable to locate an order for [REDACTED]. She revealed that she gave the medication without looking at the e-MAR. She was not sure if other nurses who worked on the cart were giving the Plavix or not. In an interview conducted on 11/10/16 at 11:10 AM with Nurse #3 she confirmed that she only passed medications listed on the e-MAR. She said if there was a medication bubble pack in a resident ' s drawer that was not listed on the e-MAR she would investigate why the medication was in the drawer and either send it back to the pharmacy or give it to the resident depending upon the results of her investigation. She commented that such an investigation had not been conducted for Resident #16. In an interview conducted on 11/10/16 at 11:11 AM with Nurse #4 she stated that she would not give a medication unless it was listed on the e-MAR. She revealed that she flagged medications found in the medication cart without corresponding orders in the e-MAR until she could investigate if the medication was to be given. However, she commented she was unaware of such an investigation being conducted for Resident #16. In an interview conducted on 11/10/16 at 11:15 AM with Nurse #5 she revealed that she passed medications listed in the e-MAR. She stated she would not give a medication if it was not listed on the computer. She would investigate the medication and return it to the pharmacy if it was discontinued. However, she commented she was unaware of such an investigation being conducted for Resident #16. At 1:12 PM on 11/10/16, during a telephone conversation, Consultant Pharmacist #1 stated during her monthly medication reviews she reviewed orders and medication administration documented in the electronic record keeping system. During her October 2016 reviews she reported she noticed there were orders entered incorrectly in the electronic system, there were orders omitted from the electronic system, and there were holes in the administration records where staff were not initialing off that they provided medications. However, when she reviewed her October 2016 pharmacy recommendations for Resident #16 she reported she did not catch that the resident ' s order for Plavix was not carried over from the paper administration system into the electronic system on 10/01/16. At 1:28 PM on 11/10/16, during a telephone conversation, Consultant Pharmacist #2 stated during his monthly medication reviews he reviewed orders and medication administration documented in the electronic record keeping system. During his 11/02/16 and 11/03/16 medication reviews he reported he did not catch that resident #16 ' s order for Plavix was not carried over from the paper administration system into the electronic system on 10/01/16. He commented he did not discuss order accuracy and missing documentation with the facility since he understood the facility ' s usual pharmacist (Consultant Pharmacist #1) had discussed these issues with the facility the month before. 2. Record review revealed Resident #50 was admitted to the facility on [DATE]. The resident's documented [DIAGNOSES REDACTED]. A 07/21/16 physician order specified magnesium oxide 400 milligrams (mg) twice daily (BID) at 8:00 AM and 8:00 PM was to be discontinued, and the resident was to be started on magnesium oxide 400 mg daily (QD) at 9:00 AM. A magnesium level was to be determined for the resident in two weeks via a lab draw. Lab results received on 08/04/16 documented Resident #50's magnesium level was 2.3 milligrams per deciliter (mg/dL) with the normal range being 1.6 - 2.3 mg/dL. A 08/04/16 physician order documented Resident #50's magnesium oxide was to be discontinued. Review of Resident #50's August 2016 and September 2016 paper medication administration records (MARs) revealed the resident did not receive any magnesium oxide from 08/05/16 through 09/30/16. Resident #50's 09/22/16 quarterly minimum data set (MDS) documented his cognition was severely impaired, he exhibited no behaviors including rejection of care, and he required extensive assistance from staff to being totally dependent on staff for all his activities of daily living (ADLs) except eating. Review of the facility's electronic Medication Administration Record [REDACTED]revised. On 10/01/16, when the facility transitioned between paper MARs and the e-MAR system, orders for both magnesium oxide BID and QD appeared on the e-MAR for Resident #50. Record review revealed there were no physician orders, physician progress notes [REDACTED].#50's magnesium supplementation should have been resumed. Review of Resident #50's October 2016 e-MAR documented he received 24 doses of magnesium oxide 400 mg at 8:00 AM, 21 doses of magnesium oxide 400 mg at 9:00 AM, and 23 doses of magnesium oxide 400 mg at 8:00 PM from 10/01/16 through 10/31/16. Review of Resident #50's November 2016 e-MAR documented he received 9 doses of magnesium oxide 400 mg at 8:00 AM, and 8 doses of magnesium oxide 400 mg at 9:00 AM from 11/01/16 through 11/09/16. 