Every finding on record at Westminster-Canterbury of Lynchburg Inc

Based on staff interview and clinical record review the facility staff failed to ensure an accurate MDS assessment for 1 of 25 residents, Resident #2. The findings included:For Resident #2, the facility staff coded an admission MDS assessment to indicate the resident was taking an antibiotic at the time of the assessment. Resident #2 had not been on an antibiotic.Resident #2's diagnoses included genital tract fistulae and anxiety disorder.Section C (cognitive patterns) of Resident #2's admission MDS assessment with an assessment reference date (ARD) of 01/15/26 included a brief interview for mental status (BIMS) score of 15, indicating Resident #2 was cognitively intact. Section N (medications) had been coded to indicate the resident was taking an antibiotic.Resident #2's clinical record included a provider order for Hiprex (Methenamine Hippurate) 1 gram 1 tablet by mouth twice a day for urinary tract infection (UTI) prophylaxis.Per the Cleveland Clinic Methenamine Hippurate prevents UTIs caused by bacteria. It is not an antibiotic. Resident #2's comprehensive care plan included the focus area resident has potential for UTI. On 03/18/26 at 11:00 a.m., during an interview with the MDS coordinator this staff stated the use of an antibiotic was miscoded on the MDS and a correction had been completed. On 03/18/2026 at 4:30 p.m., during an end of the day meeting with the Administrator, Director of Nursing, MDS Coordinator, Nurse Supervisor #1, #2, and #3 the issue with the miscoding of the MDS assessment for Resident #2 was reviewed.No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observations, staff interview, clinical record review and facility document review the facility staff failed to follow medical provider orders for 2 of 25 residents, Resident #5 and Resident #8. The findings included:1. For Resident #5, the facility staff failed to follow a medical provider orders to apply TED hose (Thrombo-Embolic Deterrent hose are specialized medical compression stockings designed to prevent blood clots) to the resident's BLE (bilateral lower extremities) on 3/18/26. Resident #5's diagnosis list indicated diagnoses, which included, but not limited to, Alzheimer's disease, osteoarthritis, lymphedema, and edema. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 2/5/26, assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating Resident #5 was severely impaired in cognition. On 3/18/26 at 8:23 AM, Resident #5 was observed and interviewed. Bilateral TED hose were not visible to be on the resident's lower extremities. A review of a medical provider orders with a start date of 11/12/25 read in part, .TED hose to bilateral lower extremities on in the AM (morning) off at HS (hour of sleep/bedtime) for edema. On 3/18/26 at 1:12 PM, Resident #5 was observed. Bilateral TED hose were not visible to be on the resident's lower extremities. A review of Resident #5's March 2026 TAR (treatment administration record), was coded to indicate the TED hose were applied on 3/18/26 to Resident #5's BLEs. A review of Resident #5's comprehensive person-centered care plan disclosed a focus which read in part, .requires assistance with ADL's (activities of daily living).Related to.Edema. An intervention associated to the focus read in part, .TEDS as ordered. On 3/18/26 at 2:23 PM, the director of nursing (DON) was interviewed and agreed the TED hose should have been applied to Resident #5 as ordered by the provider. The DON agreed it should not have been documented on the TAR that the TED hose were applied if they were not and nursing should have verified the TED hose were applied. This concern was discussed at the end of day meeting on 3/18/26 at 4:30 PM with the administrator, director of nursing, nursing supervisor, nursing household supervisor, household coordinator, MDS coordinator, and assistant director of nursing. Requested and received a facility policy titled, Physician's Orders with a revision date of 8/7/25 which read in part, .Purpose.To ensure that all physician orders are carried out accurately.to promote optimal resident care and comply with regulatory standards.All licensed staff must follow physician orders as prescribed.3.Nursing staff must.Adhere to facility protocols and standards of care. No further information was provided prior to exit on 3/19/26. 2.For Resident #8 the facility staff failed to follow a medical provider orders to apply TubiGrips (a multi-purpose, elasticated tubular support bandage designed to provide consistent, even, and firm compression to the limbs to support injured tissues, reduce swelling (edema), and manage venous disorders) to the resident's BLE (bilateral lower extremities) on 3/18/26. Resident #8's diagnosis list indicated diagnoses, which included, but not limited to, acute on chronic congestive heart failure, idiopathic peripheral autonomic neuropathy, chronic pulmonary embolism, and atrial fibrillation. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/11/26, assigned the resident a brief interview for mental status (BIMS) summary score of 13 out of 15 for cognitive abilities, indicating Resident #8 was cognitively intact. On 3/18/26 at 8:25 AM, Resident #8 was observed and interviewed. Bilateral TubiGrips were not visible to be on the resident's lower extremities. Certified nursing assistant #1 (CNA#1) was present in the resident's room and when asked if the resident wears TubiGrips, CNA#1 stated, No. A review of a medical provider orders with a start date of 11/19/25 read in part, .Tubi grips to bilateral lower extremity for prevention, apply in am (morning) and remove at HS (hour of sleep/bedtime). On 3/18/26 at 1:15 PM, Resident #8 was observed. Bilateral TubiGrips were not visible to be on the resident's lower extremities. A review of Resident #8's March 2026 TAR (treatment administration record), was coded to indicate the TubiGrips were applied on 3/18/26 to Resident #8's BLEs. A review of Resident #8's comprehensive person-centered care plan disclosed a focus which read in part, .requires assistance with ADL's (activities of daily living). An intervention associated to the focus read in part, .Tubi-grip.as ordered. On 3/18/26 at 4:12 PM, the director of nursing (DON) was interviewed and agreed the TubiGrips should have been applied to Resident #8 as ordered by the provider. This concern was discussed at the end of day meeting on 3/18/26 at 4:30 PM with the administrator, director of nursing, nursing supervisor, nursing household supervisor, household coordinator, MDS coordinator, and assistant director of nursing. Requested and received a facility policy titled, Physician's Orders with a revision date of 8/7/25 which read in part, .Purpose.To ensure that all physician orders are carried out accurately.to promote optimal resident care and comply with regulatory standards.All licensed staff must follow physician orders as prescribed.3.Nursing staff must.Adhere to facility protocols and standards of care. No further information was provided prior to exit on 3/19/26.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) for one of twenty residents in the survey sample (Resident #56). The findings include: Section L. of Resident #56's annual MDS dated [DATE] assessed the resident with no dental impairments when the resident had multiple broken teeth with likely decay. Resident #56 was admitted to the facility with diagnoses that included hypertension, glaucoma, heart failure, anemia, obstructive sleep apnea, epilepsy, vitamin D deficiency and atrial flutter. The MDS dated [DATE] assessed Resident #56 with moderately impaired cognitive skills. On 2/6/23 at 3:15 p.m., Resident #56 was interviewed about quality of life and care in the facility. During this interview, Resident #56's lower bottom teeth were observed fragmented near the gum with dark, jagged areas on the tooth fragments. Resident #56 was interviewed at this time about the condition of his teeth. Resident #56 displayed his front teeth showing multiple broken teeth with dark gray/black areas of possible decay. Resident #56 stated he had several broken teeth and the lower front teeth were decayed almost to the gum. Resident #56 stated his teeth had been in poor condition prior to his admission to the facility. The resident's annual MDS with an assessment reference date of 1/12/23 documented in section L0200 that the resident had no dental issues. Item Z. in this section was checked indicating no tooth fragments, no obvious/likely cavities or broken natural teeth. On 2/7/23 at 4:00 p.m., the registered nurse MDS coordinator (RN #1) was interviewed about Resident #56's broken, fragmented teeth and the conflicting assessment indicating no dental issues. RN #1 stated the resident had broken, fragmented teeth. After reviewing the 1/12/23 MDS, RN #1 stated section L0200 was inaccurately coded indicating no dental issues. RN #1 stated item D. in section L0200 should have been marked indicating the resident had obvious or likely cavities and broken natural teeth. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual on pages L-1 and L-2 documented regarding section L. Oral/Dental status, .Assessment can identify periodontal disease that can contribute to or cause systemic diseases and conditions, such as aspiration, malnutrition, pneumonia, endocarditis, and poor control of diabetes . Conduct exam of the resident's lips and oral cavity . Check for abnormal mouth tissue, abnormal teeth, or inflamed or bleeding gums. The assessor should use his or her gloved fingers to adequately feel for masses or loose teeth .Check L0200D, obvious or likely cavity or broken natural teeth: if any cavity or broken tooth is seen . (1) This finding was reviewed with the administrator and director of nursing during a meeting on 2/7/23 at 5:10 p.m. (1) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, Centers for Medicare & Medicaid Services, Revised October 2019

