2. For Resident #112, the facility staff failed to follow the medical provider's order for the administration of Metoprolol Succinate, a beta-blocker used to treat angina, heart failure, and hypertension, on six (6) separate occasions. Resident #112's diagnosis list indicated diagnoses, which included, but not limited to Hypertensive Chronic Kidney Disease, End Stage Renal Disease, Essential Hypertension, and Hemiplegia and Hemiparesis following Cerebral Infarction. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 2/07/23 assigned the resident a brief interview for mental status (BIMS) summary score of 13 out of 15 indicating the resident was cognitively intact. Resident #112's current physician's orders included an active order dated 6/10/22 for Metoprolol Succinate ER 50 mg one time a day for essential hypertension and hold for a systolic blood pressure (SBP) less than 110, heart rate less than 60. A review of Resident #112's April 2023 and May 2023 medication administration records (MARs) documented the administration of Metoprolol Succinate on the following occasions when the SBP was less than 110: 4/02/23 9:00 am - SBP 107 4/06/23 9:00 am - SBP 99 4/09/23 9:00 am - SBP 88 4/29/23 9:00 am - SBP 108 5/02/23 9:00 am - SBP 109 5/03/23 9:00 am - SBP 99 Resident #112's current comprehensive person-centered care plan included an intervention dated 1/26/23 stating in part to give medications as ordered by the physician. On 5/03/23 at 5:23 pm, the survey team met with the Administrator, Assistant Administrator #1 and #2, Director of Nursing, and the Assistant Director of Nursing and discussed the concern of staff administering Resident #112's Metoprolol Succinate when the SBP was less than 110. On 5/04/23 at 12:42 pm, surveyor spoke with licensed practical nurse (LPN) #7, who stated they did not administer Resident #112's Metoprolol Succinate on 5/03/23 but might have documented administration in error. LPN #7 further stated Resident #112 watched their blood pressure and when it was low, they did not want the medication. No further information regarding this concern was presented to the survey team prior to the exit conference on 5/04/23. Based on staff interview, clinical record review and facility document review the facility staff failed to ensure residents received treatment and care in accordance with provider orders for 2 of 43 residents, Resident #284 and Resident #112. The findings were: 1. Facility staff failed to ensure Resident #284 received occupational therapy (OT) and speech therapy (ST) as ordered and according to the therapy plans of care. Resident #284's minimum data set with an assessment reference date of 09/02/22 coded the resident's brief interview for mental status a 04 out of 15 in Section C (cognitive patterns). Section G (functional status) coded the resident required extensive assistance with bed mobility, toileting, and eating. For support with eating, the resident needed one person physical assist. The clinical record contained provider orders for OT and ST: 1. OT clarification order on 8/28/22 for five times/week for 30 days to address in strength, functional mobility and ADL (activities of daily living) performance. An order written on 9/30/22 was to continue OT Plan of Care: Skilled OT five times a week for 4 weeks for self care management training, therapeutic activities, therapeutic exercises, group therapeutic procedure, and neuromuscular regarding education. 2. An order, written on 8/29/22, for ST to treat five times a week for four weeks for dysphagia management, cognitive-linguistic communication, verbal expression/comprehension, caregiver training and discharge planning. On 5/03/23 at 3:21 p.m., the director of rehabilitation services (DOR) and the rehabilitation services' area manager were interviewed. The area manager reported looking into Resident #284's therapy treatments and determined the resident missed some therapy appointments for documented reason such as have a CT Scan. The area manager acknowledged there was a week and half where approximately 6 OT visits were missed without explanation. The DOR and area manager were interviewed again on 5/04/22 at 12:35 p.m. when the manager acknowledged Resident #284's OT appointments were not scheduled at a correct frequency. There was no explanation for those missed visits. There was also one missed speech therapy appointment without explanation. The DOR and area manager reported none of the therapists familiar with the resident's treatments were working during the survey. The DOR at the time of Resident #284's stay was no longer employed at the facility. The administrator was informed of the above findings on 5/04/23 at 4:35 p.m. No further information was provided prior to the exit conference.

Based on medical record review, facility document review and staff interview, the facility staff failed to ensure a licensed pharmacist completed medication regimen reviews monthly on one of 5 residents in the survey sample. Findings include: For resident # 182 the facility staff failed to ensure a medication regimen review (MRR) was performed for the month of November 2022. Resident #182's diagnoses included but was not limited to hypertension, Parkinson's Disease, unspecified mood disorder, neurocognitive disorder with lewy bodies, and major depressive disorder. The most recent quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 2/21/23 assigned resident #182 a Brief Interview for Mental Status (BIMS) score of 13/15 indicating they are cognitively intact. Upon review of resident #182's clinical record, surveyor was unable to locate the November 2022 medication regimen review completed by a pharmacist. On 5/4/23, during a review of resident #182's clinical record, the surveyor was unable to locate the MRR for November 2022 and requested the Director of Nursing (DON) look for evidence that it was done. On 5/4/23 at 2:43 PM, the DON stated to surveyor that they had spoken to the pharmacist and determined the review for November 2022 was not done. They went on to explain that resident #182 had moved rooms when the November reviews were being done and This one was just missed. Surveyor requested and received the policy entitled, Medication Regimen Reviews which read in part, Medication regimen reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated. On 5/4/23 at 4:23 PM surveyor met with the Administrator and reviewed this concern. No further information regarding this concern was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, family interview, clinical record review and facility document review and in the course of a complaint investigation the facility staff failed to ensure the resident was able to make choices important to the resident as evidenced by staff placement of a Wander Guard device to prevent the resident leaving the nursing unit for 1 of 40 residents in the survey sample (Resident #381). The findings include: Resident #381 was admitted to the facility with diagnoses including surgical aftercare, respiratory failure with hypoxia, cardiopulmonary disease, malnutrition, bronchitis, intra-abdominal hemangioma, hypertension, and gastroesophageal reflux disorder. On the Minimum Data Set assessment with assessment reference date 2/4/2022, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The face sheet listed the resident as the responsible party/resident representative. The resident intended a short-term stay for skilled services. The State survey and certification agency received a complaint concerning violation of the resident's rights on 2/9/2022. The complainant alleged the resident's rights had been violated when facility staff placed a wanderguard on the resident to prevent the resident from going outside to smoke. Clinical record review revealed no documentation of safety concerns such as confusion, wandering, or unsteady gait. A Navigation Planning Update (care plan) note dated 2/2/2022 at 13:42 did not mention concerns with the resident's cognitive status or safety. The resident's care plan (printed 2/16/2022 at 12:54 PM) in the electronic record did not address concerns with safety regarding smoking or list concerns that would prohibit the resident from leaving the building. (Note: After the surveyor expressed concern that the resident's care plan did not address smoking, a form titled Interdisciplinary Careplan Smoking Risk was uploaded to the resident's closed record under the miscellaneous tab. This document did not mention restricting residents to the building or placing restraints on residents.) Nursing notes on 2/5/2022 included a Health Status Note on 2/5/2022 at 7:15 AM During morning shift change resident noted sitting at the lobby area [NAME] a jacket. Writer asked resident if she is planning to go outside. Resident voiced wanting to go outside for smoke. Writer explained to resident about facility protocol and resident agreed and returned to the room. Resident is own RR. Shift supervisor notified. A second Health Status Note on 2/5/2022 at 11:07 AM Resident requested to leave against medical advice> Resident refused to wear Wander Guard and gave writer her Cigarette lighter. Resident stated 'my Dr will be here at 2pm to discharge me'. Resident is self(Responsible party). Will continue to monitor. The surveyor interviewed the minimum data set (MDS) assessment nurse on 2/16/2022. The MDS nurse indicated that the wander guard was intended to keep the resident from going outside. The Smoking risk did not address strategies to address the resident's desire to smoke other than to apply nicotine patches and monitor compliance with nicotine patches. There was no explanation for lack of interventions to assist the resident in overcoming the desire to smoke or to safeguard a resident who wanted to smoke. The nurse caring for the resident that day stated during an interview on 2/24/22 that the nursing supervisor instructed the nurse to put a wander guard on the resident to keep the resident from trying to go outside, so the nurse did. The administrator and director of nursing were made aware of the concern with resident choice on 2/16/22 during interviews concerning the resident's allegations. This is a complaint deficiency.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to address code status for 2 of 40 residents in the survey sample, Resident #180 and #275. For Resident #180 and #275, the current physician's orders did not address code status. The findings included: 1. Resident #180 diagnosis list indicated diagnoses, which included, not limited to Nontraumatic Intracerebral Hemorrhage, Chronic Respiratory Failure, Dependence on Respirator, Persistent Vegetative State, Type 2 Diabetes Mellitus, Muscle Wasting and Atrophy, Major Depressive Disorder, Dysphagia, Aphonia, and Malignant Neoplasm of Prostate. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 1/20/22 coded the resident as being in a persistent vegetative state. On 2/16/22, surveyor reviewed Resident #180 clinical record and was unable to locate a current physician's order regarding the resident's code status. Surveyor requested and received the facility policy entitled Advanced Directives which read in part 20. The director of nursing services or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The attending physician will not be required to write orders for which he or she has an ethical or conscientious objection. On 2/16/22 at 4:00 pm, surveyor met with the administrator, assistant administrator, and the DON (director of nursing) and discussed the concern of Resident #180 not having a current physician's order addressing their code status. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/24/22. 2. Resident #275's diagnosis list indicated diagnoses, which included, but not limited to Amyotrophic Lateral Sclerosis, Acute and Chronic Respiratory Failure, Dependence on Respirator Status, Type 2 Diabetes Mellitus, Epilepsy, Heart Failure, Severe Protein-Calorie Malnutrition, Dysphagia, Hypotension, and Sacral Pressure Ulcer. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 2/04/22 assigned the resident a BIMS (brief interview for mental status) summary score of 15 out of 15 indicating the resident was cognitively intact. On 2/16/22, surveyor reviewed Resident #275's clinical record and was unable to locate a current physician's order regarding the resident's code status. Surveyor requested and received the facility policy entitled Advanced Directives which read in part 20. The director of nursing services or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The attending physician will not be required to write orders for which he or she has an ethical or conscientious objection. On 2/16/22 at 4:00 pm, surveyor met with the administrator, assistant administrator, and the DON (director of nursing) and discussed the concern of Resident #275 not having a current physician's order addressing their code status. On 2/23/22, the DON provided surveyor with a copy of a physician's order for Resident #275 dated 2/16/22 at 4:57 pm stating Full Code. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/24/22.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to promptly consult the provider and inform the resident representative of a significant change in the resident's physical status for 1 of 40 residents in the survey sample, Resident #8. The findings include: For Resident #8, the facility staff failed to promptly notify the provider and RR (resident representative) of a significant weight loss. A 21.8 pound weight loss was identified on 1/07/22, however, the provider and RR were not notified until 1/26/22. Resident #8's diagnosis list indicated diagnoses, which included, but not limited to Muscle Wasting and Atrophy, Respiratory Failure, Essential Hypertension, Anoxic Brain Damage, Persistent Vegetative State, Protein-Calorie Malnutrition, Osteomyelitis, Acute Kidney Failure, and Unstageable Pressure Ulcer of Sacral Region. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/12/21 coded the resident as being severely impaired in cognitive skills for daily decision making. Resident #8 was coded as requiring extensive assistance with personal hygiene and being totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, and bathing. The resident was coded for the presence of a feeding tube in which they received 51% or more of total calories and 501 cc/day or more average fluid intake. Resident #8's current comprehensive person-centered plan of care included a focus area initiated 5/27/21 stating Resident is at risk for nutritional decline related to multiple wounds, NPO (nothing by mouth) status, recurring hospitalizations, and unplanned wt. (weight) loss. Resident receives 100% of estimated nutritional needs via enteral nutrition. Current interventions include in part Monitor & evaluate weight/weight changes and Notify RD (registered dietician), family, and physician of significant weight changes. Resident #8's current physician's orders included an order dated 11/09/21 for Jevity 1.5 (tube feeding formula) at 65 ml/hour for 20 hours, up at 12:00 pm and down at 8:00 am. Order states provides 1300 ml total volume / 1950 kcals/ 88 g pro (protein) / 988 ml H2O (water). On 2/15/22 at 3:04 pm, surveyor observed Resident #8 in bed receiving Jevity 1.5 via tube feeding pump at 65 ml/hour. Resident did not respond to the surveyor's presence in the room. Surveyor reviewed Resident #8's documented weights in the clinical record and noted a significant weight loss of 21.8 pounds which occurred in a 5 day span from 1/02/22 to 1/07/22. On 1/02/22 the resident weighed 133.8 pounds and on 1/07/22 the resident weighed 112 pounds. Documented weights surrounding the loss were: 12/13/21 135.8, 1/01/22 133.8, 1/02/22 133.8, 1/07/22 112, 1/19/22 114.7. Resident #8's current weight of 113.4 was obtained on 2/23/22. Surveyor was unable to locate documentation of provider or RR notification of the significant weight loss. A RD progress note dated 1/13/22 states in part Resident triggers for an unplanned significant weight loss. Appears weight mostly stable at 134 - 136 # (pounds) since 11/24 (x approximately 1.5 months), now with a sig (significant) weight loss of -21.8 # in 5 days which is unlikely. Order reweight to confirm weight loss. RD to continue POC (plan of care). The next documented weight following this RD note was obtained on 1/19/22 and was 114.7 pounds. The RD next addressed Resident #8's weight on 1/26/22, the progress note states in part CBW (current body weight) 114.7 #, BMI (body mass index) 18.0 (underweight). Resident triggers for significant weight loss x 1 month and 6 months (unfavorable). Currently with favorable 2.7 # weight gain x 2 weeks. Resident noted with weight fluctuations. Resident at risk for weight fluctuations r/t enteral nutrition RD recs (recommendations): continue enteral as ordered, continue active protein r/t (related to) wound healing and weight stability/gain. On 2/24/22 at 2:50 pm, surveyor met with the DON (director of nursing) and DON provided surveyor with a late entry nursing progress note created on 2/23/22 at 2:14 pm for the effective date of 1/26/22 2:11 pm stating Resident was noted with a significant weight lose [sp]. MD and RR made aware of the above. On 2/24/22 at 2:58 pm, surveyor spoke with RD #1 who stated Resident #8 was being weighed weekly and weights were stable. RD #1 also stated the resident was tolerating tube feedings well. Surveyor requested and received the facility policy entitled Change in a Resident's Condition or Status which read in part: 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): d. significant change in the resident's physical/emotional/mental condition; 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b. there is a significant change in the resident's physical, mental, or psychosocial status; 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. On 2/24/22 at 4:35 pm, survey team met with the administrator, assistant administrator, and DON and discussed the concern of the delay in notifications regarding of Resident #8's significant weight loss. