**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and clinical record review, facility staff failed to administer medicated shampoo as ordered for 1 of 23 residents in the survey sample (Resident #42). Resident #42 was admitted to the facility with diagnoses including psoriasis, above the knee amputation, hypertension, peripheral vascular disease, end stage renal disease, anxiety, depression, bipolar disorder, and schizoaffective disorder. On the most recent Minimum Data Set assessment, the resident scored 15/15 on the Brief Interview For Mental Status and was assessed as without signs of delirium, psychosis, behaviors affecting care, or rejecting care. The assessment indicated the resident was fully dependent for showering and bathing and required substantial/maximal assistance for personal hygiene (includes washing and drying face and combing hair). During initial tour on 4/15/24 at approximately 4:20 PM, the resident's face appeared red and skin was peeling over about 30% of face. The resident's hair showed a significant level of dandruff both peeling from scalp and distributed throughout the resident's hair. The resident's only complaint on interview was psoriasis of her face and scalp which she stated bothered her a great deal. The surveyor asked the resident if three showers per week were offered. The resident stated the last shower had been last week. The resident stated usually received 1-2 showers. Clinical record review on 4/15 revealed a physician order for shower with Neutrogena Tsal external with salicylic acid shampoo 3 times per week on Tuesday, Thursday, and Saturday. The care plan addressed developing psoriasis and the intervention was to treat as ordered until resolved. The [NAME] (a document listing information specifically to inform CNAs of resident-specific care needs) did not mention medicated shampoo or the Tuesday, Thursday, Saturday shower schedule. On 4/17/24 at approximately 2:20 PM, the surveyor spoke with the CNA assigned to the resident, who stated there was medicated shampoo in the resident's grooming supplies which is used when she showers twice per week. The resident's bathing record documented by the CNAs under the Tasks tab in the clinical record included shower-scheduled day shift every Tuesday Thursday Saturday Last 30 days printed on 4/16 documented the resident received 6 showers during that time: Last 30 days scheduled: Last 30 days received: March 19,21,23,26,28,30 18,28 April 2,4,6,8,10,12,16 1,4,8,11 During a 30 day period, the resident should have received at least 12 showers. Resident #42 received 6 showers during that period. None of the showers occurred on a Saturday. The administrator and director of nursing were notified of the concern during a summary meeting on 4/17/24. On 4/18/22, the director of nursing informed the surveyor that the nurse practitioner had assessed the resident and had ordered a new medicated shampoo to be administered three times per week. 04/17/24 4:30 told the DON and corporate consultant informed of issues.

Based on interviews and clinical record review, the facility staff failed to ensure complete and/or accurate clinical records for one (1) of 23 sampled residents (Resident #82). The findings include: Resident #82's clinical record included documentation that indicated the resident was administered medications when the resident was not present at the facility. Resident #82's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/2/24, was signed as completed on 3/6/24. Resident #82 was assessed as being able to make self understood and as able to understand others. Resident #82's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. Resident #82 was assessed as requiring assistance with toileting hygiene, dressing, and bathing. Resident #82's clinical documentation indicated the resident was not present at the facility on 4/5/24. Resident #82's medication administration record (MAR) indicated the following medications were administered at 9:00 a.m. on 4/5/24 (when the resident was not at the facility): cetirizine, cholecalciferol, dexamethasone, losartan, magnesium, nifedipine, fluoxetine, acyclovir, cosopt ophthalmic solution, apixaban, erythromycin ophthalmic ointment, metformin, and metoprolol. Resident #82's blood pressure and pulse were documented as 151/64 and 95 respectively for 4/5/24 at 9:00 a.m. On the afternoon of 4/16/24, the surveyor discussed, with the Director of Nursing (DON), the documentation on Resident #82's MAR indicating medications had been administered on 4/5/24 when the resident was not present in the facility. The DON indicated the documentation of these medications being administered was incorrect documentation. On 4/16/24 at 3:38 p.m., the survey team met with the facility's Administrator, DON, and Regional Director of Clinical Services (RDCS). During this meeting, the surveyor shared the finding of Resident #82's clinical documentation indicating the resident had been administered medications when the resident was not present at the facility.