Based on medication pass and pour observation, staff interview, and clinical record review the facility staff failed to follow physician's orders for Resident # 58. Findings include: A medication pass and pour observation was conducted 2/7/23 beginning at 8:20 a.m. with LPN (licensed practical nurse) # 1. LPN # 1 prepared medications for Resident # 58, which included acetaminophen (Tylenol) 325 mg, two tablets. On 2/7/23 at approximately 9:05 a.m. the clinical record was reviewed to reconcile medications observed having been administered to the resident. An order with a start dated of 8/28/22 and included on the current POS (physician order summary) directed Tylenol Ex-Str 500 mg tablet- 2 tabs (1000 mg) po (by mouth) BID (twice a day) for general and/or mild pain . On 2/7/23 at approximately 9:35 a.m. LPN # 1 was asked about the discrepancy in what was observed administered, and the physician order. LPN # 1 stated Yes, she gets the 1000 mg tabs here on the medication card . LPN # 1 went to pull the card, stopped, and stated But that's not what I gave her, is it? I gave the 'house stock' Tylenol of 325 mg that's a med error On 2/7/23 the administrator and DON (director of nursing) were informed of the above findings. The DON stated LPN # 1 called me and told me what happened; we got a one time order from the medical director for additional Tylenol to equal the 1000 mg. No further information was provided prior to the exit conference.