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/24/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, family interview, clinical record review and in the course of a complaint investigation the facility staff failed to ensure a resident was free from physical restraint not required to treat the resident's medical symptoms as evidenced by staff placement of a Wander Guard device to prevent the resident leaving the nursing unit for 1 of 40 residents in the survey sample (Resident #381). The findings include: Resident #381 was admitted to the facility with diagnoses including surgical aftercare, respiratory failure with hypoxia, cardiopulmonary disease, malnutrition, bronchitis, intra-abdominal hemangioma, hypertension, and gastroesophageal reflux disorder. On the Minimum Data Set assessment with assessment reference date 2/4/2022, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The face sheet listed the resident as the responsible party/resident representative. The resident intended a short-term stay for skilled services. The State survey and certification agency received a complaint concerning violation of the resident's rights on 2/9/2022. The complainant alleged the resident's rights had been violated when facility staff placed a wanderguard on the resident to prevent the resident from going outside to smoke. Clinical record review revealed no documentation of safety concerns such as confusion, wandering, or unsteady gait. A Navigation Planning Update (care plan) note dated 2/2/2022 at 1:42 p.m. did not mention concerns with the resident's cognitive status or safety. The resident's care plan (printed 2/16/2022 at 12:54 PM) in the electronic record did not address concerns with safety regarding smoking or list concerns that would prohibit the resident from leaving the building. (Note: After the surveyor expressed concern that the resident's care plan did not address smoking, a form titled Interdisciplinary Careplan Smoking Risk was uploaded to the resident's closed record under the miscellaneous tab. This document did not mention restricting residents to the building or placing restraints on residents.) Nursing notes on 2/5/2022 included a Health Status Note on 2/5/2022 at 7:15 AM During morning shift change resident noted sitting at the lobby area [NAME] a jacket. Writer asked resident if she is planning to go outside. Resident voiced wanting to go outside for smoke. Writer explained to resident about facility protocol and resident agreed and returned to the room. Resident is own RR. Shift supervisor notified. A second Health Status Note on 2/5/2022 at 11:07 AM Resident requested to leave against medical advice> Resident refused to wear Wander Guard and gave writer her Cigarette lighter. Resident stated 'my Dr will be here at 2pm to discharge me'. Resident is self(Responsible party). Will continue to monitor. The surveyor interviewed the minimum data set (MDS) assessment nurse on 2/16/2022. The MDS nurse indicated that the wander guard was intended to keep the resident from going outside. The Smoking risk did not address strategies to address the resident's desire to smoke other than to apply nicotine patches and monitor compliance with nicotine patches. There was no explanation for lack of interventions to assist the resident in overcoming the desire to smoke or to safeguard a resident who wanted to smoke. The nurse caring for the resident that day stated during an interview on 2/24/22 that the nursing supervisor instructed the nurse to put a wander guard on the resident to keep the resident from trying to go outside, so the nurse did. The surveyor determined the resident was restrained for convenience based on the CMS definition of position change alarms and the facility policy Wander Management System, Use of: Policy Interpretation and Implementation 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will implement a wander management system device, if recommended as part of care. 3. The wander management system device will be used in conjunction with other resident-specific interventions for the management of unsafe wandering. The surveyor found no documented evidence that the resident had been assessed and found to be at risk due to the expressed desire to go outside to smoke and the resident had not been found unable to make decisions concerning daily life. The facility policy Use of Restraints: Policy Statement- Restraints shall only be used for the safety and well-being of residents and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or prevention of falls. Policy Interpretation and Implementation 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove the device in the same manner that facility staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, this device is considered a restraint. 5. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to: a. treat the medical symptom; b. protect the resident's safety; and c. help the resident attain the highest practicable well-being. During record review and staff interview, the surveyor was unable to discover a medical symptom being treated by placement of a Wander Guard device on the resident. Staff members (MDS nurse and charge nurse) reported the purpose of the device was to prevent the resident leaving the nursing unit without staff knowledge. The resident's decision to leave the facility and make a formal complaint about being unduly restrained indicated the resident was capable of understanding the situation and considered the device to be a restraint. Facility staff did not assess the resident for need of a restraint device, contact the physician for an order, or contact the resident's family contact to discuss consent for restraint. The administrator and director of nursing were made aware of the concern with resident restraint on 2/24/22 during interviews concerning the resident's allegations. This is a complaint deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review the facility staff failed to develop and implement baseline care plan in order to provide effective and person-centered care as evidenced by lack of a baseline care plan that included approaches to assist a resident who smokes in coping with residents in a non-smoking facility for 1 of 40 residents, Resident #381. The findings include: Resident #381 was admitted to the facility with diagnoses including surgical aftercare, respiratory failure with hypoxia, cardiopulmonary disease, malnutrition, bronchitis, intra-abdominal hemangioma, hypertension, and gastroesophageal reflux disorder. On the Minimum Data Set assessment with assessment reference date 2/4/2022, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The face sheet listed the resident as the responsible party/resident representative. The resident intended a short-term stay for skilled services. The State survey and certificantion agency received a complaint concerning violation of the resident's rights on 2/9/2022. The complainant alleged the resident's rights had been violated when facility staff placed a wanderguard on the resident to prevent the resident from going outside to smoke. A Navigation Planning Update (care plan) note dated 2/2/2022 at 1:42 did not mention concerns with the resident's risk for smoking. The resident's care plan (printed 2/16/2022 at 12:54 PM) in the electronic record did not address concerns with safety regarding smoking or list concerns that would prohibit the resident from leaving the building. After the surveyor expressed concern that the resident's care plan did not address smoking, a form titled Interdisciplinary Careplan Smoking Risk was uploaded to the resident's closed record under the miscellaneous tab. The minimum data set assessment nurse reported the facility's care plan did not allow staff to address smoking because the facility was a non-smoking facility. The document uploaded had been stored in that nurse's files. The document listed Goal:Resident will be in compliance with nicotine patch with no episodes of smoking through next review Approaches: 1. Nicotine Patch as MD ordered 2. Monitor resident compliance with nicotine patch. No other interventions were listed. The medication administration record documented the nicotine patches were not administered (code 22) on 2/1, 2/2, 2/3, and 2/5 and refused (code 2) on 2/4. Nursing notes on 2/5/2022 included a Health Status Note on 2/5/2022 at 7:15 AM During morning shift change resident noted sitting at the lobby area [NAME] a jacket. Writer asked resident if she is planning to go outside. Resident voiced wanting to go outside for smoke. Writer explained to resident about facility protocol and resident agreed and returned to the room. Resident is own RR. Shift supervisor notified. A second Health Status Note on 2/5/2022 at 11:07 AM Resident requested to leave against medical advice. Resident refused to wear Wander Guard and gave writer her Cigarette lighter. Resident stated 'my Dr will be here at 2pm to discharge me'. Resident is self(Responsible party). Will continue to monitor. There was no explanation for lack of interventions to assist the resident in overcoming the desire to smoke or to safeguard a resident who wanted to smoke. The administrator and director of nursing were made aware of the concern with care planning on 2/16/22 during interviews concerning the resident's care plan.

2. Resident #380's face sheet listed diagnoses which included but not limited to acute and chronic respiratory failure, heart failure, malignant neoplasm of bronchus or lung, atrial fibrillation, and hypertension. Resident #380's admission MDS (minimum data set) with an ARD (assessment reference date) of 02/10/22 assigned the resident a BIMS (brief interview for mental status score of 6 out of 15 in section C, cognitive patterns. This indicates the resident is moderately cognitively impaired. Resident #380's comprehensive care plan was reviewed and contained a care plan for Resident is at risk for chronic pain r/t (related to) Disease Process from S/P (status post) Fall, Metastatic Right Lung Cancer . Resident #380's clinical record was reviewed and contained a physician's order summary for the month of February 2022 which read in part, Dexamethasone Tablet 4 mg. Give 1 tablet by mouth three times a day related to MALIGNANT NEOPLASM OF UNSPECIFIED PART OF UNSPECIFIED BRONCHUS OR LUNG (C34.90). Resident #380's eMAR (electronic medication administration record) for the month of February 2022 was reviewed and contained an entry which read in part, Dexamethasone Tablet 4 mg. Give 1 tablet by mouth three times a day related to MALIGNANT NEOPLASM OF UNSPECIFIED PART OF UNSPECIFIED BRONCHUS OR LUNG (C34.90). This entry was coded 22 on 02/21/22 for all three administration times. Chart code 22 is the equivalent of Drug/Treatment Not Administered. Resident #380's nurse's progress notes were reviewed and contained notes which read in part, Effective Date: 2/21/2022 13:40 eMAR-Medication Administration Note. Dexamethasone Tablet 4 MG. Give 1 tablet by mouth three times a day related to MALIGNANT NEOPLASM OF UNSPECIFIED PART OF UNSPECIFIED BRONCHUS OR LUNG (C34.90). Medication pending delivery. None available in STAT box. and Effective Date: 2/21/2022 21:31 eMAR-Medication Administration Note. Dexamethasone Tablet 4 MG. Give 1 tablet by mouth three times a day related to MALIGNANT NEOPLASM OF UNSPECIFIED PART OF UNSPECIFIED BRONCHUS OR LUNG (C34.90). Medication is on order. Surveyor requested and was provided a list of medications located the facility stat medication supply. Dexamethasone was not listed. Surveyor requested and was provided with a facility policy entitled Unavailable Medication which read in part, Policy: In conjunction with the contracted pharmacy, the facility will make every effort to ensure that medication ordered for the resident is available to meet their needs. Procedure: 2. In the event that a medication ordered for a resident is noted to be unavailable near or at the time it is to be dispensed, nursing staff shall: a. Contact the pharmacy regarding the unavailable medication. b. Attempt to obtain the medication from the facility's automated medication dispensing system or emergency kit. c. Notify the physician of the unavailable medication, explain the circumstances, report the date of expected availability, and provide the alternative medication(s) recommended by pharmacy. i. Obtain a new order and discontinue prior order, or ii. Obtain a hold order for the unavailable medication. d. Notify the pharmacy, if applicable. The concern of Resident #380's medications not being available for administration was discussed with the administrative staff (administrator, assistant administrator, director of nursing) during a meeting on 02/24/22 at 4:35 pm. Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure the physician ordered medication Oxybutynin was available for administration for 2 of 40 residents, Resident #7 and Resident #380.Resident #7's physician ordered medication Oxybutynin was not administered by the nursing staff on 02/06/22. The nursing staff documented awaiting from pharmacy. Resident #380's dexamethasone was not administered on 02/21/22 for three administrations. The findings included: 1. This was a closed record review. Resident #7's face sheet included the diagnoses fusion of cervical spine, traumatic subdural hemorrhage with loss of consciousness, Parkinson's disease, diabetes, and neuromuscular dysfunction of bladder. Section C (cognitive patterns) of Resident #7's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/09/21 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. Resident #7's comprehensive care plan included the focus area neurogenic bladder. Interventions included, but were not limited to, administer medications as ordered. Resident #7's physician orders included an order for Oxybutynin Chloride ER tablet extended release 24 hour 10 MG Give 1 tablet by mouth at bedtime for BLADDER SPASM. The order date was documented as 11/02/21. A review of Resident #7's eMARs (electronic medication administration records) revealed that on 02/06/22 at 9:00 p.m. the nursing staff documented a 22 on the eMAR for the medication Oxybutynin. Per the code on the eMAR a 22=Drug/Treatment not available. On 02/06/22 8:18 p.m., the nursing staff documented Oxybutynin .The medication is on order. On 02/15/22 at 2:30 p.m., the DON (director of nursing) was made aware of that Resident #7's Oxybutynin was not available for administration on 02/06/22. 02/15/22, the DON provided the surveyor with a copy of the stat box list. A review of this list revealed that this medication was not available in the stat box for administration. The DON also provided the surveyor with a copy of their policy titled, Unavailable Medication. This policy read in part, In conjunction with the contracted pharmacy, the facility will make every effort to ensure that a medication ordered for the resident is available to meet their needs .In the event that a medication ordered for a resident is noted to be unavailable near or at the time it is to be dispensed, nursing staff shall .Contact the pharmacy regarding the unavailable medication .Obtain a hold order for the unavailable medication . No further information regarding the unavailable medication was provided prior to the exit conference.