Based on observations, interviews, and facility document review, the facility staff failed to appropriately store and/or serve resident food items. The findings include: The facility staff failed to ensure residents' beverages (orange juice, apple juice, cranberry juice, and iced tea) were appropriately stored and/or served. The following information was found in a facility dietary policy titled Meal Distribution (with a date of October 2019): It is the center policy that meals are transported to the dining locations in a manner that insures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner. On 4/16/24 at 9:25 a.m., two (2) carts used to transport breakfast to the facility's residents on the nursing units were noted to have been placed outside a door leading to the facility's kitchen. One of these carts had three (3) pitchers of beverages placed on the top of the cart; the Dietary Services Manager (DSM) reported that the beverages were orange juice, cranberry juice, and apple juice. The other cart had one (1) pitcher of orange juice placed on the top of the cart. One (1) of the orange juice pitchers had a yellow lid; this lid was cracked and had a rubbery, sticky substance on the lid. One (1) of the orange juice pitchers had a blue lid; this lid had a rubbery, sticky substance on the lid. The DSM reported the rubbery, sticky substance was from the stickers used to date the beverage pitchers. On the morning of 4/16/24, the DSM reported that pitchers of orange juice, apple juice, and cranberry juice were removed from the refrigerator and placed on top of the carts used to transport resident meals to the nursing units. The DSM confirmed that the beverage pitchers were not placed on ice or another chilling device. The DSM reported the beverage pitchers, when they are returned with the meal carts, are placed in the refrigerator for future use. The DSM stated the pitchers are dated to indicate when the beverage contained in the pitcher will be discarded. On the morning of 4/16/24, the surveyor, with the DSM present, observed multiple pitchers of iced tea that had been prepared for the midday meal. Five (5) of the iced tea pitchers had sticky, adhesive residue from the stickers used to date the beverage. One (1) of the pitchers of tea was noted to have a cracked lid and a small broken piece of the plastic pitcher missing at the top of the pitcher. On 4/16/24 at 3:38 p.m., the survey team met with the facility's Administrator, Director of Nursing, and Regional Director of Clinical Services (RDCS). During this meeting, the surveyor shared the aforementioned observations and interviews related to the storage of residents' beverages.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure a resident who is fed by enteral means received the provider ordered tube feeding nutrition and hydration for 1 of 2 residents who received tube feedings, Resident #5. The findings included: The facility nursing staff failed to set Resident #5's tube feeding at the provider order rate of 60 ml/hour. The rate was observed to be set at 55 ml/hour. Resident #5's diagnoses included, but were not limited to, aphasia, gastrostomy status, diabetes, and dysphagia. There was no completed Minimum Data Set assessment for this resident. Resident #5 was nonverbal. Resident #5's care plan included the focus area at risk for complications related to the need for an enteral tube feeding. Interventions included, administer tube feedings and flushes per order and Registered Dietician consult as needed. Resident #5's clinical record included a provider order for Glucerna 1.5 at 60 ml/hour. The order date was documented as 02/09/24. On 02/09/24 the dietician had transcribed a progress note that read in part, .change tube feed formula, rate .New Order: Glucerna @60mL/hr [hour]x22 hrs via PEG . On 02/12/24 at 1:08 p.m., Resident #5's tube feeding was observed to be running at 55 ml/hour. Licensed Practical Nurse (LPN) #1 confirmed the proper rate with the Unit Manager and verbalized to the surveyor that Resident #5's tube feeding was running at 55 ml/hour and the provider order read 60 ml/hour. During an end of the day meeting on 02/12/24 at 4:00 p.m., the issue with the inaccurate tube feeding rate was reviewed with the Administrator, Director of Nursing, and Nurse Consultant. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, employee record review, and facility document review, the facility staff failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property as evidenced by failure to pre-screen 2 of 25 new hire employees #22 and #25. Both employees were agency Certified Nursing Assistants (CNAs). The findings included: The facility staff failed to obtain reference checks per their policy for two agency employees #22 and #25. A review of employee records revealed the following. New hire #22 (agency) hire date 01/24/23 employee file did not include any reference checks. This staff last worked at the facility in 02/17/23. New hire #25 (agency) hire date 02/03/23 employee file did not include any reference checks. This staff last worked at the facility on 03/31/23. The facility provided the survey team with a copy of their policy titled, Prevention/Screening/Training. This policy read in part, .Criminal background and reference checks are performed on all employees . 04/12/23 4:00 p.m., Director of Nursing (DON) stated they were unable to obtain reference checks on these 2 employees from the agency. 04/12/23 4:14 p.m., during an end of the day meeting with the Administrator, DON, and Regional Nurse Consultant the issue regarding the missing reference checks was reviewed. Prior to the exit conference on 04/13/23 the DON provided the surveyor with reference checks obtained on these two employees by the facility. These documents were dated 04/13/23.