Based on clinical record review and staff interview, the facility staff failed to ensure a pharmacy GDR [gradual dose reduction] recommendation was completed for one of 20 residents [Resident #8]. Resident #8's physician signed a GDR pharmacy recommendation for [MEDICATION(S)] [a hypnotic medication for sleep] to be decreased from 2 mg [milligrams] to 1 mg nightly; however, Resident #8 continued to received 2 mg nightly for over 5 months. Findings include: Resident #8 was admitted to the facility on [DATE]. Diagnoses for Resident #8 included, but were not limited to: [CONDITION(S)], Alzheimer's dementia, restless leg syndrome, anxiety disorder, and [CONDITION(S)]. The most current MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident as having short and long term memory impairment with severe impairment in daily decision making skills. Resident # 8's clinical records were reviewed on 05/05/21. A pharmacy recommendation dated 11/10/20 documented, .resident has been taking .hypnotic [MEDICATION(S)] 2 mg [milligram] .along with [MEDICATION(S)] 9 mg. Upon review, no episodes of [CONDITION(S)] were noted .please evaluate the current dose and consider a dose reduction .attempt dose reduction to [MEDICATION(S)] 1 mg .and continue current [MEDICATION(S)] . The physician marked agreed to the dose reduction from 2 mg to 1 mg and signed the recommendation on 11/16/20. Resident # 8's current physician's orders were reviewed and revealed the resident was still receiving [MEDICATION(S)] 2 mg every night, along with [MEDICATION(S)] 9 mg each night. The pharmacy recommendation dated 11/10/20 that the physician signed had not been completed. The resident's behavior tracking sheets for the medication [MEDICATION(S)] were reviewed from November 2020 through present [May 2021]. There were no behaviors listed. A pharmacy recommendation dated 03/09/21 was also reviewed. This recommendation documented, .resident has been taking .hypnotic [MEDICATION(S)] 2 mg [milligram] .along with [MEDICATION(S)] 9 mg. Upon review, no episodes of [CONDITION(S)] were noted .please evaluate the current dose and consider a dose reduction .attempt dose reduction to [MEDICATION(S)] 1 mg .and continue current [MEDICATION(S)] . The DON [director of nursing] signed that the recommendation was reviewed and signed on 03/13/21. There were three boxes to be checked by the provider, which were agree, disagree or other; none of the boxes were marked. A hand written entry by the DON documented, POA [power of attorney] does not want any changes. The PA [physician's assistant] signed this pharmacy recommendation. There was no clinical justification listed on the pharmacy recommendation or in the resident's clinical record. Resident #8's current care plan dated 04/26/21 was reviewed and documented, .receiving hypnotic medication .is necessary to treat [CONDITION(S)] .will receive gradual dose reduction, unless clinically contraindicated, in an effort to discontinue hypnotic medication .assure therapeutic dose .pharmacy recommendation to reduce dose of [MEDICATION(S)] declined per MD/PA [medical doctor/physician's assistant] review .will continue hypnotic . On 05/05/21 at 12:30 PM, the DON was made aware of the above information and was asked for clarification as to why the pharmacy recommendation dated 11/10/20 was not carried out and the resident continued to receive this medication for over 5 months. The DON was also asked to clarify why pharmacy recommendation dated 03/09/21 was not completed by the provider with a clinical justification if the medication was to be continued. On 05/05/21 at 2:00 PM, the administrator and DON were interviewed. The DON stated that a nursing note was written on 11/16/20 and stated that the nurse had called the resident's POA [power of attorney] and that the resident's POA did not want any changes to the resident's medications and that the physician agreed. The DON and administrator were made aware that there was no evidence in the resident's clinical record to evidence that the physician did not want to proceed with a GDR for [MEDICATION(S)] and that the family/POA not wanting medication changes for Resident #8 was not a clinical rationale for the continued use of this medication at a higher dose. No further information and/or documetnation was presented prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate clinical record for one of 20 residents in the survey sample. Resident #18's clinical record documented an inaccurate response to a pharmacy recommendation regarding use of an antipsychotic medication and documented [CONDITION(S)] medication management by a consultant when psychiatric services had been discontinued. The findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #18 with short and long-term memory problems and severely impaired cognitive skills. Resident #18's clinical record documented a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record documented a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated 2/22/21 listed all psychiatric services as discontinued because the resident was now on hospice. Resident #18's clinical record documented a pharmacy recommendation about a [MEDICATION(S)] dose reduction dated 2/2/21. The consultant psychiatrist documented a response on 2/9/21 to decline a reduction in the [MEDICATION(S)] dose. This response to the pharmacy recommendation was uploaded to the electronic health record on 3/19/21. Resident #18's clinical record documented a duplicate pharmacy recommendation about a [MEDICATION(S)] dose reduction dated 3/9/21. A physician's assistant (PA) documented a response to the recommendation on 3/15/21 stating the resident was followed by psychiatric consultant services even though the psychiatric services had been discontinued on 2/22/21. Resident #18's current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/5/21 at 2:05 p.m., the director of nursing (DON) was interviewed about the conflicting pharmacy recommendation responses and clinical record references to psychiatric services when the psychiatrist was discontinued on 2/22/21. The DON stated the original pharmacy recommendation about the [MEDICATION(S)] dose reduction was made on 2/2/21. The DON stated the psychiatrist response was not scanned into the electronic health record promptly. The DON stated when the pharmacist performed the next monthly medication review on 3/9/21 she found no response to the previous recommendation in the clinical record so re-issued another recommendation. The DON stated the response to the 2/2/21 recommendation was not uploaded into the electronic health record until 3/19/21, after the pharmacy review for March. The DON stated the information documented by the PA on the 3/9/21 recommendation that a consultant managed the psychiatric medications was not accurate as psychiatric services for Resident #18 were discontinued on 2/22/21. On 5/5/21 at 3:15 p.m., the DON stated documents were usually scanned and uploaded to the electronic health records daily. The DON stated Resident #18's pharmacy recommendation response dated 2/9/21 must have been missed. This finding was reviewed with the administrator and DON during a meeting on 5/5/21 at 3:00 p.m.

Based on review of employee personnel files and staff interview, the facility failed to ensure one of 25 employees reviewed was currently licensed. A Certified Nursing Assistant (CNA A), was working with an expired license, and did not renew the licensed until [DATE]. The findings were: On [DATE], during review of employee personnel files, a CNA A who was hired on [DATE] was found to have a Nurse Aide license that expired on [DATE]. The surveyor reported the finding to the Administrator and the Director of Nursing (DON) and asked if they could find a current license for the CNA A. At approximately 2:30 p.m. on [DATE], both the Administrator and the DON indicated there was not a current license on file for the CNA A. Asked if the CNA Awas still working, the DON said, Yes. The DON went on to say they were in phone contact with the CNA A and she (the CNA A) was in the process of sending them a copy of her license via text message. At approximately 3:00 p.m. on [DATE], the DON furnished the surveyor with a copy of the license sent by the CNA A. The license consisted of an Online Licensing Payment Receipt from the Board of Health Professions, which had a received date and time of [DATE] at 2:49 p.m. The matter of the expired license was discussed during a meeting with the administrative staff and the survey team prior to the Exit Conference.