Based on interviews and the review of documents, the facility staff failed to ensure medication regimen reviews (MRRs) were addressed by a medical provider for one (1) of 40 sampled residents, Resident #78. The findings include: Resident #78's MRR dated 12/21/21 had yet to be acted on at the time of Resident #78 clinical record review on 2/24/22. Resident #78's diagnoses included, but were not limited to: high blood pressure, thyroid disorder, dementia, Parkinson's disease, and lung disease. Resident #78's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/10/21, was signed as completed on 12/25/21. Resident #78 was assessed as able to make self understood and as able to understand others. Resident #78 was assessed as having a BIMS (Brief Interview for Mental Status) Summary Score of a 13 out of 15; this indicated intact or borderline cognition. Resident #78 was assessed as requiring assistance with bed mobility, eating, dressing, toilet use, and personal hygiene. Resident #78 was assessed as receiving antipsychotic medications. The following information was found in a facility policy titled Medication Regimen Reviews (this document was not dated): - The consultant pharmacist performs a medication regiment review (MRR) for every resident in the facility receiving medication. - The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. - The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities . - The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. Resident #78's clinical record included the following Pharmacy Consultant note dated 12/21/21 at 2:42 a.m.: Medication Regimen Review: Recommend re-evaluation of a muscle relaxant, methocarbamol and concomitant use of quetiapine and risperidone. (Methocarbamol is a muscle relaxant medication. Quetiapine and risperidone are antipsychotic medications.) The following communication of the above MRR was found in Resident #78's clinical record on a PHYSICIAN RECOMMENDATIONS form dated 12/21/21. The information on this form included: - This resident is receiving the muscle relaxant, Methocarbamol. Current clinical guidelines indicate that these drugs are poorly tolerated in the elderly, leading to anticholinergic side effects, sedation, and weakness. Additionally, their effectiveness at doses tolerated by the elderly is questionable. Please consider one of the following options: ( ) Medication should be continued, patient responds well to this medication, and it improves the quality of the resident's life. The benefits of therapy outweigh the risks of adverse effects. ( ) Taper Methocarbamol to discontinuation. This form also included an area for a medical provider to mark if they agree, disagree, or have other responses. This PHYSICIAN RECOMMENDATIONS form did not include information about the concomitant use of quetiapine and risperidone. No evidence was found or provided to indicate a medical provider was notified of the MRR recommendation to re-evaluation the concomitant use of quetiapine and risperidone. A medical provider responded to the aforementioned 12/21/21 PHYSICIAN RECOMMENDATIONS form on 12/22/21. The medical provider did not select from the options to either continue or taper the methocarbamol. From the agree, disagree, or other options, the medical provider selected OTHER and wrote in that psychiatry follows the resident. No evidence was found or provided to indicate a psychiatry staff member had reviewed and/or acted upon the 12/21/21 MRR recommendations. On 2/24/22 at 1:10 p.m., the Director of Nursing (DON) was interviewed about Resident #78's 12/21/21 MRR. The DON was asked for evidence that psychiatry had acted on the recommendations. The failure of the 12/22/21 PHYSICIAN RECOMMENDATIONS form to include the pharmacist's comments about the concomitant use of quetiapine and risperidone was also discussed. On 2/24/22 at 3:03 p.m., the DON was unable to provide evidence of psychiatry acting on the aforementioned MRR recommendations. The DON reported they had telephoned the nurse practitioner (NP) for psychiatry related to Resident #78's 12/21/21 MRR. The DON stated the NP for psychiatry confirmed they were behind but were working to catch-up. The DON acknowledge the MRR information provided to the doctor as part of the PHYSICIAN RECOMMENDATIONS form did not include all the medication concerns documented in the pharmacy consultant note. The facility's Administrator, Director of Nursing, and Assistant Administrator met with the survey team on 2/24/22 at 4:39 p.m. The absence of psychiatry action on Resident #78's 12/21/21 MRR was discussed. No additional information was provided related to this issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #92's diagnosis list indicated diagnoses, which included, but not limited to Acute Respiratory Failure, Dependence on Respirator Status, Type 2 Diabetes, Anxiety Disorder, Essential Hypertension, Dysphagia, and Aphonia. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 12/16/21 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. Resident #92 was also coded for the active diagnosis of anxiety disorder. Resident #92 was admitted to the facility on [DATE]. Resident #92's current physician's orders included an active order dated 12/09/21 for Lorazepam 2 mg via PEG-tube every 6 hours as needed for anxiety. This order did not include a limitation of 14 days or less. Lorazepam is a benzodiazepine used to treat anxiety. A review of Resident #92's February 2022 MAR (medication administration record) revealed the resident received Lorazepam 2 mg on 2/01/22 and 2/06/22. A NP (nurse practitioner) progress note dated 2/16/22 stated Anxiety - cont. (continue) Lorazepam tablet 0.5 mg). Surveyor requested and received the facility policy entitled Antipsychotic Medication Use which read in part 14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rational for the extended order. The duration of the PRN order will be indicated in the order. On 2/24/22 at 8:05 am, surveyor met with the administrator and DON (director of nursing) and discussed the concern of Resident #92 receiving Lorazepam PRN, a psychotropic medication, without a duration indicated in the order. On 2/24/22 at 2:55 pm, the DON provided the surveyor with a copy of an order for Resident #92 dated 2/24/22 9:36 am for Lorazepam 2 mg via PEG-tube every 6 hours as needed for anxiety until 3/10/22. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/24/22. Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure two (2) of 40 residents were free of unnecessary psychotropic medications, Resident #90 and Resident #92. For Resident #90 and Resident #92, it was determined the facility staff failed to ensure as needed psychotropic medication orders were renewed every 14 days by a medical provider. The findings include: 1. Resident #90's diagnoses included, but were not limited to: cancer, anemia, high blood pressure, diabetes, depression, respiratory failure. Resident #90's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/15/21, was signed as completed on 12/21/21. Resident #90 was assessed as able to make self understood and as able to understand others. Resident #90 was assessed as having a BIMS (Brief Interview for Mental Status) Summary Score of a 12 out of 15; this indicated moderate cognitive impairment. Resident #90 was documented as depending on others for bed mobility, dressing, personal hygiene, and bathing. Resident #90 was documented as requiring assistance with eating and toilet use. Resident #90 was assessed as receiving antianxiety medications. The facility staff failed to provide a stop date for an 'as needed' psychotropic medication ordered for Resident #90. Resident #90's medical documentation included an order for alprazolam 0.5 mg to be given via the resident peg-tube every six (6) hours as needed for anxiety. This order did not include a stop date. Resident #90 clinical documentation did not include documentation for this 'as needed' order to be continued for greater than 14 days. Resident #90's care plan included the following focus area: Resident use anti-anxiety and antidepressant medications (related to) Anxiety disorder and Depression. One of the interventions for this focus area was to Give anti-anxiety medications ordered by physician [sic]. The following information was found in a policy titled Antipsychotic Medication Use (this document was not dated): - Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. - The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rational for the extended order. The duration of the PRN order will be indicated in the order. (PRN is a medical abbreviation for a Latin phrase meaning 'as needed'.) Resident #90's medication administration record (MAR) was reviewed for 1/1/22 through 2/20/22. Documentation indicated the resident was administered at least one dose of the 'as needed' alprazolam all but one (1) day during this time. (Resident #90's MAR documentation for 1/5/22 did not have a dose of the alprazolam recorded as being given.) The failure Resident #90's medical record to address a stop date for an 'as needed' anti-anxiety medication was discussed with the facility's Administrator, Director of Nursing, and Assistant Administrator on 2/24/22 at 4:39 p.m. No additional information was provided related to this issue.

Based on observation, staff interview, and facility document review, the facility staff failed to store drugs and biologicals in locked compartments on 1 of 6 facility units, TCU. For the TCU Unit, the facility staff failed to lock an unattended medication cart containing resident medications and left a bottle of Vitamin C 500 mg unattended on top of the medication cart. The findings included: On 2/17/22 at 9:10 am, surveyor observed an unlocked, unattended medication cart in the hallway of the TCU Unit. On top of the medication cart was a multi-dose bottle of Vitamin C 500 mg tablets. Surveyor remained beside the medication cart for approximately three (3) minutes until LPN (licensed practical nurse) #1 emerged from a resident room into the hall. LPN #1 acknowledged it was not normal practice to leave the medication cart unlocked but stated they had ran into a resident's room to check an alarm. LPN #1 placed the bottle of Vitamin C into the medication cart and locked the cart. Surveyor requested and received the facility policy entitled, Storage of Medications which read in part 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications and 6. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medications carts are not left unattended. On 2/24/22 at 4:35 pm, survey team met with the administrator, assistant administrator, and the director of nursing and discussed the concern of LPN #1 leaving an unlocked medication cart with a bottle of Vitamin C tablets on top of the cart unattended in the hall. No further information regarding this issue was presented to the survey team prior to the exit conference on 2/24/22.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to obtain physician ordered laboratory tests for 1 of 40 residents in the survey sample, Resident #180. For Resident #180, the facility staff failed to obtain a sputum culture and a stool for occult blood for testing. The findings included: Resident #180 diagnosis list indicated diagnoses, which included, not limited to Nontraumatic Intracerebral Hemorrhage, Chronic Respiratory Failure, Dependence on Respirator, Persistent Vegetative State, Type 2 Diabetes Mellitus, Muscle Wasting and Atrophy, Major Depressive Disorder, Dysphagia, Aphonia, and Malignant Neoplasm of Prostate. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 1/20/22 coded the resident as being in a persistent vegetative state. A review of Resident #180's clinical record included a NP (nurse practitioner) note dated 2/14/22 at 2:48 pm stating in part Patient has been seen and examined today because nurse reported patient had brown emesis on 2/13/22 and this morning (he/she) had another episode. Assess patient noted clear saliva in patient's mouth. Ordered sputum culture and stool for occult blood. Corresponding physician orders dated 2/14/22 2:35 pm stated stool for occult blood and 2/14/22 3:53 pm stated Sputum C&S (culture and sensitivity). Upon reviewing Resident #180's clinical record on 2/16/22, surveyor was unable to locate results for the sputum culture and stool for occult blood. On 2/16/22 at 4:00 pm, surveyor met with the administrator and DON (director of nursing) and requested the results. As of 2/23/22, surveyor had not received the results of Resident #180's sputum culture and stool for occult blood results. On 2/23/22, surveyor again reviewed the resident's clinical record and the following documentation was noted in the resident's progress notes: 2/16/22 10:10 pm Lab for sputum culture and occult blood done result pending. 2/16/22 10:57 pm sputum specimen sent to the lab for culture. Result pending. 2/17/22 4:07 am (name omitted) Laboratory called about the resident stool for occult blood that they could not do the testing due to wrong kit. NP notified and [sp] reorder the test. Resident #180 was seen by a NP on 2/17/22 at 5:11 pm, the progress note stated in part has brownish sputum draining from side of (his/her) mouth, issue has been addressed by another provider, labs have been ordered. Awaiting results which usually takes couple of days. In the meantime, patient will be continually monitored for any bleeding as (he/she) has chronic anemia. A progress note dated 2/18/22 5:19 pm stated in part Writer unable to collect the stool for occult [sp] due to stool kit is unavailable. Nurse on evening shift and manager notified. A progress note dated 2/21/22 at 12:41 pm states Resident stool for occult blood done, result negative, MD notified. A progress note dated 2/22/22 at 3:09 pm states Lab called for resident result for sputum culture, according to result culture cancelled 2/17/22 due to specimen quality is inadequate for culture. NP notified assessment done order to discontinue culture repeat test not needed at this time, resident [sp] remain stable. Surveyor requested and received the facility policy entitled Lab and Diagnostic Test Results - Clinical Protocol which read in part: 1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. On 2/24/22 at 8:05 am, surveyor met with the administrator and DON and discussed the concern of Resident #180's stool for occult blood ordered on 2/14/22 was not completed until 2/21/22 and the sputum culture which was also ordered on 2/14/22 was never successfully obtained and the order was discontinued on 2/22/22. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/24/22.