11/10/16 lab results documented Resident #50's magnesium level was 2.3 mg/dL with the normal range being 1.6 - 2.3 mg/dL. At 1:12 PM on 11/10/16, during a telephone conversation, Consultant Pharmacist #1 stated during her monthly medication reviews she reviewed orders and medication administration documented in the electronic record keeping system. During her October 2016 reviews she reported she noticed there were orders entered incorrectly in the electronic system, there were orders omitted from the electronic system, and there were holes in the administration records where staff were not initialing off that they provided medications. However, when she reviewed her October 2016 pharmacy recommendations for Resident #50 she reported she did not catch that the resident's order for magnesium oxide (which was discontinued on 08/04/16) was somehow introduced back into the electronic system without a physician order to do so when the facility transitioned from the paper medication administration system to the electronic system on 10/01/16. At 1:28 PM on 11/10/16, during a telephone conversation, Consultant Pharmacist #2 stated during his monthly medication reviews he reviewed orders and medication administration documented in the electronic record keeping system. During his 11/02/16 and 11/03/16 medication reviews he reported he did not catch that Resident #50's discontinued order for magnesium oxide was reactivated without a physician order to do so when the facility transitioned from the paper medication administration system to the electronic system on 10/01/16. He commented he did not discuss order accuracy and missing documentation with the facility since he understood the facility's usual pharmacist (Consultant Pharmacist #1) had discussed these issues with the facility the month before. 3. Resident #129 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of physician orders, dated 10/28/16, showed that Resident # 129 was ordered the following medications: [REDACTED] 1. Calcium Carbonate - Vit D - Min Tablet 600-200 Mg-Unit: Give 1 tablet by mouth at bedtime for supplement. 2. Cosopt Solution 22.3-6.8 mg/ml: Instill 1 drop in left eye two times a day for glaucoma. 3. Ambien Tablet 5 mg: Give 1 tablet by mouth at bedtime for insomnia. 4. Flovent HFA Aerosol 110 Mcg/act: 2 puff inhale orally two times a day for SOB/wheezing. A review of the electronic Medication Administration Record [REDACTED]. At 11:18 AM on 11/10/16 Nurse #1 stated she did administer PM doses of Flovent, Cosopt, Ambien, and calcium/vitamin D to Resident #129, but could not figure out how to document this administration in the e-MAR. At 1:28 PM on 11/10/16, during a telephone conversation, Consultant Pharmacist #2 stated during his monthly medication reviews he reviewed orders and medication administration documented in the electronic record keeping system. During his 11/02/16 and 11/03/16 medication reviews he reported he did not catch that Resident #129's PM administration of medications was not be initialed off on the e-MAR as given. He commented he did not discuss order accuracy and missing documentation with the facility since he understood the facility's usual pharmacist (Consultant Pharmacist #1) had discussed these issues with the facility the month before.

Based on observation, staff interview, and record review the facility failed to obtain clarification regarding 1 of 1 sampled residents (Resident #16) with a bubble pack of [MEDICATION NAME] (medication used to prevent blood clots) on the medication cart but without an order to administer it in the electronic medication administration system which was needed to guarantee the resident was receiving [MEDICATION NAME] daily as ordered by the physician. Findings included: Record review revealed Resident #16 was admitted to the facility on [DATE] with a physician order [REDACTED]. Review of Resident #16's electronic Medication Administration Record [REDACTED]. An observation on 11/10/16 at 10:06 AM revealed that resident #16 had a bubble pack of [MEDICATION NAME] 75mg in the medication cart with six missing. The bubble pack was received from the pharmacy on 10/28/16. In an interview conducted on 11/10/2016 at 10:40 AM Nurse #2 was unable to locate an order for [REDACTED]. She revealed that she gave the medication without looking at the e-MAR. She was not sure if other nurses who worked on the cart were giving the [MEDICATION NAME] or not. In an interview conducted on 11/10/16 at 11:10 AM with Nurse #3 she confirmed that she only passed medications listed on the e-MAR. She said if there was a medication bubble pack in a resident ' s drawer that was not listed on the e-MAR she would investigate why the medication was in the drawer and either send it back to the pharmacy or give it to the resident depending upon the results of her investigation. She commented that such an investigation had not been conducted for Resident #16. In an interview conducted on 11/10/16 at 11:11 AM with Nurse #4 she stated that she would not give a medication unless it was listed on the e-MAR. She revealed