Based on staff interview, and clinical record review, facility staff failed to ensure an accurate Code Status for one (1) of 20 residents in the survey sample, Resident #31. Findings included: Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 04/25/2019. Resident #31 was assessed as moderately impaired in his cognitive status with a total cognitive score of nine (9) out of 15. Resident #31's EMR (electronic medical record) was reviewed on 06/05/2019 at 10:00 a.m. While reviewing the Profile Page the Resuscitate status at the top of the page was noted as Yes-Full Code. On the same page, a chart flag included a DNR box (do not resuscitate). The physician order [REDACTED].Do Not Resuscitate . RN #1 (registered nurse) was interviewed on 06/05/2019 at 10:50 a.m. regarding where to locate a resident's code status. RN #1 stated, I look at the smart chart and then look at attachments to make sure a signed DNR is scanned into the system. LPN #1 (licensed practical nurse) was interviewed at 10:52 a.m. and she stated, I just look at the smart chart tab. I have never looked at the Resuscitate at the top of the screen. RN #1 called the SW (social worker) and asked who is responsible for filling in the Resuscitate portion on the profile page. The SW came to the sixth floor nurse's station and stated, That information is entered by (Name) (Medical Records) on admission. If the Code status changes, then the nurse should change on the profile screen. On 06/05/19 at 01:20 p.m. the DON (director of nursing) was interviewed regarding code statuses. The DON stated, We are working with AOD (answers on demand-computer system) right now. When the code status is Full Code or DNR this should automatically change the Resuscitate status in the computer. It is a glitch in the system and they are working on it. Hopefully it will be corrected in the next 24 hours. The Administrator was informed of the above information during a meeting with the survey team on 06/05/19. No further information was received prior to the exit conference.

Based on observations, clinical record review, staff interview, and review of facility documents, the facility staff failed, for one of 15 residents in the survey sample (Resident # 10), to administer medications in the correct manner. Resident # 10 was administered a nasal spray via the wrong route. The findings were: Resident # 10 in the survey sample, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set, an Annual with an Assessment Reference Date of 3/16/17, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 13 out of 15. Resident # 10 had the following medication order, dated 12/8/16: New order per Dr. (name). DC (Discontinue) [MEDICATION NAME] and replace with Calcitonin 1 spray to right nostril QOD (every other day) and 1 spray to left nostril QOD for [MEDICAL CONDITION]. The order was entered on Resident # 10's E-MAR (Electronic - Medication Administration Record) as two separate orders: Calcitonin (salmon) 200 unit/actuation nasal spray (generic) - 1 spray into Right nostril QOD. Dx (Diagnosis) [MEDICAL CONDITION]. Time 0800 (8:00 a.m.). Calcitonin (salmon) 200 unit/actuation nasal spray (generic) - 1 spray into Left nostril QOD. Dx (Diagnosis) [MEDICAL CONDITION]. Time 0800 (8:00 a.m.). Review of the E-MAR revealed the Right nostril days and the Left nostril days were clearly identified on the E-MAR. NOTE: Calcitonin (salmon) is a polypeptide hormone used to increase deposits of calcium in bone. Mosby's Nursing Drug Reference notes the following regarding nasal use, To use alternating nostrils for nasal spray. (Ref. Mosby's 2017 Nursing Drug Reference, 30th Edition, pages 181 and 182.) During the medication pass and pour observation at 8:00 a.m. on 3/29/17, RN # 1 (Registered Nurse) was observed passing medications to Resident # 10, who was seated at a table in the fifth floor dining room waiting for breakfast. After administering several medications in tablet form to Resident # 10, RN # 1 took the Calcitonin nasal spray dispenser, inserted the spray tip in the resident's left nostril and administered one spray. During reconciliation of the medications administered with the medication orders on the E-MAR, it was revealed the Calcitonin should have been administered in the right nostril. According to the E-MAR, the administration of the Calcitonin was signed off as having been administered in the right nostril, which was the day identified on the E-MAR, even though it was administered in the left nostril. At approximately 8:50 a.m. on 3/29/17, the surveyor asked the Director of Nursing (DON) for a copy of the facility's policy on medication administration. Review of the policy provided by the DON revealed the following on page 6 of the policy: 10. Nurse should always remember the 5 R's when administering medications: [REDACTED] RIGHT RESIDENT RIGHT DRUG RIGHT DOSE RIGHT ROUTE RIGHT TIME RIGHT of REFUSAL The Potter-Perry Fundamentals of Nursing manual notes the following regarding medication administration: To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication, 2. The right dose, 3. The right client, 4. The right route, 5. The right time, 6. The right documentation. (Ref. Fundamentals of Nursing, Potter-Perry, 7th Edition, page 707.) The medication pass and pour observations were discussed with the Administrator and DON during a meeting with the survey team at 1:15 p.m. on 3/29/17.

Based on observations, clinical record review, and staff interview, the facility staff failed, for one of 15 residents in the survey sample (Resident # 10), to administer a medication according to physician's orders [REDACTED].# 10 was administered a nasal spray via the wrong nostril. The findings were: Resident # 10 in the survey sample, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set, an Annual with an Assessment Reference Date of 3/16/17, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 13 out of 15. Resident # 10 had the following medication order, dated 12/8/16: New order per Dr. (name). DC (Discontinue) [MEDICATION NAME] and replace with Calcitonin 1 spray to right nostril QOD (every other day) and 1 spray to left nostril QOD for [MEDICAL CONDITION]. The order was entered on Resident # 10's E-MAR (Electronic - Medication Administration Record) as two separate orders: Calcitonin (salmon) 200 unit/actuation nasal spray (generic) - 1 spray into Right nostril QOD. Dx (Diagnosis) [MEDICAL CONDITION]. Time 0800 (8:00 a.m.). Calcitonin (salmon) 200 unit/actuation nasal spray (generic) - 1 spray into Left nostril QOD. Dx (Diagnosis) [MEDICAL CONDITION]. Time 0800 (8:00 a.m.). Review of the E-MAR revealed the Right nostril days and the Left nostril days were clearly identified on the E-MAR. NOTE: Calcitonin (salmon) is a polypeptide hormone used to increase deposits of calcium in bone. Mosby's Nursing Drug Reference notes the following regarding nasal use, .use alternating nostrils for nasal spray. (Ref. Mosby's 2017 Nursing Drug Reference, 30th Edition, pages 181 and 182.) During the medication pass and pour observation at 8:00 a.m. on 3/29/17, RN # 1 (Registered Nurse) was observed passing medications to Resident # 10, who was seated at a table in the fifth floor dining room waiting for breakfast. After administering several medications in tablet form to Resident # 10, RN # 1 took the Calcitonin nasal spray dispenser, inserted the spray tip in the resident's left nostril and administered one spray. During reconciliation of the medications administered with the medication orders on the E-MAR, it was revealed the Calcitonin should have been administered in the right nostril. According to the E-MAR, the administration of the Calcitonin was signed off as having been administered in the right nostril, which was the day identified on the E-MAR, even though it was administered in the left nostril. The medication pass and pour observations were discussed with the Administrator and DON during a meeting with the survey team at 1:15 p.m. on 3/29/17.