Based on resident representative interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the residents receive care in accordance with the comprehensive person-centered care plan and/or medical provider orders for 2 of 25 residents in the survey sample, Residents #25 and #264. The findings included: 1. For Resident #25, the facility staff failed to perform a hemoccult test to detect the presence of occult blood in the stool according to the medical provider's direction. Resident #25's diagnosis list indicated diagnoses, which included, but not limited to Fibromyalgia, Chronic Obstructive Pulmonary Disease, History of Venous Thrombosis and Embolism, Peripheral Vascular Disease, and Alzheimer's Disease. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 3/04/23 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 indicating the resident was moderately cognitively impaired. Resident #25's current comprehensive person-centered care plan included a focus area stating in part .the resident is at risk for bleeding, hemorrhage, excessive bruising and complications related to anticoagulant use secondary to: history of DVT [deep vein thrombosis], AFib [atrial fibrillation] with an intervention dated 11/21/22 for labs as ordered. According to Resident #25's clinical record, the resident was seen by the nurse practitioner (NP) on 2/21/23, the progress note stated in part .The patient is seen at the request of nursing staff due to long history of diarrhea which is increasing recently [sic] nursing staff describes stools as dark, very loose, and having a foul odor .Obtain Hemoccult . Resident #25 was again seen by the NP on 3/02/23, the progress noted stated in part .The patient is seen for reviewing of labs. CBC [complete blood count] which shows WBC [white blood count] 8.2, hemoglobin is 7.7, hematocrit 24.7, platelets 382. Last hemoglobin and hematocrit on 1/24 [1/24/23] were 10.6 and 33.8. Review of medication show the patient is on Eliquis 5 mg twice a day .If hemoglobin remains less than 8, we will type and crossmatch for 2 units as well as discontinue anticoagulant. Patient had a hemocult [sic] ordered last week where no results are seen, therefore, we will reorder today . Resident #25's clinical record included a 3/03/23 5:19 pm progress note documenting the results of the hemoccult test as positive indicating the presence of occult blood in the resident's stool. Surveyor reviewed Resident #25's clinical record and was unable to locate hemoccult results prior to 3/03/23. On 4/11/23 at 9:58 am, surveyor spoke with licensed practical nurse (LPN) #3 who stated Resident #25's hemoccult was obtained on 3/03/23 and that was the only one obtained. LPN #3 stated there was no order entered into the resident's record for a hemoccult following the NP's visit on 2/21/23. LPN #3 further stated it was unclear what happened, and it was the NP's first week at the facility. On 4/12/23 at 11:10 am, surveyor spoke with the NP who stated when they returned the following week, they noticed the hemoccult was not done and asked for it to be done again. NP stated they did not ask the reason why the hemoccult was not obtained as ordered. NP stated lab orders are given by verbal orders and all other orders are entered into the system at the time of the order. Surveyor asked if a hemoccult was a lab order and the NP stated yes. When asked if the delay in obtaining the hemoccult impacted Resident #25's outcome, the NP stated no, and they were continuing to monitor their CBCs, and the resident has an upcoming GI (gastrointestinal) consult appointment. On 4/12/23 at 4:14 pm, the survey team met with the interim administrator, director of nursing (DON), and the regional director of clinical services and discussed the concern of staff failing to perform a hemoccult test for Resident #25 as ordered by the physician. On 4/13/23 at 10:48 am, the DON stated lab tests performed by the lab company are given by verbal order and hemoccult tests are performed onsite therefore the provider enters the order themselves. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/13/23. 