that she flagged medications found in the medication cart without corresponding orders in the e-MAR until she could investigate if the medication was to be given. However, she commented she was unaware of such an investigation being conducted for Resident #16. In an interview conducted on 11/10/16 at 11:15 AM with Nurse #5 she revealed that she passed medications listed in the e-MAR. She stated she would not give a medication if it was not listed on the computer. She would investigate the medication and return it to the pharmacy if it was discontinued. However, she commented she was unaware of such an investigation being conducted for Resident #16. In an interview conducted on 11/10/16 at 11:28 AM with the facility's corporate pharmacist she revealed that there was an active order for Resident #16 to receive [MEDICATION NAME] 75 mg daily that had been in effect for the last three years. She stated the pharmacy was not responsible for the e-MAR. She reported the facility was responsible for keying information into the e-MAR. In an interview conducted on 11/10/16 at 11:45 AM with the Director of Nursing she said the nurses were to only pass those medications listed in the e-MAR. She revealed that the facility had been having trouble auditing the transition from paper charting to the e-MAR. She commented she was unsure how the [MEDICATION NAME] order for Resident #16 was missed during the transition of orders from paper to the electronic system. She stated she would not expect a nurse to give a medication that was not listed on the e-MAR. She would expect the nurse to pull the medication and investigate why it was not listed on the computer e-MAR. She would then expect the nurse to call the doctor to reinstate the order if it had not been discontinued or to send the medication back to the pharmacy if it was discontinued. She reported the nursing staff should have sought clarification when they discovered Resident #16 had [MEDICATION NAME] on the medication cart but was without an order to administer it in the electronic system. She confirmed that it could not be determined whether Resident #16 received [MEDICATION NAME] daily since the 10/01/16 transition between paper MARs and e-MARs because since 10/01/16 there was no place to document any administration. At 12:10 PM on 11/15/16, during a telephone interview, the medical director and primary physician for Resident #16 stated [MEDICATION NAME] was more effective when it was administered at about the same time daily, and the side effects of not receiving it daily varied depending on the progression of the resident's [MEDICAL CONDITION] and whether the resident was receiving other anti-platelet medications. Again, she reported going without the [MEDICATION NAME] or having erratic doses for a couple of weeks would be less likely to cause problems than going without it or having erratic dosing for longer periods of time.

Based on staff interview and record review the facility failed to accurately audit orders transcribed from a paper Medication Administration Record [REDACTED]. This resulted in incomplete and inaccurate medical records for 1 of 1 sampled resident (Resident #16) whose order for [MEDICATION NAME] was not carried forward from the paper MAR indicated [REDACTED]#129) reviewed for unnecessary medications who was not having the administration of his PM doses of Ambien, [MEDICATION NAME], and calcium/vitamin D documented on the e-MAR. Findings included: 1. Record review revealed Resident #16 was admitted to the facility on [DATE] with a physician order for [REDACTED]. Review of Resident #16's electronic Medication Administration Record [REDACTED]. An observation on 11/10/16 at 10:06 AM revealed that resident #16 had a bubble pack of [MEDICATION NAME] 75mg in the medication cart with six missing. The bubble pack was received from the pharmacy on 10/28/16. In an interview conducted on 11/10/2016 at 10:40 AM Nurse #2 was unable to locate an order for [REDACTED]. She revealed that she gave the medication without looking at the e-MAR. She was not sure if other nurses who worked on the cart were giving the [MEDICATION NAME] or not. In an interview conducted on 11/10/16 at 11:10 AM with Nurse #3 she confirmed that she only passed medications listed on the e-MAR. She said if there was a medication bubble pack in a resident ' s drawer that was not listed on the e-MAR she would investigate why the medication was in the drawer and either send it back to the pharmacy or give it to the resident depending upon the results of her investigation. She commented that such an investigation had not been conducted for Resident #16. In an interview conducted on 11/10/16 at 11:11 AM with Nurse #4 she stated that she would not give a medication unless it was listed on the e-MAR. She revealed that she flagged medications found in the medication cart without corresponding orders in the e-MAR until she could investigate if the medication was to be given. However, she commented she was unaware of such an investigation being