Based on observation, staff interview and facility document review, the facility staff failed to wash dishes in a sanitary manner in the main kitchen. The dishwasher in the main kitchen was operating with the wash temperature below the 160 degree F minimum recommended by the dishwasher manufacturer. The findings include: On 3/2/16 at 11:40 a.m. accompanied by the dining services manager, operation of the dishwasher in the main kitchen was observed. During three observed wash/rinse cycles the wash temperature ranged from 148 degrees F to 152 degrees F. The manufacturer's label above the wash/rinse temperature gauges displayed the minimum wash temperature as 160 degrees F. The dining services manager turned the power off, restarted the dishwasher then ran another wash/rinse cycle with the maximum wash temperature reaching 152 degrees F. The dining services manager was interviewed at this time about the wash temperature running below the recommended minimum of160 degrees F. The dining services manager stated the dishwasher was a hot temp machine and that wash/rinse temperatures were supposed to be at or above the minimum temperatures posted on the machine. The dining services manager stated the machine was working properly yesterday. The dining service manager stated she would get maintenance to evaluate the low wash temperature. On 3/2/16 at 2:30 p.m. the facility's maintenance director was interviewed about the low dishwasher temperature. The maintenance director stated the wash temperature was running low and they adjusted the thermostat up to get the temperature to read above 160 degrees F. The maintenance director stated the thermostat has age on it. These findings were reviewed with the administrator and director of nursing on 3/2/16 at 3:35 p.m. On 3/3/16 at 8:50 a.m. the administrator stated an outside vendor evaluated the dishwasher last evening (3/2/16) and the vendor found the temperature sensor was bad and needed replacement. The administrator presented a copy of the outside vendor's maintenance report. This report dated 3/2/16 stated, Found that wash temp was only getting to 162 but not holding. the sensor to the float switch and temp board were shorting out . (sic)

Based on resident interview, staff interview and clinical record review, facility staff failed to ensure an accurate MDS (minimum data set) for one of 15 residents in the survey sample, Resident #8. Facility staff coded Resident #8 as having no impairment in her upper and lower extremities contrary to documentation throughout the clinical record that stated she is flaccid on her left side resulting from [MEDICAL CONDITION]. Findings included: Resident #8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS was a quarterly assessment with an ARD (assessment reference date) of 12/24/2015. Resident #8 was assessed as moderately impaired in her cognitive status with a total cognitive score of 11 out of 15. During the clinical record review of Resident #8 on 03/02/2016 at approximately 7:45 a.m., Section G, Functional Status, Subsection G0400. Functional Limitation in Range of Motion was noted to be coded as zero (No impairment) for both Upper and Lower extremities on her admission MDS with an ARD of 10/07/2015 and also on her quarterly MDS with an ARD of 12/24/2016. Subsequent review of Resident #8's progress notes included documentation of this resident being flaccid on her left side. She also had a cradle with straps attached to the left side of her wheelchair for placement of her left arm. At approximately 10:45 a.m. Resident #8 was interviewed with her helper present. Resident #8 was asked if she had any purposeful movement in her left arm and she stated, No. The helper then stated, She has a little movement in her left leg now, but cannot walk. She is able to stand and pivot with maximum assistance. The MDS Coordinator, RN #1 (registered nurse) was interviewed at approximately 11:20 a.m. regarding the coding of subsection G0400. RN #1 stated, Although she can't move her left side we can perform full ROM (range of motion) of her extremities, so I code her 0/0 (zero/zero) because she isn't contracted. That is what I was told to do by a surveyor in the past. At approximately 11:35 a.m., RN #1 and the DON (director of nursing) entered the conference room and spoke with the survey team regarding instruction in the RAI (resident assessment instrument) manual for coding subsection G0400 of the MDS. It was determined this section for Resident #8 should have been coded 1/1 (one/one). RN #1 stated, Well there is my lesson for the day. The Administrator was informed of the above information during a meeting with the survey team on 03/02/2016 at approximately 3:30 p.m. No further information was received by the survey team prior to the exit conference on 03/03/2016.

Based on medication pass and pour observation, clinical record review and staff interview, the facility staff failed to administer medications per physician order for [REDACTED].# 10. Resident # 10 was administered Mytabs Gas prior to a meal (breakfast). Findings include: Resident # 10 was admitted to the facility 2/10/12 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly review dated 2/25/16. Resident # 10 was coded as cognitively intact with a total summary score of 15 out of 15. On 3/2/16 beginning at 8:05 a.m. a medication pass and pour observation was conducted with RN (registered nurse) # 2. This surveyor recorded medications to be administered to Resident # 10 from the label on the medication card. Included in the medications recorded was Mytabs Gas 80 mg. Give 2 tabs prior to meals and at bedtime. RN # 2 then prepared the medications, and went into the dining room to administer them. Resident # 10 was sitting in the dining room waiting on breakfast. The two Mytabs Gas tablets were the last medications administered. On 3/2/16 at 8:30 a.m. the clinical record was reviewed to reconcile the medications as administered to Resident # 10. A physician order with a start date of 7/5/14 read Mytabs Gas 80 mg. Give 2 tabs after meals and at bedtime. At 8:50 a.m. this surveyor returned to where RN # 2 was continuing to administer medications. Resident # 10 was observed in the dining room eating breakfast. RN # 2 was asked to retrieve the medication card of Mytabs Gas for Resident # 10 to ensure the order had been correctly transcribed by this writer. The label was written as had been transcribed earlier and directed the tablets to be given prior to meals. RN # 2 was asked about the label, and asked what the eMAR (electronic medication administration record) had for the order. RN # 2 pulled up Resident # 10's eMAR and stated It says after meals; I wasn't aware of that. I think you can give it either way. The DON (director of nursing) was also present and stated she would check with pharmacy regarding the labeling of the medication. On 3/2/16 at 9:20 a.m., the DON came to the conference room and told this surveyor The pharmacy said they sent the wrong label; so that was wrong. We got the order changed. On 3/2/16 at 3:30 p.m., the administrator and DON were informed of the above findings during a meeting with facility staff. No further information was provided prior to the exit conference.