2. For Resident #264 the facility staff failed to administer the antidiabetic medication, Trulicity, as ordered by the physician. Resident #264's face sheet listed diagnoses which included but not limited to type 2 diabetes mellitus. Resident #264's most recent minimum data set with an assessment reference date of 02/10/23 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicated that the resident was cognitively intact. Resident #264's comprehensive care plan was reviewed and contained a care plan for the resident is at risk for complications blood glucose fluctuations related to diagnosis of diabetes mellitus with: insulin use. Interventions for this care plan included administer medications as ordered. Resident #264's physician's orders were reviewed and contained orders, which read in part Trulicity Solution Pen-injector 0.75 mg/0.5 ml (Dulaglutide). Inject 0.5 ml subcutaneously one time a day every Mon for DM2(diabetes mellitus 2). Order date 11/26/22, D/C (discontinued date) 12/12/22, Trulicity Solution Pen-injector 0.75 mg/0.5 ml (Dulaglutide). Inject 0.5 ml subcutaneously one time a day every Tue for DM. Order date 12/12/22, D/C date 12/22/22., Trulicity Solution Pen-injector 0.75 mg/0.5 ml (Dulaglutide). Inject 0.5 ml subcutaneously one time a day every Tue for DM. Order date 12/26/22, D/C date 01/16/23., Trulicity Solution Pen-injector 0.75 mg/0.5 ml (Dulaglutide). Inject 0.5 ml subcutaneously one time a day every Fri for DM. Order date 01/16/23, D/C date 02/07/23, and Dulaglutide Subcutaneous Solution Pen-injector 0.75 mg/0.5 ml (Dulaglutide). Inject 0.75 mg subcutaneously one time a day every Tue for DM. Order Date 02/07/23. Resident #264's medication administration records (MAR) for the months of November and December 2022, January, February, and March 2023 were reviewed and contained orders as above. The December MAR was coded 5 on 12/12/22 and 9 on 12/13/23. The January MAR was coded 9 on 01/10/23. The February MAR was coded 5 on 02/21/23. Chart code 5 is equivalent to Hold/see nurses notes. Chart code 9 is equivalent to Other/see nurses notes. Resident #264's nurse's progress notes were reviewed and contained notes which read in part, 12/12/2022 10:31 Note Text: Trulicity SolutionPen-injector 0.75 mg/0.5 ml. Inject 0.5 ml subcutaneously one time a day every Mon for DM2. due 12/13, 12/13/2022 07:46 Note Text: held per md orders, 01/10/2023 10:30 Note Text: not available re-ordered from pharmacy, and 02/21/2023 09:26 Note Text: on order awaiting pharmacy. Surveyor spoke with pharmacy technician on 04/12/23 at 11:35 am regarding Resident #254's Trulicity order. Surveyor asked pharmacy technician how often they sent the Trulicity and pharmacy technician stated that they sent it when they got a refill request, and each refill was one administration. Pharmacy technician stated that the Trulicity was refilled a total of 9 times while the resident was at the facility. For the duration the resident's stay at the facility, they should have received a total of 15 administrations of Trulicity. The concern of not administering the resident's Trulicity per the physician's orders was discussed with the administrator, director of nursing and regional director of clinical services on 04/15/23 at 10:50 am. No further information provided prior to exit. Resident #264's blood pressure documentation was reviewed. Abnormal blood pressures were documented for 1/5/23. On 1/5/23 at 9:17 a.m., Resident #264's blood pressure was documented as 208/82. On 1/5/23 at 13:22 a.m., Resident #264's blood pressure was documented as 206/90. Resident #264's clinical record included a provider note dated 1/5/23; this provider note was completed by Staff Member (SM) #4 (a nurse practitioner). This 1/5/23 note indicated the medication amlodipine (5mg) was to be started and proved daily. No evidence was found to indicate this medication had been started. On 4/13/23 at 10:40 a.m., SM #4 was asked about why the amlodipine was not started. SM #4 reported they expected the medication to have been provided. SM #4 stated they would have given the order, to be entered into the computerized medical records, by the facility's nursing staff. SM #4 stated they would have provided the order verbally or written to the facility's nursing staff. (SM #4 stated when written orders are provided to staff to be entered into the computerized record, the page the order is written on is not maintained as part of residents' clinical record.) On 4/12/23 at 4:14 p.m., the survey team met with the facility's Administrator, DON, and Regional Director of Clinical Services. Resident #264's clinical record not containing evidence the amlodipine order had been entered into the computerized order system was discussed. No evidence Resident #264 had received the amlodipine, based on the 1/5/23 medical provider progress note, was discussed. No additional information related to this issue was provided to the survey team. (Amlodipine is a medication used to treat high blood pressure.)