conducted for Resident #16. In an interview conducted on 11/10/16 at 11:15 AM with Nurse #5 she revealed that she passed medications listed in the e-MAR. She stated she would not give a medication if it was not listed on the computer. She would investigate the medication and return it to the pharmacy if it was discontinued. However, she commented she was unaware of such an investigation being conducted for Resident #16. In an interview conducted on 11/10/16 at 11:28 AM with the facility's corporate pharmacist he revealed that there was an active order for Resident #16 to receive [MEDICATION NAME] 75 mg daily that had been in effect for the last three years. He stated the pharmacy was not responsible for the e-MAR. He reported the facility was responsible for keying information into the e-MAR. In an interview conducted on 11/10/16 at 11:02 AM with the Director of Nursing she stated Resident #16's medical record was not accurate and complete because some nurses were administering [MEDICATION NAME] to the resident without an order in the e-MAR, and its administration was not being captured. 2. Record review revealed Resident #50 was admitted to the facility on [DATE]. The resident's documented [DIAGNOSES REDACTED]. A 07/21/16 physician order specified magnesium oxide 400 milligrams (mg) twice daily (BID) at 8:00 AM and 8:00 PM was to be discontinued, and the resident was to be started on magnesium oxide 400 mg daily (QD) at 9:00 AM. A magnesium level was to be determined for the resident in two weeks via a lab draw. Lab results received on 08/04/16 documented Resident #50's magnesium level was 2.3 milligrams per deciliter (mg/dL) with the normal range being 1.6 - 2.3 mg/dL. A 08/04/16 physician order documented Resident #50's magnesium oxide was to be discontinued. Review of Resident #50's August 2016 and September 2016 paper medication administration records (MARs) revealed the resident did not receive any magnesium oxide from 08/05/16 through 09/30/16. Resident #50's 09/22/16 quarterly minimum data set (MDS) documented his cognition was severely impaired, he exhibited no behaviors including rejection of care, and he required extensive assistance from staff to being totally dependent on staff for all his activities of daily living (ADLs) except eating. Review of the facility's electronic Medication Administration Record [REDACTED]revised. On 10/01/16, when the facility transitioned between paper MARs and the e-MAR system, orders for both magnesium oxide BID and QD appeared on the e-MAR for Resident #50. Record review revealed there were no physician orders, physician progress notes [REDACTED].#50's magnesium supplementation should have been resumed. Review of Resident #50's October 2016 e-MAR documented he received 24 doses of magnesium oxide 400 mg at 8:00 AM, 21 doses of magnesium oxide 400 mg at 9:00 AM, and 23 doses of magnesium oxide 400 mg at 8:00 PM from 10/01/16 through 10/31/16. Review of Resident #50's November 2016 e-MAR documented he received 9 doses of magnesium oxide 400 mg at 8:00 AM, and 8 doses of magnesium oxide 400 mg at 9:00 AM from 11/01/16 through 11/09/16. 11/10/16 lab results documented Resident #50's magnesium level was 2.3 mg/dL with the normal range being 1.6 - 2.3 mg/dL. In an interview conducted on 11/10/16 at 11:02 AM with the Director of Nursing she stated Resident #50's medical record was not accurate because Resident #50 was not supposed to be receiving magnesium oxide after 08/04/16, but received it until 11/10/16 according to the e-MAR. 3. Resident #129 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Minimum Data Set (MDS) information for Resident # 129 was not yet available due to his recent admission, but a Brief Interview for Mental Status (BIMS) assessment, completed on 10/28/16 indicated that his cognition was intact. A review of physician orders, dated 10/28/16, showed that Resident #129 was ordered the following medications: [REDACTED] 1. Calcium [MEDICATION NAME] - Vit D - Min Tablet 600-200 Mg-Unit: Give 1 tablet by mouth at bedtime for supplement. 2. [MEDICATION NAME] Solution 22.3-6.8 mg/ml: Instill 1 drop in left eye two times a day for [MEDICAL CONDITION]. 3.[MEDICATION NAME] 5 mg: Give 1 tablet by mouth at bedtime for [MEDICAL CONDITION]. 4. [MEDICATION NAME] HFA Aerosol 110 Mcg/act: 2 puff inhale orally two times a day for SOB/wheezing. A review of the electronic Medication Administration Record [REDACTED]. At 11:18 AM on 11/10/16 Nurse #1 stated she did administer PM doses of [MEDICATION NAME], Ambien, and calcium/vitamin D to Resident #129, but could not figure out how to document this administration in the e-MAR. In an interview with the Director of Nursing (DON) at 11:45 AM on 11/10/16 she stated she would not consider Resident #129's medical record to be complete and accurate since a nurse claimed she provided PM doses of [MEDICATION NAME], Ambien, and calcium/vitamin D, but this nurse reported she did not document the administration because she could not figure out how to enter it into the e-MAR.