Based on observation, staff interview the facility staff failed to store food in a safe and sanitary manner on 2 of 6 units in the facility. The findings include: During rounds on 2/24/2022, the surveyor observed that the refrigerator in the nutrition room on unit 1 North had debris in the refrigerator compartment handle and there was a sticky substance on the freezer handle and down the front of the refrigerator compartment and in the floor in front of the refrigerator. On 2 north, a vanilla magic cup in the freezer appears to have melted, then refrozen (lying on its side with the white substance in a stream around the lid and on the bottom of the freezer). There was also hair and debris on the floor of the freezer. There was no thermometer in the freezer, but the nurse found a second thermometer in the refrigerator compartment and moved it to the freezer. The temperature record sheet said the unit was clean. The nurse on the unit stated night shift take care of the temperatures and cleaning. The surveyor notified the dietary manager of the concern. The administrator and director of nursing were notified of the concern during a summary meeting on 2/24/2022.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to provide specialized rehabilitative services as ordered by the physician for 1 of 40 residents in the survey sample, Resident #275. For Resident #275, the facility staff failed to provide occupational therapy as ordered by the physician. The findings included: Resident #275's diagnosis list indicated diagnoses, which included, but not limited to Amyotrophic Lateral Sclerosis, Acute and Chronic Respiratory Failure, Dependence on Respirator Status, Type 2 Diabetes Mellitus, Epilepsy, Heart Failure, Severe Protein-Calorie Malnutrition, Dysphagia, Hypotension, and Sacral Pressure Ulcer. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 2/04/22 assigned the resident a BIMS (brief interview for mental status) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #275 was coded as requiring extensive assistance with dressing and being totally dependent with bed mobility, transfers, toileting, personal hygiene, and bathing. In section O, Special Treatments, Procedures, and Programs, the resident was coded as receiving 1 day of OT (occupational therapy) for at least 15 minutes in the last 7 days and 43 individual minutes of OT in the past 7 days. On 2/15/22 at 4:14 pm, surveyor spoke with Resident #275 with the resident communicating using a dry-erase board. Surveyor asked the resident if they had any concerns and the resident responded they were not getting therapy. A review of Resident #275's clinical record revealed a current physician's order dated 1/28/22 stating Occupational Therapy Eval (evaluation) and Treat as Indicated and an order dated 1/31/22 stating OT clarification order: Skilled OT tx (therapy) QD (every day) 3 x a week x 8 weeks for self care management training, therapeutic activities, therapeutic exercises. Resident #275's current comprehensive person-centered plan of care included an intervention dated 1/29/22 stating PT (physician therapy)/OT evaluation and treatment as per MD orders. Surveyor was unable to locate OT evaluation or any treatment notes in the resident's clinical record. On 2/16/22 at 4:00 pm, surveyor met with the administrator, assistant administrator, and DON (director of nursing) and requested to review any OT documentation regarding Resident #275. On 2/23/22 at 10:47 am, the DON (director of nursing) provided surveyor with a copy of the resident's OT Evaluation & Plan of Treatment dated 1/31/22. The OT Evaluation & Plan of Treatment stated in part Reason for Skilled Services: Skilled OT services are warranted to assess safety with adaptive equipment, assess the need for adaptations/assistive devices, develop and instruct in exercise program, develop and instruct on adaptation techniques, develop and instruct on compensatory strategies, facilitate dynamic standing balance, facilitate independence with ADLs (activities of daily living), facilitate sitting tolerance and postural control, increase functional activity tolerance and increase safety awareness in order to enhance patient's quality of life by improving ability to be able to return to prior level of living. Along with the OT Evaluation & Plan of Treatment, the administrator provided copies of OT Treatment Encounter Note(s) for 1/31/22 and 2/18/22. On 2/24/22 at 9:01 am, surveyor spoke with OT (occupational therapist) #1 and requested OT treatment encounter notes between 1/31/22 and 2/18/22. OT #1 checked in the computer and stated the resident did not have OT visits between 1/31/22 and 2/18/22. OT #1 stated they were unsure of the reason and stated their supervisor makes the treatment schedule, OT #1 attempted to call their supervisor, however, they were unavailable. On 2/24/22 at 9:21 am, surveyor spoke with IDOR (Interim Director of Rehab and Area Manager) via phone who verified Resident #275 was not seen by OT between 1/13/22 and 2/18/22 due to OT staff being out due to COVID-19. IDOR stated the facility has a total of four (4) OTs and one COTA (certified occupational therapy assistant) and one OT was out with suspected COVID-19 and another OT out due to testing positive for COVID-19. IDOR stated during this time residents were seen based on priority with the biggest focus being on residents with falls and Skilled residents and Resident #275 was not skilled. IDOR further stated employees are now returning and they are working to improve in the future and a new OT has been hired. IDOR stated Resident #275 will now be seen three (3) times per week. On 2/24/22 at 10:26 am, surveyor informed the administrator of the call and information received from the IDOR. Administrator stated they would contact the IDOR and see what has been done. On 2/24/22 at 1:20 pm, the administrator returned to the surveyor and stated they are doing an audit to identify other residents whose OT may have been affected. Administrator provided surveyor with a therapy clinical update note dated 2/24/22 at 1:11 pm stating This interim DOR (director of rehab) spoke with NP (nurse practitioner) to discuss inability to meet frequency on POC (plan of care) starting on 1.31.2022. NP reports understanding in the matter and has no further questions. A second therapy clinical update note dated 2/24/22 at 1:15 pm was provided, note stated in part, This interim DOR spoke with resident via phone regarding the inability to meet frequency during this POC. Resident able to report understanding via head nod. On 2/24/22 at 4:35 pm, survey team met with the administrator, assistant administrator, and director of nursing and discussed the concern of Resident #275 not receiving OT as ordered. No further information regarding this issue was presented to the survey team prior to the exit conference on 2/24/22.

Based on observation, staff interview, and facility document review, the facility staff failed to ensure a clean environment for 3 of 40 residents in the survey sample (Resident #8, #62, and #143) whose rooms had a dried, light brown substance visible on multiple surfaces in their rooms. For Resident #8, #62, and #143, a dried, light brown substance was visible on multiple surfaces in their rooms. The findings included: 1. Resident #8's diagnosis list indicated diagnoses, which included, but not limited to Muscle Wasting and Atrophy, Respiratory Failure, Essential Hypertension, Anoxic Brain Damage, Persistent Vegetative State, Protein-Calorie Malnutrition, Osteomyelitis, Acute Kidney Failure, and Unstageable Pressure Ulcer of Sacral Region. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/12/21 coded the resident as being severely impaired in cognitive skills for daily decision making. Resident #8 was coded as requiring extensive assistance with personal hygiene and being totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, and bathing. The resident was coded for the presence of a feeding tube in which they received 51% or more of total calories and 501 cc/day or more average fluid intake. On 2/15/22 at 12:07 pm, surveyor observed Resident #8 in bed with Jevity 1.5 TF (tube feeding) formula hanging on a TF pole beside the resident's bed, TF pump was turned off at this time. The Jevity 1.5 formula was liquid and light brown in color. Surveyor observed five (5) separate spots of a dried, light brown substance on the ceiling tiles at the head of the resident's bed above the TF pole with dried drips down the wall from the ceiling. On 2/23/22 at 11:36 am, surveyor observed the same five (5) separate spots of a dried, light brown substance on the ceiling tiles at the head of the resident's bed above the TF pole with dried drips down the wall from the ceiling and a dried, light brown substance was also present on the base of the TF pole and on the floor near the TF pole. Surveyor requested and received the facility policy entitled Cleaning and Disinfection of Environmental Surfaces which read in part: 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 11. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. On 2/23/22 at 4:11 pm, surveyor spoke with the DHK (director of housekeeping) who stated resident rooms are cleaned by housekeeping once a day. On 2/24/22 at 8:09 am, surveyor notified the administrator and director of nursing of the observations of the dried, light brown substance in Resident #8's room. On 2/24/22 at approximately 2:15 pm, surveyor spoke with Housekeeper #1 who stated they cleaned Resident #8's room. Surveyor accompanied Housekeeper #1 to the resident's room and all previous areas of the dried, light brown substance had been cleaned. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/24/22. 2. Resident #62's diagnosis list indicated diagnoses, which included, but not limited to Chronic Respiratory Failure, Type 2 Diabetes Mellitus, Left Thigh Myositis, Metabolic Encephalopathy, Persistent Vegetative State, Nutritional Deficiency, Essential Hypertension, Orthostatic Hypotension, Post Traumatic Seizures, and Dependence on Respirator. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/21/21 coded the resident as being in a persistent vegetative state. Resident #62 was coded as being totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. The resident was coded for the presence of a feeding tube in which they received 51% or more of total calories and 501 cc/day or more average fluid intake. On 2/15/22 at 4:26 pm, surveyor observed Resident #62 in bed receiving Glucerna 1.2 TF (tube feeding) formula via pump at 60 ml/hour. The Glucerna 1.2 TF formula was liquid and light brown in color. Surveyor observed a dried, light brown substance on the tube feeding pump and down the TF pole. On 2/23/22 at 11:47 am, surveyor observed a dried, light brown substance present on Resident #62's TF pump, at the base of the TF pole, on the floor to the upper left side of the bed and under the bed, and dried drips were present on the wall behind the TF pump. Surveyor requested and received the facility policy entitled Cleaning and Disinfection of Environmental Surfaces which read in part: 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 11. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. On 2/23/22 at 4:11 pm, surveyor spoke with the DHK (director of housekeeping) who stated resident rooms are cleaned by housekeeping once a day. On 2/24/22 at 8:09 am, surveyor notified the administrator and director of nursing of the observations of the dried, light brown substance in Resident #62's room. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/24/22. 3. Resident #143's diagnosis list indicated diagnoses, which included, but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction, Cerebral Edema, Dysphagia, Acute Respiratory Failure, Type 2 Diabetes Mellitus, Chronic Kidney Disease Stage 3, Essential Hypertension, Chronic Diastolic (Congestive) Heart Failure, and Dependence on Respirator. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 12/31/21 coded the resident as being severely impaired in cognitive skills for daily decision making. Resident #143 was coded as being totally dependent on staff for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. The resident was coded for the presence of a feeding tube in which they received 51% or more of total calories and 501 cc/day or more average fluid intake. On 2/15/22 at 3:16 pm, surveyor observed Resident #143 in bed with Jevity 1.2 TF (tube feeding) formula running via pump set at 65 ml/hour. The Jevity 1.2 TF formula was liquid and light brown in color. Surveyor observed a dried, light brown substance present on the TF pump, down TF pole, at the base of the pole, and in the floor. On 2/23/22 at 11:58 am, surveyor again observed the dried, light brown substance on Resident #143's TF pump, down TF pole, at the base of the pole, and in the floor. The substance was also observed with dried drips down the wall behind the TF pump. Surveyor requested and received the facility policy entitled Cleaning and Disinfection of Environmental Surfaces which read in part: 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 11. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. On 2/23/22 at 4:11 pm, surveyor spoke with the DHK (director of housekeeping) who stated resident rooms are cleaned by housekeeping once a day. On 2/24/22 at 8:09 am, surveyor notified the administrator and director of nursing of the observations of the dried, light brown substance in Resident #143's room. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/24/22.