Based on medication pass and pour observation, clinical record review and staff interview, the facility staff failed to correctly label a medication according to the physician order for [REDACTED].# 10. Resident # 10's Mytabs Gas medication card was not labeled as the physician order dictated. Findings include: Resident # 10 was admitted to the facility 2/10/12 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly review dated 2/25/16. Resident # 10 was coded as cognitively intact with a total summary score of 15 out of 15. On 3/2/16 beginning at 8:05 a.m. a medication pass and pour observation was conducted with RN (registered nurse) # 2. This surveyor recorded medications to be administered to Resident # 10 from the label on the medication card. Included in the medications recorded was Mytabs Gas 80 mg. Give 2 tabs prior to meals and at bedtime. RN # 2 then prepared the medications, and went into the dining room to administer them. Resident # 10 was sitting in the dining room waiting on breakfast. The two Mytabs Gas tablets were the last medications administered. On 3/2/16 at 8:30 a.m. the clinical record was reviewed to reconcile the medications as administered to Resident # 10. A physician order with a start date of 7/5/14 read Mytabs Gas 80 mg. Give 2 tabs after meals and at bedtime. At 8:50 a.m. this surveyor returned to where RN # 2 was continuing to administer medications. Resident # 10 was observed in the dining room eating breakfast. RN # 2 was asked to retrieve the medication card of Mytabs Gas for Resident # 10 to ensure the order had been correctly transcribed by this writer. The label was written as had been transcribed earlier and directed the tablets to be given prior to meals. RN # 2 was asked about the label, and asked what the eMAR (electronic medication administration record) had for the order. RN # 2 pulled up Resident # 10's eMAR and stated It says after meals; I wasn't aware of that. I think you can give it either way. The DON (director of nursing) was also present and stated she would check with pharmacy regarding the labeling of the medication. On 3/2/16 at 9:20 a.m. the DON came to the conference room and told this surveyor The pharmacy said they sent the wrong label; so that was wrong. We got the order changed. On 3/2/16 at 3:30 the administrator and DON were informed of the above findings during a meeting with facility staff. No further information was provided prior to the exit conference.

Based on observation and staff interview, the facility staff failed to store and distribute food in a sanitary manner. Four quarts of liquid egg product with an expired use by date were available for use in the main kitchen refrigerator. A counter mounted can opener in the main kitchen was dirty. The findings include: On 3/10/15 at 1:40 p.m. accompanied by the general manager of food services and the dining operations manager, the facility's main kitchen and food storage areas were inspected during the initial tour of the facility. During this inspection four quart cartons of liquid egg product labeled by the manufacturer with a use by date of 2/20/15 were stored in the walk-in refrigerator. The quart containers had not been opened and had no facility applied labels on the cartons. The containers of liquid egg product were shown to the general manager of food services and the dining operations manager at the time of the inspection. The dining operations manager removed the items from storage and discarded them. On 3/10/15 at 1:50 p.m. the counter mounted manual can opener in the food preparation area was inspected and found to be dirty. Accumulated, dried black debris was observed on the can opener base bracket and on the removable cylinder and blade of the opener. At the time of this inspection the general manager of dining operations was shown and interviewed about the can opener. The general manager of dining operations stated the can opener needed to be cleaned. On 3/10/15 at 1:55 p.m. the executive chef was interviewed about the four quarts of liquid egg product with a use by date of 2/20/15. The executive chef stated, "That (out of date egg product) shouldn't have been there...That doesn't make sense." On 3/11/15 at 9:00 a.m. the executive chef presented a copy of a "pull sheet" listing items removed on 3/6/15 from the freezer. The executive chef stated he thought the four quarts of egg product had been previously frozen and were removed from the freezer on 3/6/15. The executive chef stated they had 7 days to use the product after removal from the freezer. When asked how the four quart cartons of egg product with the expired use by date were identified as those on the pull sheet, the executive chef stated the cartons were supposed to be labeled with a sticker indicating the date removed from the freezer and a use by date. Concerning the dirty can opener, the executive chef stated the can openers were supposed to be cleaned at the end of each day's use. These findings were reviewed with the administrator and director of nursing on 3/11/15 at 12:00 p.m.