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to follow physician's orders for 6 of 40 residents in the survey sample, Residents #8, #92, #143, #180, and #275 . For Resident #8, the facility staff failed to monitor blood pressure prior to the administration of Midodrine HCL, a medication used to increase blood pressure, on 42 separate occasions. The resident's Midodrine HCL was not administered on two (2) separate occasions without a documented reason. For Resident #92, the facility staff failed to monitor blood pressure and/or heart rate prior to the administration of Metoprolol Tartrate, a medication used to treat high blood pressure and prevent chest pain, on 15 separate occasions. Facility staff also failed to monitor blood pressure prior to the administration of Amlodipine Besylate, a medication used to treat high blood pressure, on 13 separate occasions. For Resident #143, the facility staff failed to monitor blood pressure and heart rate prior to the administration of Metoprolol Tartrate, a medication used to treat high blood pressure and prevent chest pain, on 5 separate occasions. For Resident #180, the facility staff failed to monitor blood pressure and heart rate prior to the administration of Metoprolol Tartrate, a medication used to treat high blood pressure and prevent chest pain, on 4 separate occasions. For Resident #275, the facility staff failed to monitor blood pressure prior to the administration of Midodrine HCL, a medication used to increase blood pressure, on 30 separate occasions. The findings include: 1. Resident #8's diagnosis list indicated diagnoses, which included, but not limited to Muscle Wasting and Atrophy, Respiratory Failure, Essential Hypertension, Anoxic Brain Damage, Persistent Vegetative State, Protein-Calorie Malnutrition, Osteomyelitis, Acute Kidney Failure, and Unstageable Pressure Ulcer of Sacral Region. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/12/21 coded the resident as being severely impaired in cognitive skills for daily decision making. Resident #8 was coded as requiring extensive assistance with personal hygiene and being totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, and bathing. Resident #8's current physician's orders included an order dated 11/05/21 for Midodrine HCL tablet 10 mg via PEG-tube every 8 hours for hypotension hold for SBP (systolic blood pressure) greater than 120. A review of Resident #8's clinical record including the Blood Pressure Summary, Progress Notes, and the February 2022 MAR (medication administration record) revealed Midodrine HCL was administered without documentation of assessment of the resident's blood pressure within one (1) hour of the scheduled administration time on the following occasions: 2/01/22 6:00 am, 10:00 pm; 2/02/22 6:00 am, 10:00 pm; 2/03/22 6:00 am; 2/04/22 6:00 am, 2:00 pm, 10:00 pm; 2/05/22 2:00 pm, 10:00 pm; 2/06/22 6:00 am, 2:00 pm, 10:00 pm; 2/07/22 6:00 am, 10:00 pm; 2/08/22 6:00 am, 2:00 pm; 2/09/22 6:00 am, 2:00 pm; 2/10/22 6:00 am, 10:00 pm; 2/11/22 6:00 am, 2:00 pm; 2/12/22 6:00 am, 2:00 pm, 10:00 pm; 2/13/22 6:00 am, 2:00 pm, 10:00 pm; 2/14/22 6:00 am, 10:00 pm; 2/15/22 6:00 am; 2/16/22 6:00 am, 2:00 pm; 2/17/22 6:00 am, 10:00 pm; 2/18/22 6:00 am, 2:00 pm, 10:00 pm; 2/19/22 6:00 am, 2:00 pm, 10:00 pm. Resident #8's February MAR also included documentation that the resident's Midodrine HCL was held on 2/14/22 at 2:00 pm without a documented reason and surveyor was unable to locate a corresponding blood pressure for this administration. Midodrine HCL was not signed on the MAR for 2/14/22 at 10:00 pm as being administered or held, the administration box was left blank. Resident #8's clinical record included documentation of at least daily blood pressure readings, however, on the occasions listed above, the readings did not occur within one hour of the scheduled administration of Midodrine HCL. Surveyor requested and received the facility policy entitled Administering Medications which states in part 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals and 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. On 2/24/22 at 8:05 am, surveyor met with the administrator and DON (director of nursing) and discussed the concern of staff administering Midodrine HCL without assessing Resident #8's blood pressure on multiple occasions during February 2022. On 2/24/22 at 10:51 am, surveyor spoke with the DON who stated ideally the nurse should take the blood pressure when administering the medication. On 2/24/22 at 2:42 pm, the DON returned to the surveyor and stated the facility was educating staff on administering medications with parameters. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/24/22. 2. Resident #92's diagnosis list indicated diagnoses, which included, but not limited to Acute Respiratory Failure, Dependence on Respirator Status, Type 2 Diabetes, Anxiety Disorder, Essential Hypertension, Dysphagia, and Aphonia. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 12/16/21 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. Resident #92's current physician's orders included an active order dated 1/21/22 for Metoprolol Tartrate tablet 25 mg via G-Tube one time a day for Tachycardia/elevated BP (blood pressure) hold if BP less than 120 or HR (heart rate) less than 60. A review of Resident #92's clinical record including the Blood Pressure Summary, Progress Notes, and the February 2022 MAR (medication administration record) revealed Metoprolol Tartrate was administered without documentation of assessment of the resident's BP and/or HR within one (1) hour of the scheduled administration time on the following days: 2/01/22, 2/03/22, 2/04/22, 2/06/22, 2/07/22, 2/08/22, 2/09/22, 2/10/22, 2/11/22, 2/13/22, 2/15/22, 2/17/22, 2/18/22, 2/19/22, and 2/20/22. Resident #92 also had an active order dated 12/09/21 for Amlodipine Besylate tablet 10 mg via PEG-tube one time a day for Hypertension hold for SBP (systolic blood pressure) less than 100. A review of Resident #92's clinical record including the Blood Pressure Summary, Progress Notes, and the February 2022 MAR revealed Amlodipine Besylate was administered without documentation of assessment of the resident's BP within one (1) hour of the scheduled administration time on the following days: 2/01/22, 2/03/22, 2/04/22, 2/06/22, 2/07/22, 2/08/22, 2/09/22, 2/11/22, 2/13/22, 2/15/22, 2/17/22, 2/18/22, and 2/20/22. Resident #92's clinical record included documentation of at least daily blood pressure readings and heart rates, however, on the occasions listed above, the readings did not occur within one (1) hour of the scheduled administration of Metoprolol Tartrate or Amlodipine Besylate. Surveyor requested and received the facility policy entitled Administering Medications which states in part 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals and 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. On 2/24/22 at 8:05 am, surveyor met with the administrator and DON (director of nursing) and discussed the concern of staff administering Metoprolol Tartrate and Amlodipine Besylate without assessing Resident #92's blood pressure and/or heart rate on multiple occasions during February 2022. On 2/24/22 at 10:51 am, surveyor spoke with the DON who stated ideally the nurse should take the blood pressure when administering the medication. On 2/24/22 at 2:42 pm, the DON returned to the surveyor and stated the facility was educating staff on administering medications with parameters. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/24/22. 3. Resident #143's diagnosis list indicated diagnoses, which included, but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction, Cerebral Edema, Dysphagia, Acute Respiratory Failure, Type 2 Diabetes Mellitus, Chronic Kidney Disease Stage 3, Essential Hypertension, Chronic Diastolic (Congestive) Heart Failure, and Dependence on Respirator. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 12/31/21 coded the resident as being severely impaired in cognitive skills for daily decision making. Resident #143 was coded as being totally dependent on staff for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. Resident #143's current physician's orders included an order dated 12/24/21 for Metoprolol Tartrate tablet 25 mg one time a day related to Essential Hypertension hold for SBP (systolic blood pressure) less than 110 or HR (heart rate) less than 60. A review of Resident #143's clinical record including the Blood Pressure Summary, Progress Notes, and the February 2022 MAR revealed Metoprolol Tartrate was administered without documentation of assessment of the resident's BP and HR within one (1) hour of the scheduled administration time on the following days: 2/03/22, 2/06/22, 2/07/22, 2/12/22, and 2/17/22. Resident #143's clinical record included documentation of at least daily blood pressure readings and heart rates, however, on the occasions listed above, the readings did not occur within one (1) hour of the scheduled administration of Metoprolol Tartrate. Surveyor requested and received the facility policy entitled Administering Medications which states in part 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals and 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. On 2/24/22 at 8:05 am, surveyor met with the administrator and DON (director of nursing) and discussed the concern of staff administering Metoprolol Tartrate without assessing Resident #143's blood pressure and heart rate on multiple occasions during February 2022. On 2/24/22 at 10:51 am, surveyor spoke with the DON who stated ideally the nurse should take the blood pressure when administering the medication. On 2/24/22 at 2:42 pm, the DON returned to the surveyor and stated the facility was educating staff on administering medications with parameters. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/24/22. 4. Resident #180 diagnosis list indicated diagnoses, which included, not limited to Nontraumatic Intracerebral Hemorrhage, Chronic Respiratory Failure, Dependence on Respirator, Persistent Vegetative State, Type 2 Diabetes Mellitus, Muscle Wasting and Atrophy, Major Depressive Disorder, Dysphagia, Aphonia, and Malignant Neoplasm of Prostate. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 1/20/22 coded the resident as being in a persistent vegetative state. Resident #180's current physician's orders included an order dated 1/26/22 for Metoprolol Tartrate tablet 50 mg via G-tube one time a day for Tachycardia and HTN (hypertension) hold for SBP (systolic blood pressure) less than 120 and HR (heart rate) less than 60. A review of Resident #180's clinical record including the Blood Pressure Summary, Progress Notes, and the February 2022 MAR revealed Metoprolol Tartrate was administered without documentation of assessment of the resident's BP and HR within one hour of the scheduled administration time on the following days: 2/02/22, 2/03/22, 2/09/22, 2/13/22, and 2/14/22. Resident #180's clinical record included documentation of at least daily blood pressure readings and heart rates, however, on the occasions listed above, the readings did not occur within one (1) hour of the scheduled administration of Metoprolol Tartrate. Surveyor requested and received the facility policy entitled Administering Medications which states in part 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals and 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. On 2/24/22 at 8:05 am, surveyor met with the administrator and DON (director of nursing) and discussed the concern of staff administering Metoprolol Tartrate without assessing Resident #180's blood pressure and heart rate on multiple occasions during February 2022. On 2/24/22 at 10:51 am, surveyor spoke with the DON who stated ideally the nurse should take the blood pressure when administering the medication. On 2/24/22 at 2:42 pm, the DON returned to the surveyor and stated the facility was educating staff on administering medications with parameters. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/24/22. 5. Resident #275's diagnosis list indicated diagnoses, which included, but not limited to Amyotrophic Lateral Sclerosis, Acute and Chronic Respiratory Failure, Dependence on Respirator Status, Type 2 Diabetes Mellitus, Epilepsy, Heart Failure, Severe Protein-Calorie Malnutrition, Dysphagia, Hypotension, and Sacral Pressure Ulcer. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 2/04/22 assigned the resident a BIMS (brief interview for mental status) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #275 was coded as requiring extensive assistance with dressing and being totally dependent with bed mobility, transfers, toileting, personal hygiene, and bathing. Resident #275's current physician's orders included an active order dated 1/28/22 for Midodrine HCL tablet 10 mg via PEG-tube three times a day for hypotension hold for SBP (systolic blood pressure) greater than 120. A review of Resident #275's clinical record including the Blood Pressure Summary, Progress Notes, and the February 2022 MAR (medication administration record) revealed Midodrine HCL was administered without documentation of assessment of the resident's blood pressure within one hour of the scheduled administration time on the following occasions: 2/01/22 8:00 am; 2/02/22 8:00 am, 12:00 pm; 2/03/22 8:00 am, 12:00 pm; 2/04/22 8:00 am, 12:00 pm; 2/05/22 12:00 pm, 4:00 pm; 2/07/22 4:00 pm; 2/08/22 8:00 am, 12:00 pm; 2/09/22 8:00 am, 12:00 pm; 2/10/22 8:00 am, 12:00 pm, 4:00 pm; 2/12/22 4:00 pm; 2/13/22 4:00 pm; 2/14/22 8:00 am, 12:00 pm; 2/15/22 8:00 am, 12:00 pm; 2/16/22 12:00 pm; 2/17/22 8:00 am, 12:00 pm; 2/18/22 12:00 pm, 4:00 pm; 2/19/22 12:00 pm; 2/20/22 4:00 pm. Resident #275's clinical record included documentation of at least daily blood pressure readings, however, on the occasions listed above, the readings did not occur within one hour of the scheduled administration of Midodrine HCL. Surveyor requested and received the facility policy entitled Administering Medications which states in part 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals and 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. On 2/24/22 at 8:05 am, surveyor met with the administrator and DON (director of nursing) and discussed the concern of staff administering Midodrine HCL without assessing Resident #275's blood pressure on multiple occasions during February 2022. On 2/24/22 at 10:51 am, surveyor spoke with the DON who stated ideally the nurse should take the blood pressure when administering the medication. On 2/24/22 at 2:42 pm, the DON returned to the surveyor and stated the facility was educating staff on administering medications with parameters. At 2:55 pm, the DON provided a nursing progress note dated 2/24/22 1:13 pm stating (physician name omitted) notified that Midodrine order was noted without BP parameters, order to put parameters in place. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/24/22.

3. Resident #8's diagnosis list indicated diagnoses, which included, but not limited to Muscle Wasting and Atrophy, Respiratory Failure, Essential Hypertension, Anoxic Brain Damage, Persistent Vegetative State, Protein-Calorie Malnutrition, Osteomyelitis, Acute Kidney Failure, and Unstageable Pressure Ulcer of Sacral Region. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/12/21 coded the resident as being severely impaired in cognitive skills for daily decision making. Resident #8 was coded as requiring extensive assistance with personal hygiene and being totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, and bathing. Resident #8's current physician's orders included an order dated 11/05/21 for Midodrine HCL tablet 10 mg via PEG-tube every 8 hours for hypotension hold for SBP (systolic blood pressure) greater than 120. A review of Resident #8's February 2022 MAR (medication administration record) revealed Midodrine HCL was administered with a SBP greater than 120 on the following occasions: 2/03/22 2:00 pm - BP 129/81 2/05/22 6:00 am - BP 138/62 2/07/22 2:00 pm - BP 124/70 2/10/22 2:00 pm - BP 130/78 2/15/22 2:00 pm - BP 136/70 2/20/22 2:00 pm - BP 132/77 Surveyor requested and received the facility policy entitled Administering Medications which states in part 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. On 2/24/22 at 8:05 am, surveyor met with the administrator and DON (director of nursing) and discussed the concern of Resident #8 receiving Midodrine HCL with a SBP greater than 120 on six (6) separate occasions. On 2/24/22 at 2:42 pm, the DON returned to the surveyor and stated the facility was educating staff on administering medications with parameters. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/24/22. 4. Resident #92's diagnosis list indicated diagnoses, which included, but not limited to Acute Respiratory Failure, Dependence on Respirator Status, Type 2 Diabetes, Anxiety Disorder, Essential Hypertension, Dysphagia, and Aphonia. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 12/16/21 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. Resident #92's current physician's orders included an active order dated 1/21/22 for Metoprolol Tartrate tablet 25 mg via G-Tube one time a day for Tachycardia/elevated BP (blood pressure) hold if BP less than 120 or HR (heart rate) less than 60. A review of Resident #92's February 2022 MAR (medication administration record) revealed Metoprolol Tartrate was administered with a BP less than 120 on 2/02/22 at 9:00 am with a BP of 110/76 and 2/16/22 at 9:00 am with a BP of 102/68. Surveyor requested and received the facility policy entitled Administering Medications which states in part 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. On 2/24/22 at 8:05 am, surveyor met with the administrator and DON (director of nursing) and discussed the concern of Resident #92 receiving Metoprolol Tartrate on two (2) separate occasions with BP less than 120. On 2/24/22 at 2:42 pm, the DON returned to the surveyor and stated the facility was educating staff on administering medications with parameters. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/24/22. 5. Resident #275's diagnosis list indicated diagnoses, which included, but not limited to Amyotrophic Lateral Sclerosis, Acute and Chronic Respiratory Failure, Dependence on Respirator Status, Type 2 Diabetes Mellitus, Epilepsy, Heart Failure, Severe Protein-Calorie Malnutrition, Dysphagia, Hypotension, and Sacral Pressure Ulcer. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 2/04/22 assigned the resident a BIMS (brief interview for mental status) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #275 was coded as requiring extensive assistance with dressing and being totally dependent with bed mobility, transfers, toileting, personal hygiene, and bathing. Resident #275's current physician's orders included an active order dated 1/28/22 for Midodrine HCL tablet 10 mg via PEG-tube three times a day for hypotension hold for SBP (systolic blood pressure) greater than 120. A review of the Resident #275's February 2022 MAR (medication administration record) revealed Midodrine HCL was administered with a SBP greater than 120 on the following occasions: 2/02/22 4:00 pm - BP 131/75 2/06/22 12:00 pm - BP 132/66 2/11/22 4:00 pm - BP 130/80 2/16/22 4:00 pm - BP 121/70 2/20/22 8:00 am - BP 123/66 Surveyor requested and received the facility policy entitled Administering Medications which states in part 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. On 2/24/22 at 8:05 am, surveyor met with the administrator and DON (director of nursing) and discussed the concern of Resident #275 receiving Midodrine HCL with a SBP greater than 120 on five (5) separate occasions. On 2/24/22 at 2:42 pm, the DON returned to the surveyor and stated the facility was educating staff on administering medications with parameters. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/24/22. Based on staff interview and clinical record review the facility staff failed to ensure 5 out of 40 residents were free of significant medication errors, Resident #249, Resident #380, Resident #8, Resident #92 adn #275. For Resident #249, the facility staff held the resident's blood pressure medication, Metoprolol, when it should have been administered, and failed to obtain blood pressure prior to administering the blood pressure medication Amlodipine. For Resident #380, the facility staff administered the resident's blood pressure medication, Metoprolol, when it should have been held, on three separate occasion. For Resident #8, the facility staff failed to follow physician's orders for the administration of Midodrine HCL, a medication used to increase blood pressure, on six (6) separate occasions. For Resident #92, the facility staff failed to follow physician's orders for the administration of Metoprolol Tartrate, a medication used to treat high blood pressure and prevent chest pain, on two (2) separate occasions. For Resident #275, the facility staff failed to follow the physician's orders for the administration of Midodrine HCL, a medication used to increase blood pressure, on five (5) separate occasions. The findings included: 1. Resident #249's face sheet listed diagnoses which included but not limited to Type 2 diabetes mellitus, hypertensive chronic kidney disease, depression, insomnia, and hypertension. Resident #249's most recent annual MDS (minimum data set) with an ARD (assessment reference date) of 01/26/22 assigned the resident a BIMS (brief interview for mental status) score of 13 out 15. This indicates that the resident is cognitively intact. Resident #289's clinical record was reviewed and contained a physician's order summary for the month of February 2022 which read in part, Amlodipine Besylate 5 mg tab. Give 1 tablet orally in the evening every Mon, Wed, Fri, Sun related to ESSENTIAL (PRIMARY) HYPERTENSION (I10). HOLD FOR SBP (systolic blood pressure) <110. Do not give prior to dialysis, and Metoprolol Succinate ER (extended release) Tablet Extended Release 24 Hour 50 mg. Give 1 tablet by mouth one time a day every Mon, Wed, Fri, Sun related to ESSENTIAL (PRIMARY) HYPERTENSION (I10). HOLD FOR SBP (systolic blood pressure) <110, HEART RATE <60. Do not give blood pressure med prior to dialysis treatment due to hypotension during dialysis treatment . Resident #289's eMAR (electronic medication administration record) was reviewed and contained entries which read in part, Amlodipine Besylate 5 mg tab. Give 1 tablet orally in the evening every Mon, Wed, Fri, Sun related to ESSENTIAL (PRIMARY) HYPERTENSION (I10). HOLD FOR SBP (systolic blood pressure) <110. Do not give prior to dialysis, and Metoprolol Succinate ER (extended release) Tablet Extended Release 24 Hour 50 mg. Give 1 tablet by mouth one time a day every Mon, Wed, Fri, Sun related to ESSENTIAL (PRIMARY) HYPERTENSION (I10). HOLD FOR SBP (systolic blood pressure) <110, HEART RATE <60. Do not give blood pressure med prior to dialysis treatment due to hypotension during dialysis treatment . The administration time for the Amlodipine was listed as 8 pm. The entry for Amlodipine was coded 5 on 02/04/22 and documented as administered on the remaining days. Chart code 5 is the equivalent of Hold. There was no corresponding blood pressure recorded related to these times of administration. The entry for Metoprolol was coded as 5 on 02/02/22, with a corresponding blood pressure of 114/68. Resident #289's blood pressure summary was reviewed and contained blood pressure readings of 99/68 on 02/04/22 at 10:07 am, 99/68 on 02/07/22 at 9:48 am, 98/62 on 02/09/22 at 9:58 am, and 98/62 on 02/18/22 at 9:56 am. Surveyor spoke with the DON (director of nursing) on 02/24/22 at 11:00 am regarding Resident #289's medications and blood pressures. Surveyor asked DON when a blood pressure related to a medication should be taken, and DON stated, prior to the administration of the medication. Surveyor asked the DON if blood pressure obtained in the morning was valid for a medication administered in the evening and DON stated that it was not. The concern of not checking the resident's blood pressure prior to the administration of Amlodipine and administering the medication Metoprolol outside the physician ordered parameters was discussed with the administrative team (administrator, assistant administrator, director of nursing) on 02/24/22 at 4:35 pm. No further information was provided prior to exit. 2. Resident #380's face sheet listed diagnoses which included but not limited to acute and chronic respiratory failure, heart failure, malignant neoplasm of bronchus or lung, atrial fibrillation, and hypertension. Resident #380's admission MDS (minimum data set) with an ARD (assessment reference date) of 02/10/22 assigned the resident a BIMS (brief interview for mental status score of 6 out of 15 in section C, cognitive patterns. This indicates the resident is moderately cognitively impaired. Resident #380's clinical record was reviewed and contained a physician's order summary for the month of February 2022 which read in part, Metoprolol Tartrate Tablet 25 mg. Give 1 tablet by mouth every 12 hours related to ESSENTIAL (PRIMARY) HYPERTENSION (I10); UNSPECIFIED ATRIAL FIBRILLATION (I48.91) HOLD FOR SBP (systolic blood pressure) <110, HEART RATE <60 Resident #380's eMAR (electronic medication record) for the month of February was reviewed and contained and entry which read in part, Metoprolol Tartrate Tablet 25 mg. Give 1 tablet by mouth every 12 hours related to ESSENTIAL (PRIMARY) HYPERTENSION (I10); UNSPECIFIED ATRIAL FIBRILLATION (I48.91) HOLD FOR SBP (systolic blood pressure) <110, HEART RATE <60. This entry was documented as administered on 02/05/22 at 9 pm with a corresponding blood pressure of 105/65, on 02/10/22 at 9 pm with a corresponding blood pressure of 103/60, and on 02/14/22 at 9 pm with a corresponding blood pressure of 109/61. Surveyor spoke with DON (director of nursing) on 02/24/22 at 11:00 am regarding Resident #380's blood pressure medication. DON stated that the medication should not have been administered on the aforementioned dates/times. The concern of administering Resident #380's blood pressure medication, Metoprolol, outside the physician ordered parameters was discussed with the administrative staff (administrator, assistant administrator, director of nursing) on 02/24/22 at 4:35 pm. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #62's diagnosis list indicated diagnoses, which included, but not limited to Chronic Respiratory Failure, Type 2 Diabetes Mellitus, Left Thigh Myositis, Metabolic Encephalopathy, Persistent Vegetative State, Nutritional Deficiency, Essential Hypertension, Orthostatic Hypotension, Post Traumatic Seizures, and Dependence on Respirator. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of [DATE] coded the resident as being in a persistent vegetative state. Resident #62 was coded as being totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. The resident was coded for the presence of a feeding tube in which they received 51% or more of total calories and 501 cc/day or more average fluid intake. Resident #62's current comprehensive person-centered plan of care included a focus area stating Resident requires tube feeding r/t (related to) NPO status. A review of Resident #62 clinical record indicated the resident was ventilator dependent, in a persistent vegetative state, receives nutrition via tube feeding, and has a current physician's order for an NPO (nothing by mouth) diet. Surveyor reviewed the resident's current physician's orders and noted an active order dated [DATE] for Levothyroxine Sodium tablet 137 mcg 1 tablet by mouth one time a day for low thyroid. Resident #62's February 2022 MAR (medication administration record) indicated Levothyroxine was being signed as administered by mouth despite the resident's NPO status. On [DATE] at 11:32 am, surveyor spoke with LPN (licensed practical nurse) #2 who stated Resident #62 does not take any PO (by mouth) meds (medications). On [DATE] at 8:05 am, surveyor met with the administrator and DON (director of nursing) and informed them of Resident #62 having a current physician's order for Levothyroxine to be given by mouth. On [DATE] at 2:55 pm, DON provided a copy of a physician's order dated [DATE] 9:00 am for Resident #62 stating Levothyroxine Sodium tablet 137 mcg to be administered via PEG-tube. DON also provided a nursing progress note dated [DATE] 1:05 pm stating in part Clarification: (physician name omitted) made aware . levothyroxine change from PO to G-tube. Surveyor requested and received the facility policy entitled Administering Medications which read in part 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Surveyor also reviewed the facility policy Charting and Documentation which read in part 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. No further information regarding this concern was presented to the survey team prior to the exit conference on [DATE]. 6. Resident #92's diagnosis list indicated diagnoses, which included, but not limited to Acute Respiratory Failure, Dependence on Respirator Status, Type 2 Diabetes, Anxiety Disorder, Essential Hypertension, Dysphagia, and Aphonia. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of [DATE] coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. The resident was coded for the presence of a feeding tube in which they received 51% or more of total calories and 501 cc/day or more average fluid intake. A review of Resident #92's current physician's orders revealed a current order dated [DATE] for a NPO (nothing by mouth) diet. The resident's current physician orders included active orders for the medications Famotidine and Keppra to be administered by mouth, all other oral medications were ordered to be given via PEG-tube. The resident's February 2022 MAR (medication administration record) indicated the Famotidine and Keppra were signed as being administered by mouth despite the resident's NPO status. On [DATE] at 11:32 am, surveyor spoke with LPN (licensed practical nurse) #2 who stated Resident #92 does not take any PO (by mouth) meds (medications). On [DATE] at 8:05 am, surveyor met with the administrator and DON (director of nursing) and informed them of Resident #92 having current physician's orders for Famotidine and Keppra to be given by mouth. Surveyor requested and received the facility policy entitled Administering Medications which read in part 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Surveyor also reviewed the facility policy Charting and Documentation which read in part 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. No further information regarding this concern was presented to the survey team prior to the exit conference on [DATE]. 7. Resident #143's diagnosis list indicated diagnoses, which included, but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction, Cerebral Edema, Dysphagia, Acute Respiratory Failure, Type 2 Diabetes Mellitus, Chronic Kidney Disease Stage 3, Essential Hypertension, Chronic Diastolic (Congestive) Heart Failure, and Dependence on Respirator. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of [DATE] coded the resident as being severely impaired in cognitive skills for daily decision making. Resident #143 was coded as being totally dependent on staff for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. The resident was coded for the presence of a feeding tube in which they received 51% or more of total calories and 501 cc/day or more average fluid intake. A review of Resident #143's current physician's orders revealed a current order dated [DATE] for a NPO (nothing by mouth) diet. The resident's current physician orders included an active order dated [DATE] for the medication Hydralazine to be administered by mouth, all other oral medications were ordered to be given via PEG-tube. The resident's February 2022 MAR (medication administration record) indicated the Hydralazine was signed as being administered by mouth despite the resident's NPO status. On [DATE] at 11:32 am, surveyor spoke with LPN (licensed practical nurse) #2 who stated Resident #143 does not take any PO (by mouth) meds (medications). On [DATE] at 8:05 am, surveyor met with the administrator and DON (director of nursing) and informed them of Resident #143 having a current physician's order for Hydralazine to be given by mouth. On [DATE] at 2:55 pm, the DON provided surveyor with a physician's order dated [DATE] 8:56 am for Resident #143 for Hydralazine to be administered via G-tube. Surveyor requested and received the facility policy entitled Administering Medications which read in part 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Surveyor also reviewed the facility policy Charting and Documentation which read in part 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. No further information regarding this concern was presented to the survey team prior to the exit conference on [DATE]. 