Based on staff interview, family interview, and clinical record review the facility staff failed to notify the POA (power of attorney) of a change in roommate status for one of 15 residents in the survey sample, Resident # 7. Resident # 7's daughter, the POA, was not notified that the resident was getting a new roommate. Findings include: Resident # 7 was admitted to the facility 4/14/13 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly review dated 1/2/14. Resident # 7 was assessed as being severely impaired in cognition. The electronic medical record was reviewed 2/19/14 at approximately 9:35 a.m. A nursing note dated 1/16/14 documented "Daughter expressed displeasure to charge nurse after dinner before leaving unit regarding resident having roommate without RP (responsible party) being notified. Daughter stated "you all call for the littlest things but you did not let me know that!" Apologized to RP/daughter and Supervisor informed of daughter's reaction to resident having a roommate." On 2/19/14 at approximately 2:10 p.m. the DON (director of nursing) was interviewed. The DON was asked if residents and/or the legal representatives/interested family members were told when a resident was to get a roommate. The DON stated "The roommate was most likely admitted late and (name of resident's) daughter doesn't like to be called at night." The DON was then asked if it was known what time the resident's roommate was admitted . The DON and this surveyor reviewed the roommate's admission note, and per documentation the roommate was admitted at 11:30 a.m. 1/15/14. The DON then stated "Usually social services informs the POA/RP of a roommate coming in." The DON then stated she would have the social worker (SW) come and speak with this surveyor. A few moments later, the SW came to the conference room. The SW was asked when notification was done for a resident for a potential roommate. The SW stated "I don't do that. It's explained on admission that if a resident is admitted to a semi-private room, there's a possibility they will get a roommate at some point. I get an email from admissions that we are getting a resident coming in; I usually know the day of..." On 2/19/14 at approximately 2:55 p.m. the resident's daughter was interviewed via telephone. Resident # 7's daughter stated "I hadn't been over to see mother for a couple of days due to schedule, but when I got there the 16th of January, there was a roommate in there with her. I had no idea they were putting anyone in there." The administrator and DON were informed of the above findings 2/19/14 at approximately 4:00 p.m. during an end of the day meeting with facility staff.

Based on staff interview and clinical record review, the facility staff failed to follow a physician's order for one of 15 resident's in survey sample, Resident # 8. The facility staff failed to administer Resident # 8 a physician ordered medication ([MEDICATION NAME] 40 milligrams) twice daily for 14 days, as ordered. Findings include: Resident # 8 was admitted to the facility originally on 11/04/11. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a significant change assessment, dated 01/09/14. The resident was coded as having long and short term memory impairment with severe impairment in daily decision making skills. The resident was also assessed as requiring extensive assistance from staff for most ADL's (activities of daily living). During clinical record review on 02/19/14, Resident # 8's current POS (physician's order sheet) was reviewed. The POS included orders for: "...01/25/14 [MEDICATION NAME] 40 MG granules delayed release 1 packet PO (by mouth) BID (twice daily) X (times) 2 weeks for GI bleed..." The resident's MARs (medication administration records) for January 2014 and February 2014 were reviewed and documented that the resident received [MEDICATION NAME] 40 mg BID for only 7 days, not 14 days as ordered by the physician. On 02/19/14 at 1:50 p.m., the DON (director of nursing) was interviewed to clarify the above. The DON stated that the nurse entered 14 doses into the computer, not 14 days as ordered by the physician. The administrator was made aware, along with the DON in a meeting with the survey team on 02/19/14 at 5:00 p.m. No further information was provided prior to the exit conference on 02/20/14 at 12:25 p.m.

Based on staff interview and clinical record review, the facility staff failed to provide a clinical rationale on a pharmacy recommendation for one of 15 residents in the survey sample, Resident # 10. Findings include: Resident # 10 was admitted to the facility on [DATE], with the most current readmission on 01/18/14. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of "9", which indicated the resident had moderate impairment in daily decision making skills. The resident was also assessed on this MDS as requiring limited assistance from staff for most ADL's (activities of daily living). During clinical record review on 02/20/14, the resident's current POS (physician's orders [REDACTED]...01/26/14 Famotidine 20 mg (milligrams) 1 PO (by mouth) TWICE A DAY..." Further review of the clinical record revealed a Pharmacy recommendation dated 02/06/14. The Pharmacy recommendation documented: "...This resident is receiving a drug which should not be given in severe renal impairment or dosed conservatively in moderate impairment...CrCl (creatinine clearance) based on labs dated 10/01/13 is ~32ml/min. Please consider a dose reduction of the famotidine to 20 mg PO (by mouth) q HS (every night at bedtime) unless clinically contraindicated...." The physician marked the box "DISAGREE" and signed. No rationale was provided for the continued use of this medication. The physician's progress notes for Resident # 10 were then reviewed. No information or clinical rationale was documented regarding the continued use of this medication. The resident's CCP (comprehensive care plan) was reviewed and documented: "...Potential for complication related to indigestion/GERD...select foods which do not exacerbate symptoms...upright or semi-fowler's position for eating and following meal for 30 minutes as resident allows...medications as ordered by MD (medical doctor)...Alert MD concerning resident's condition..." The DON and administrator were made aware on 02/20/14 at 10:30 a.m. in a meeting with the survey team of the failure to provide a clinical rationale for the continued use of the medication, after the pharmacy identified this irregularity on the resident's medication regimen. The DON stated that the she understood and agreed that a rationale should be provided, given the pharmacy recommendation. The DON further stated that doctors can be resistive to changing or decreasing medications. No further information or documentation was provided prior to the exit conference on 02/20/14 at 12:15 p.m.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure dignity and respect for one of 15 residents, resident #12, while performing a dressing change. Facility staff failed to close the curtains on a large window while changing a dressing to the sacral area of resident #12. Findings included: Resident #12 was admitted to the facility on [DATE], with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The latest MDS (Minimum Data Set) for resident #12 was a quarterly assessment with an ARD (Assessment Reference Date) of 12/19/2012. Resident #12 was assessed as having problems with both her short and long term memory, and was moderately impaired with daily decision making. On 02/21/2013 at approximately 10:30 a.m., the clinical (EMR-electronic medical record) record was reviewed. During this review a physician's orders [REDACTED]. At approximately 12:55 p.m. RN #1 (Registered Nurse) was asked if Resident #12's dressing had been changed and she stated, "no, they (CNA's-certified nursing assistants) are preparing to lay her down now and I will do dressing change to sacral area." This surveyor asked to observe the dressing change. At approximately 1:10 p.m., Resident #12 was lying in bed supine, with a shirt on, adult brief and bed covers to her knees. CNA #2 assisted RN #1 to position Resident #12 on her left side, with this resident's buttocks facing a large window that overlooked a deck, one floor below. The curtain on this window was not closed during the dressing change procedure. After RN #1 completed the dressing change this surveyor asked RN #1 if anyone could see in the window. RN #1 stated, "I don't think so. I can't see in windows across the way (meaning resident rooms in another building, at the opposite end of the deck). I could pull the shade." RN #1 then closed the curtain over the window during the remainder of Resident #12's incontinence care. At approximately 2:00 p.m., this surveyor went to the deck that was one floor below resident #12's room. While standing on the deck this surveyor was able to stand just below Resident #12's window and see into the room. The curtain was still partially closed and a poinsettia plant was seen sitting in the window. During a meeting with survey team at approximately 2:40 p.m., the DON (Director of Nursing) was asked what her expectations would be for closing the curtain while performing any kind of care to this resident. The DON stated, "I would expect for them to pull the curtain." The Administrator stated, "I would expect as 'best practice' the curtain to be pulled." No further information was received by the survey team prior to the exit conference on 02/21/2013.