8. Resident #180 diagnosis list indicated diagnoses, which included, not limited to Nontraumatic Intracerebral Hemorrhage, Chronic Respiratory Failure, Dependence on Respirator, Persistent Vegetative State, Type 2 Diabetes Mellitus, Muscle Wasting and Atrophy, Major Depressive Disorder, Dysphagia, Aphonia, and Malignant Neoplasm of Prostate. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of [DATE] coded the resident as being in a persistent vegetative state. The resident was coded for the presence of a feeding tube in which they received 51% or more of total calories and 501 cc/day or more average fluid intake. A review of Resident #180 clinical record indicated the resident was ventilator dependent, in a persistent vegetative state, receives nutrition via tube feeding, and has a current physician's order dated [DATE] for an NPO (nothing by mouth) diet. Resident #180's current comprehensive person-centered plan of care included a focus area stating Resident requires tube feeding r/t (related to) Dysphagia, Swallowing problem. Resident #180's current physician's orders included an active order dated [DATE] for the medication Ferrous Sulfate to be administered by mouth, all other oral medications were ordered to be given via PEG-tube. The resident's February 2022 MAR (medication administration record) indicated the Ferrous Sulfate was signed as being administered by mouth despite the resident's NPO status. On [DATE] at 11:32 am, surveyor spoke with LPN (licensed practical nurse) #2 who stated Resident #180 does not take any PO (by mouth) meds (medications). On [DATE] at 8:05 am, surveyor met with the administrator and DON (director of nursing) and informed them of Resident #180 having a current physician's order for Ferrous Sulfate to be given by mouth. Surveyor requested and received the facility policy entitled Administering Medications which read in part 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Surveyor also reviewed the facility policy Charting and Documentation which read in part 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. No further information regarding this concern was presented to the survey team prior to the exit conference on [DATE]. Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a complete and accurate clinical record for 8 of 40 residents, Resident #279, #214, #236, #260, #62, #92, #143 and #180. For Resident #279, the nurse practitioner documented the resident expired in the ED (emergency department). When in fact the resident was pronounced and expired at the nursing facility. Resident #214 and Resident #236's clinical documentation failed to include evidence of the collection of laboratory samples for a C. auris test and for a CRE test. Resident #214's clinical documentation failed to include laboratory results for the C. auris test and for the CRE test. Resident #260's clinical documentation failed to include evidence of the collection of a laboratory specimen for a C. auris test. Resident #260's clinical documentation failed to include laboratory results for the C. auris test. Candida auris (C. auris) is a fungus that is often multidrug-resistant (https://www.cdc.gov/fungal/candida-auris/index.html on [DATE]). Carbapenem-resistant Enterobacterales (CRE) are bacteria that commonly cause infections in healthcare settings . CRE are difficult to treat because they do not respond to commonly used antibiotics. (https://www.cdc.gov/hai/organisms/cre/ on [DATE]). For Resident #62, the facility staff documented the administration of Levothyroxine by mouth when the medication was being administered via PEG-tube. For Resident #92, the facility staff documented the administration of Famotidine and Keppra by mouth when the medications were being administered via PEG-tube. For Resident #143, the facility staff documented the administration of Hydralazine by mouth when the medication was being administered via PEG-tube. For Resident #180, the facility staff documented the administration of Ferrous Sulfate by mouth when the medication was being administered via PEG-tube. The findings included: 1. This was a closed record review. Resident #279's face sheet included the diagnoses, unilateral primary osteoarthritis left hip, dementia with behavioral disturbance, and peripheral vascular disease. Section C (cognitive patterns) of Resident #279's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of [DATE] was coded [DATE] to indicate the resident had problems with long and short term memory and was moderately impaired in cognitive skills for daily decision making. Resident #279's clinical record was reviewed on [DATE] and included the following progress notes. [DATE] Nurse Practitioner documented a Death Summary that read in part, .was found unresponsive 1/23 CPR initiated and EMS called .passed away in ED. [DATE] LPN (licensed practical nurse) #1, .Resident was finally pronounced expired at 09:53, by Dr. _____ per 911 staff member____ Dr. ____ was informed and gave order to release resident's remains to _____ Funeral home .At 14:15, resident remains was released to _____ Funeral Home with family at bedside. [DATE] 2:30 p.m., the DON (director of nursing) stated a code was called and the resident expired at the facility. [DATE] the DON provided the surveyor with a copy of their policy titled, Charting and Documentation. This policy read in part, .Documentation in the medical record will be objective .complete and accurate . No further information regarding this issue was provided to the survey team prior to the exit conference. 2. Resident #214's diagnoses included, but were not limited to: high blood pressure, orthostatic hypotension, neurogenic bladder, diabetes, and respiratory failure. Resident #214's minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], was signed as completed on [DATE]. Resident #214 was assessed as rarely or never able to make self understood and as rarely or never able to understand others. Resident #214 was assessed as having severely impaired cognitive skills for daily decision making. Resident was documented as dependent on others for bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. The following information was found in a facility policy titled Charting and Documentation (this document was not dated): - All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. - Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Resident #214 lived in an area of the facility that was having C. auris and CRE laboratory test completed on residents as part of a plan to prevent the spread of these organisms. Review of Resident #214's clinical record failed to provide evidence the resident had been tested for C. auris and/or CRE. On [DATE] at 10:37 a.m., the facility's Director of Nursing (DON) provided a copy of a spreadsheet that included specimen collection information and test results information for facility residents. Resident #214's specimen collection information and tests results were included on this spreadsheet. The spreadsheet indicated the specimen collection for the C. auris and CRE laboratory test were obtained on [DATE] at 4:13 p.m. and 4:12 p.m. respectively. The spreadsheet indicated Resident #214 had negative results, reported on [DATE], for both test. The specimen collection information and tests results were not documented as part of Resident #214's clinical record. On [DATE] at 11:53 a.m., a local health department employee (LHDE #1) was interviewed via telephone. LHDE #1 reported the laboratory that performs the C. auris and CRE tests has had computer issues that resulted in them having to change the way they report the results of these laboratory tests. LHDE #1 reported the laboratory test results were being communicated via email. LHDE #1 reported their understanding was that the facility's staff were going to document the results in the clinical record via a health note indicating if the tests were negative or positive. On [DATE] at 4:12 p.m., the facility's Administrator was interviewed about the absence of documentation of C. auris and CRE specimen collection and test results in residents' medical records. The Administrator stated they could provide the test results, which were sent via a secure email from the local health department. The Administrator reported they would implement a form to be completed that will be used to document the test results in the residents' medical records. The Administrator reported a provider order for the C. auris and CRE test should be signed off, in residents' medical records, as completed when the specimens are collected. The failure of facility staff to document Resident #214's laboratory specimen collection and test results, for C. auris and CRE, was discussed for a final time with the facility's Administrator, Director of Nursing, and Assistant Administrator on [DATE] at 4:39 p.m. 3. Resident #236's diagnoses included, but were not limited to: high blood pressure, neurogenic bladder, diabetes, and respiratory failure. Resident #236's minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], was signed as completed on [DATE]. Resident #236 was assessed as sometimes able to make self understood and as usually able to understand others. Resident #236's BIMS (Brief Interview for Mental Status) Summary Score was documented as a 15 out of 15; this indicated intact or borderline cognition. Resident #236 was documented as requiring assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The following information was found in a facility policy titled Charting and Documentation (this document was not dated): - All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. - Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Resident #236 was living in an area of the facility that was having C. auris and CRE laboratory test completed on residents as part of a plan to prevent the spread of these organisms. Review of Resident #236's clinical record failed to provide evidence the resident had been tested for C. auris and/or CRE. On [DATE] at 10:37 a.m., the facility's Director of Nursing (DON) provided a copy of a spreadsheet that included specimen collection information and test results information for facility residents. Resident #236's specimen collection information and tests results were included on this spreadsheet. The spreadsheet indicated the specimen collection for the C. auris and CRE laboratory test were obtained on [DATE] at 4:13 p.m. and 4:12 p.m. respectively. The spreadsheet indicated Resident #236 had negative results, for both tests, reported on [DATE]. The specimen collection information and tests results were not documented as part of Resident #236's clinical record. On [DATE] at 11:53 a.m., a local health department employee (LHDE #1) was interviewed via telephone. LHDE #1 reported the laboratory that performs the C. auris and CRE tests has had computer issues that resulted in them having to change the way they report the results of these laboratory tests. LHDE #1 reported the laboratory test results were being communicated via email. LHDE #1 reported their understanding was that the facility's staff were going to document the results in the clinical record via a health note indicating if the tests were negative or positive. On [DATE] at 4:12 p.m., the facility's Administrator was interviewed about the absence of documentation of C. auris and CRE specimen collection and test results in residents' medical records. The Administrator stated they could provide the test results, which were sent via a secure email from the local health department. The Administrator reported they would implement a form to be completed that will be used to document the test results in the residents' medical records. The Administrator reported a provider order for the C. auris and CRE test should be signed off, in residents' medical records, as completed when the specimens are collected. The failure of facility staff to document Resident #236's laboratory specimen collection and test results, for C. auris and CRE, was discussed for a final time with the facility's Administrator, Director of Nursing, and Assistant Administrator on [DATE] at 4:39 p.m. 4. Resident #260's diagnoses included, but were not limited to: high blood pressure, neurogenic bladder, diabetes, kidney disease, and respiratory failure. Resident #260's minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], was signed as completed on [DATE]. Resident #260 was assessed as being in a persistent vegetative state and/or having no discernible consciousness. Resident #260 was documented as being dependent on others for bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. The following information was found in a facility policy titled Charting and Documentation (this document was not dated): - All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. - Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Resident #260 was living in an area of the facility that was having C. auris laboratory tests completed on residents as part of a plan to prevent the spread of these organisms. Review of Resident #260's clinical record failed to provide evidence the resident had been tested for C. auris. On [DATE] at 10:37 a.m., the facility's Director of Nursing (DON) provided a copy of a spreadsheet, which included specimen collection information and test results information for facility residents. Resident #260's C. auris specimen collection information and test results were included on this spreadsheet. The spreadsheet indicated the C. auris specimen was obtained on [DATE]. The spreadsheet indicated Resident #260 C. auris test had been reported as positive on [DATE]. The specimen collection information and tests results were not documented as part of Resident #260's clinical record. On [DATE] at 11:53 a.m., a local health department employee (LHDE #1) was interviewed via telephone. LHDE #1 reported the laboratory that performs the C. auris and CRE tests has had computer issues that resulted in them having to change the way they reported the results. LHDE #1 reported the laboratory test results were being communicated via email. LHDE #1 reported their understanding was that the facility's staff members were going to document the results in the clinical record via a health note indicating if the tests were negative or positive. On [DATE] at 4:12 p.m., the facility's Administrator was interviewed about the absence of documentation of the C. auris specimen collection and test results in residents' medical records. The Administrator stated they could provide the test results, which were sent via a secure email from the local health department. The Administrator reported they would implement a form to be completed that will document the test results in the residents' medical records. The Administrator reported a provider order for the C. auris test should be signed off as completed, in residents' medical records, when the specimens are collected. The failure of facility staff to document Resident #260's laboratory specimen collection and test results, for C. auris, was discussed for a final time with the facility's Administrator, Director of Nursing, and Assistant Administrator on [DATE] at 4:39 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #162's admission record listed diagnoses to include but not limited to, Parkinson's disease, immobility syndrome (paraplegic), Alzheimer's disease, dementia, and open wound, right lower leg. The quarterly minimum data set (MDS) with an assessment reference date (ARD) of 01/01/2022, in Section C (cognitive patterns) coded Resident #162's BIMS (brief interview for mental status) score of 99 meaning the resident was unable to complete the interview. Section G (functional status) coded the resident required extensive assistance with bed mobility, eating, and toilet use with personal hygiene coded as total dependence. The resident's order summary report contained an order to start on 08/09/2021 with no end date, for contact precautions and read, Contact precautions for CRE (carbapenem-resistant Enterobacterales) in urine. Staff members providing ADL (activities of daily living) care must wear an isolation gown and gloves when providing ADL care. The care plan's focus areas included, but not limited to, risk for infection due to: incontinence, history of CRE in urine, and right knee abscess with interventions that included contact precautions for CRE in urine and staff members providing ADL care must wear an isolation gown and gloves when providing ADL care. On 02/15/2022 at approximately 1:03 p.m., the surveyor (wearing an N-95 mask and goggles) entered room [ROOM NUMBER] to meet Resident #162. There was a CNA (certified nursing assistant) assisting the resident with eating. The CNA was wearing a mask and faceshield. The resident did not respond to the surveyor and continued eating. When the surveyor left the room, a contact precautions sign was noted on the door which had not been there prior to the surveyor entering. The ADON (assistant director of nursing) met the surveyor at the door and acknowledged having just hung the contact precautions sign on the resident's door while the surveyor was in the room. The resident had recently changed rooms and the precautions sign and personal protective equipment (PPE) cart had not been moved to the new room until right then. The CNA reported knowing Resident #162 was on contact precautions and acknowledged they should have worn a gown and gloves too and did not know why they had not donned all of the expected PPE. At approximately 2:30 p.m., the same CNA was interviewed again and reported that since the resident had moved rooms (within the same unit) and there was no contact precautions sign on the door, the CNA thought the resident may no longer be on precautions. The contact precautions sign indicated that prior to entering the room everyone must clean their hands, don gloves and a gown. On 02/15/2022 at 9:15 a.m. when the survey team entered the facility, the administrator reported everyone was required to wear an N-95 mask and goggles/faceshield throughout the facility. 4. Resident #226's admission record listed diagnoses to include, but not limited to, functional quadriplegia, conversion disorder with seizures or convulsions, resistance to unspecified beta lactam antibiotics, and aphasia (inability to communicate). The minimum data set (MDS) with an assessment reference date (ARD) of 01/27/2022, in Section C (cognitive patterns) coded Resident #162 as rarely/never understood and therefore no BIMS (brief interview for mental status) interview was completed. Section G (functional status) coded the resident required total dependence for bed mobility, transfer, eating, toilet use, and personal hygiene. The resident's order summary report contained an order, with a start date of 02/10/2022 and no end date, for contact and droplet isolation. On 2/24/2022 the director of nursing (DON) provided an order dated 2/23/2022 at 5:36 p.m., for Resident #226 that read, The resident is to remain on contact precautions for CRE colonization. The DON reported the resident had been on contact and droplet precautions on 02/10/2022 due to their readmission from a hospitalization. The care plan's focus areas included, but not limited to, the resident had CRE (carbapenem-resistant Enterobacterales) colonization. The interventions included, but not limited to, contact isolation and educate resident/family/caregivers regarding the importance of hand washing. On 02/15/2022 while initially meeting residents on 2 South, the surveyor donned required PPE (personal protective equipment) prior to entering room [ROOM NUMBER] which had a contact precautions sign on the door and a cart with PPE at the door. The room was semi-private with both residents being positive for CRE per the census listed. According to the precautions sign, the PPE required included gloves after hand hygiene and a gown. The surveyor was already wearing an N-95 mask and goggles as required by the facility for all individuals. Upon entering the room, the surveyor encountered Resident #226's mother who was wearing a mask but no gown, no gloves, no faceshield or goggles. The surveyor observed the resident's mother picking up the resident's legs and moving them around and also touching the resident's arms. When asked whether she was aware of the PPE required for contact precautions (per the sign on the door or other education), she did not respond directly to the question. Resident #226's mother shook her head but the surveyor could not distinguish whether she was gesturing a yes or a no. The surveyor repeated the question with no response from the mother. The assistant director of nursing (ADON) was informed of this observation and they stated Resident #226 had been at the facility long-term and they had spoken with the mother many times. Resident #226's clinical record contained a note created by the ADON, dated 02/15/2022 at 5:35 p.m. that read the ADON had spoken with the resident's mother and reviewed his CRE status. The mother voiced knowing about the resident's history of CRE and also that his sister who was his usual caregiver was very knowledgeable about his CRE status. The mother understood the need for PPE and said she would be compliant and start wearing the appropriate PPE needed to protect herself whenever she visits. The note included the ADON reviewed the need for gowns and gloves. The surveyor did not have any further observations of Resident #226's visitors during the survey. The DON provided the facility's policy titled, Isolation - Categories of Transmission-Based Precautions which read, in part, that contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff and visitors will wear gloves when entering the room and removed with hand hygiene performed before leaving the room. Staff and visitors will wear a disposable gown upon entering the room and removed before leaving the room. The DON was informed of the observations regarding Resident #162 and Resident #226 on 2/16/2021 at approximately 12:30 p.m. The administrator, DON, and assistant administrator were informed of these observations on 02/16/2022 at 4:00 p.m. The surveyor requested any specific evidence of Resident #226's family/caregivers' education regarding PPE multiple times. The DON provided the care plan that read to educate the family as mentioned above. No further information was provided prior to the end of the survey. This is a complaint deficiency. Based on observations, interviews, facility document review, and in the course of a complaint investigation, the facility staff failed to implement infection control and prevention program processes, including actions to decrease the risks of transmission of COVID-19 and/or other infectious organisms, for three (3) of 40 residents (Resident #135, Resident #162, and Resident #226. The facility staff failed to ensure a staff member completed COVID-19 screening prior to starting their work shift. For Resident #135, the facility staff failed to implement facility COVID-19 quarantine processes for a readmitted resident who had not yet received the COVID-19 booster. For Resident #135, Resident #162, and Resident #226, the facility staff failed to ensure proper personal protective equipment (PPE) was worn by individuals entering the residents' rooms, which required transmission-based precautions (TBPs). The findings include: 1. Staff Member (SM) #21 failed to consistently complete COVID-19 screenings prior to starting work. The review of SM #21's Daily Timecards information for the period of 12/26/21 to 2/5/2022 indicated they worked 25 days (12/26/21; 12/28/21; 12/29/21; 12/30/21; 12/31/21; 1/4/22; 1/6/22; 1/7/22; 1/8/22; 1/9/22; 1/11/22; 1/12/22; 1/13/22; 1/14/22; 1/17/22; 1/18/22; 1/21/22; 1/22/22; 1/23/22; 1/25/22; 1/26/22; 1/27/22; 1/28/22; 1/31/22; and 2/5/22). Review of SM #21 COVID-19 screening documentation prior to starting work (for the same time period) indicated they had only completed COVID-19 screening for two (2) days: 12/30/21 and 1/26/22. On 2/16/22 at 3:31 p.m., the Director of Nursing (DON) reported SM #21 had not consistently being completing the employee COVID-19 screening prior to starting work. On 2/23/22 at 3:40 p.m., Staff Member (SM) #21 reported they had not been completing the COVID-19 screening prior to starting work because the thermometers were providing a temperature that was too low; SM #21 reported they did not want to use an incorrect temperature. The following information was found in a facility document titled Screening of Staff, Visitors & Residents - VA (dated August 9, 2021): - Staff, visitors, and residents will be screening for COVID-19 in accordance with guidance from VDH, CMS, and CDC. - HCP (healthcare personnel) screening must be conducted at the beginning of every shift. - HCP must be screened for: - Signs and symptoms of COVID-19 including: fever (greater than or equal to) 100.0 (degrees Fahrenheit), cough, shortness of breath, sore throat, myalgia, chills, and new onset of loss of smell or taste; and - Prolonged close contact with someone with COVID-19 infection in the 14 days prior . The failure of SM #21 to consistently complete COVID-19 screening prior to starting work was discussed with the facility's Administrator, Director of Nursing, and Assistant Administrator on 2/24/22 at 4:39 p.m. 2. Resident #135's diagnoses included, but were not limited to: anemia, high blood pressure, anxiety, depression, lung disease, and respiratory failure. Resident #135's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/29/21, was signed as completed on 1/5/22. Resident #135 was assessed as able to make self understood and as able to understand others. Resident #135 was assessed as having a BIMS (Brief Interview for Mental Status) Summary Score of a 15 out of 15; this indicated intact or borderline cognition. Resident #135 was assessed as requiring assistance with bed mobility, transfers, eating, dressing, toilet use, and personal hygiene. The following information was found in a facility document titled CDC Guidance - New Admissions and Residents Who Leave the Facility (dated April 2, 2021 and last updated February 2022): Residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and residents who left the facility for more than 24 hours will be placed in quarantine. This document did not provide details for placing a resident in quarantine. The facility's Administrator and Director of Nursing (DON) were interviewed on 2/24/22 at 8:40 a.m. The failure of the CDC Guidance - New Admissions and Residents Who Leave the Facility document to detail the process for placing a resident on quarantine was discussed. The Administrator reported a resident placed on quarantine due to potential COVID-19 exposure would be placed on Droplet Isolation precautions. During an interview on 2/24/22 at 10:21 a.m., the DON reported Resident #135 would have required quarantine after their re-admission to the facility due to the resident not having received the COVID-19 vaccine booster. Resident #135's clinical record included an order for CONTACT AND DROPLET ISOLATION dated six (6) days after the resident was re-admitted to the facility. (The re-admission was after a hospital stay.) On 2/16/22 at 1:10 p.m., Staff Member (SM) #22 (a unit manager) was asked why Resident #135's room had a sign posted for Contact Isolation but not Droplet Isolation. SM #22 reported no Droplet Isolation sign was posted because the resident was only on observation after readmission from the hospital. Resident #135 had an order for both CONTACT AND DROPLET ISOLATION at the time of this observation. On 2/16/22 at 1:26 p.m., SM #23 (a licensed practical nurse) was observed posting a Droplet Isolation sign on the door leading into Resident #135's room. On 2/16/22 at 2:30 p.m., the facility's Director of Nursing and Infection Preventionist reported that Resident #135's room should have had signage posted for both Contact Isolation and Droplet isolation from the time of the resident's readmission after the hospital stay. On 2/17/22 at 8:55 a.m., SM #24 (a certified nurse aide) was observed to enter Resident #135's room without donning a gown and gloves. SM #24 placed clean linen on a table in Resident #135's room and exited the room. On 2/17/22 at 9:00 a.m., SM #22 (a unit manager) was interviewed about SM #24 entering Resident #135's room to drop-off clean linen; SM #22 reported SM #24 should have donned a gown and gloves prior to entering the room. The facility's Administrator, Director of Nursing, and Assistant Administrator met with the survey team on 2/24/22 at 4:39 p.m. The failure of the facility staff to ensure Resident #135 had orders for Droplet Isolation precautions for quarantine when re-admitted to the facility after a hospital stay was discussed. The observations of a staff member entering Resident #135's room without donning a gown or gloves was discussed.

Based on observation, staff interview and clinical record review the facility staff failed to provide the appropriate care and services in regards to a gastrostomy tube for 1 of 38 residents, Resident #20. The findings included: For Resident #20 the facility staff failed to ensure to correct feeding order was implemented. Resident #20's face sheet listed diagnoses which included but not limited to dementia, anorexia, anxiety, adult failure to thrive, dysphagia, and hypertension. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 01/10/21 coded the resident as having both long and short term memory loss with severely impaired cognitive skills for daily decision making. Section K, sub-section K0510, Nutritional Approaches, coded the resident as having a feeding tube. Sub-section K0710, percent intake by artificial route, indicated the resident receives 51% or more of total calories through tube feeding. Resident #20's comprehensive care plan was reviewed and contained a care plan for Resident requires tube feeding r/t (related to) Dysphagia. Interventions for this care plan include RD (registered dietitian) to evaluate quarterly and PRN (as needed). Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. Surveyor observed Resident #20 on 04/20/21/ at approximately 4:50 pm. Resident was resting in bed, with tube feeding running at 55 ml/hour. Surveyor checked the physician's order summary for current tube feeding order, and found two current orders, one dated 11/ 012020 for 55 ml/hour and one dated for 02/22/2021 for 65 ml/hour. Resident #20's clinical record was reviewed and contained a physician's order summary for the month of April. The physician's order summary contained an order, which read in part Enteral Feed Order one time a day for dysphagia. NUTRIENT: Jevity 1.5 (ISOSOURCE 1.5 equivalent) TF (tube feeding) VIA PUMP @ 65 ml/hour x 20 hours to provide 1950 kcals, 83 gm protein, 988 cc free water-order date 02/22/2021, start date 02/23/2021 Resident #20's eMAR (electronic medication administration record) for the month of April 2021 was reviewed and contained entries, which read in part Enteral Feed Order one time a day for dysphagia NUTRIENT: Jevity 1.5 (ISOSOURCE 1.5 equivalent) TF (tube feeding) VIA PUMP @ 65 ml/hour x 20 hours to provide 1950 kcals, 83 gm protein, 988 cc free water -Start Date- 02/23/2021 1200 and Enteral Feed Order on time a day for Dysphagia related to ANOREXIA (R63.0); ADULT FAILURE TO THRIVE (R62.7); DYSPHAGIA, OROPHARYNGEAL PHASE (R13.12) Jevity 1/5 (ISOSOURCE 1.5 equivalent) TF VIA PUMP @ 55cc/hour for 20 HRS/DAY: DOWN AT 8AM UP AT NOON -Start Date- 11/01/2020 0800. Both entries had been initialed as being administered. Resident #20's nurse's progress notes were reviewed and contained a progress noted dated 02/22/21 which read in part, 2/22/2021 09:45 Nutrition Note See past nutrition note for full evaluation of nutritional needs. Stage 4 PU (pressure ulcer) is healed and no longer present, will d/c (discontinue) beneprotein at this time. Wt. continues to trend down weekly unfavorably. Will advance tube feed to prevent further decline. Current nutritional needs: Kcals: 25-30 kcal/kg = 1500-1800, Protein: 1.5-2.0g/kg = 75-90g, Fluids: 1 cc/kcal or per MD. NEW enteral order: Jevity 1.5 @ 65 ml/hr x 20 hours to provide 1950 kcal, 83g protein, 988 free water. This continues to fit within nutritional needs. RD (registered dietitian) will continue to monitor to ensure weight gain is gradual and does not occur too quickly. RD Recommendation: 1. d/c beneprotein d/t (due to) PU no longer present. 2. start on new enteral order to prevent further weight loss Resident #20's weight record was reviewed and indicated that resident lost 2lbs from February to March, but weights remained unchanged from March to April. Surveyor spoke with LPN (licensed practical nurse) #1 on 04/20/21 at approximately 5:35 pm regarding Resident #20's tube feeding order. LPN #1 stated that the tube feeding should be running at 55 ml/hour. LPN #1 stated, That is the order that pulled over from Matrix to PCC (point click care)-[Software programs for documentation]. Surveyor asked the unit manager to confirm the order. Unit manager stated there are two order and that the order dated 02/22/21 was entered by the dietitian and is just a breakdown of the resident's nutritional needs. Unit manager stated, It's just an FYI (for your information) Surveyor spoke with the DON (director of nursing) on 04/20/21 at approximately 5:40 pm. Surveyor asked the DON when the facility changed programs from Matrix to PCC, and DON stated August of 2020. Surveyor then asked the DON which tube feeding order was correct for Resident #20 and DON stated, The one with the latest date should be the current order Surveyor observed Resident #20 on 04/21/21 at approximately 07:50 am. Resident was resting in bed with tube feed running at 65 ml/hour. On 04/21/21 at approximately 9:20 am the DON stated to the surveyor that she had called MD, resident's RP (responsible party), a head to toe assessment had been completed, resident weighed, and education provided to staff. DON stated the order for 65 ml/hour is the correct order. DON stated dietician forgot to D/C old order when they entered new order. DON provided surveyor with a copy of inservice training form for education on reading orders prior to administering tube-feedings. The concern of the facility staff failing to ensure the resident's tube feeding order was correctly implemented was discussed with the administrative team (administrator, assistant administrator, DON) during a meeting on 04/22/21 at approximately 1:45 pm. No further information was provided prior to exit.