Based on medication pass and pour observation, staff interview, and facility document review the facility staff failed to ensure the proper storage and labeling of medications and biological's on one of two floors, 6 Hearthside, and on one medication cart on 5 Drinkard. An expired vial of Aplisol (tuberculin skin test solution) was available for administration in the medication refrigerator on 6 Hearthside. A bottle of liquid Metropolol (a blood pressure medication) was left unattended on a medication cart on 5 Drinkard. Findings include: 1. An inspection of the medication refrigerator on 6 Hearthside on [DATE] at approximately 8:45 a.m. was conducted with LPN (Licensed Practical Nurse) # 1. A vial of Aplisol with a handwritten date of [DATE] was found in the refrigerator. LPN # 1 stated "The 'open' date of the vial is on a sticker on the bottom of the vial." The sticker on the bottom of the vial was dated [DATE]. LPN # 1 was asked about the dates on the vial. LPN # 1 stated "It (the vial) should be discarded after 30 days." The DON (Director of Nursing) was asked for the facility's policy for storage and labeling of Aplisol on [DATE] at approximately 10:30 a.m. The DON presented a copy of the requested policy a few minutes later. Per facility policy "Medications with Special Expiration Date Requirements" under "ITEM" was "PPD (Aplisol, Tubersol)." The expiration date beside those items was documented "30 days after opening." The administrator, DON, and director of clinical education were informed of the above findings [DATE] at approximately 10:45 a.m. during a meeting with facility staff. 2. A medication pass and pour observation was conducted on the fifth floor "Drinkard" beginning at approximately 8:00 a.m. on [DATE]. Observed on the top of the medication cart was a rectangular plastic container. The container was filled with approximately one inch of ice and various items were stored on the ice such as liquid supplements and applesauce. Also observed in the plastic container was a bottle of liquid Metoprolol labeled with a resident's name and a sticker that said "Keep Refrigerated." The Metoprolol concentration was 6.25 mg per 5 mls, the bottle contained approximately 440 mls. LPN #1 was observed preparing medications for one resident which included Hydrocodone 7XXX,[DATE] mg, a controlled substance. LPN #1 was observed to open a separate locked compartment of the medication cart to retrieve the hydrocodone. When all the medications were prepared and placed in a medication cup the medications cards were returned to the medication cart. The hydrocodone was not returned to the separate locked compartment within the cart but placed in the area with the other medications. The cart was locked and LPN # 1 proceeded to administer medications. Medications were observed being given to two different residents. LPN #1 left the cart in the hallway and went into two different rooms to administer oral medications and eye drops. The liquid Metoprolol was left on top of the cart during the entire observation. LPN #1 could not visualize the medication cart from either of the rooms she entered. Numerous residents were observed going up and down the hallway by the medication cart on their way to and from breakfast. The observation ended at approximately 8:40 a.m. LPN #1 was asked where controlled substances were stored on the medication cart. She stated, "They are over her in the narcotics box." LPN #1 was asked when the medication cards were returned to the narcotics box after a medication was obtained. She stated, "As soon as we get the medication out of the card it we put it back." LPN #1 was asked where the hydrocodone card was that had been administered during the observation. LPN #1 looked and stated, "I forgot to put it back, you made me nervous." LPN #1 then returned the hydrocodone to the separate locked compartment in the mediation cart. LPN #1 was then asked about the Metoprolol on top of the medication cart. She stated, "We get that out of the refrigerator in the morning and put it on the cart...I gave it to him at about 7:55 a.m." LPN #1 was asked what time the medication had been placed on the top of the cart and she stated, "About 7:45 this morning." LPN #1 continued, "I should have put it back in the refrigerator after I gave it but you came up to do meds and I forgot about it." The DON was on the unit at the time medication pass observation was completed and she was informed of the both the hydrocodone storage and the metoprolol on top of the cart. She stated, "(Name of LPN #1) is a very good nurse...I can say this is an isolated incident." At approximately 9:30 a.m., the DON was in the conference room and was asked for any information/policy regarding medication storage. The DON stated, "The medication should have been gotten out of the refrigerator, given to the resident and returned to the refrigerator. It should not have been placed on top of the cart. I have started a plan of correction to reeducate everybody." A policy and procedure was obtained from the DON at approximately 2:00 p.m. regarding controlled medications. According to the facility policy: "3. The access system...used to lock Scheduled II medications and other medications subject to abuse cannot be the same access system used to obtain the non-scheduled medications." Also obtained was information from the "National Children's Pharmacy that stated, the liquid metoprolol could be refrigerated or stored at room temperature. The DON was asked if the pharmacy used by the facility was the National Children's Pharmacy. She stated, "No, but that is what her pharmacy had sent." The DON was asked why the pharmacy labeled the medication to be refrigerated if that was not necessary. She stated, I don't know." The DON was asked if she could get further clarification. No further information was obtained prior to the exit conference on [DATE].