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide respiratory care consistent with the comprehensive person-centered care plan and physician's orders for 1 of 25 residents in the survey sample, Resident #75. The findings included: For Resident #75, the facility staff failed to administer oxygen as ordered by the physician. Resident #75's diagnosis list indicated diagnoses, which included, but not limited to Nonrheumatic Aortic Insufficiency, Paroxysmal Atrial Fibrillation, Obstructive Sleep Apnea, Dependence on Supplemental Oxygen, Chronic Kidney Disease, Morbid Obesity, Dementia, and Type 2 Diabetes Mellitus. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 3/03/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #75 was coded as requiring extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was also coded as receiving oxygen therapy within the last 14 days. On 4/11/23 at 11:11 am, surveyor observed Resident #75 in bed receiving oxygen via nasal cannula at the delivery rate of 3.5 liters per minute (L/M) per the oxygen concentrator setting. The concentrator was located on the right side, at the head of the bed out of the resident's reach. Resident #75 asked what setting the concentrator was on and surveyor informed the resident the concentrator was set at 3.5 L/M. Resident #75 stated I don't think it's supposed to be that much and asked surveyor to have it checked. Surveyor immediately notified licensed practical nurse (LPN) #3 who stated she would check the oxygen setting. Later in the day on 4/11/23, surveyor observed Resident #75 in bed receiving oxygen via nasal cannula at 2 L/M. Resident #75's current physician's orders included an order dated 4/05/23 for oxygen at 2 L/M via nasal cannula for shortness of breath. Resident #75's current comprehensive person-centered care plan included an intervention dated 9/29/22 to administer oxygen as ordered. Surveyor reviewed Resident #75's April 2023 Treatment Administration Record (TAR) and the administration of oxygen at 2 L/M via nasal cannula was initialed by the nurse for 4/11/23 dayshift. Surveyor requested and received the facility policy entitled Respiratory/Oxygen Equipment which read in part Licensed staff will administer and maintain respiratory equipment, oxygen administration, and oxygen equipment per provider's order and in accordance with standards of practice . On 4/11/23 at 4:32 pm, the survey team met with the interim administrator, director of nursing, and regional director of clinical services and discussed the concern of Resident #75 receiving oxygen at the rate of 3.5 L/M instead of the ordered rate of 2 L/M. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/13/23.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents were free of significant medication errors for 2 of 25 residents in the survey sample, Residents #75 and #30. The findings included: 1. For Resident #75, the facility staff failed to administer Novolin 70/30 as ordered by the medical provider. Novolin 70/30 is an intermediate acting insulin used to control blood sugar. Resident #75's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Nonrheumatic Aortic Insufficiency, Paroxysmal Atrial Fibrillation, Obstructive Sleep Apnea, Chronic Kidney Disease, and Morbid Obesity. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 3/03/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #75's current physician's orders included active orders for Novolin 70/30 10 units subcutaneously in the morning and hold if blood sugar was less than 150 and Novolin 70/30 15 units subcutaneously in the evening and hold if blood sugar less than 150. The morning Novolin 70/30 was scheduled for administration at 9:00 am and the evening dose was scheduled at 6:00 pm. Surveyor reviewed Resident #75's clinical record and was unable to locate documentation of the resident's blood sugars prior to Novolin 70/30 administration on the following occasions: 4/06/23 9:00 am, 4/07/23 9:00 am, 4/08/23 9:00 am, 4/10/23 6:00 pm, and 4/11/23 9:00 am. According to Resident #75's April 2023 Medication Administration Record (MAR), Novolin 70/30 15 units was not administered on 4/06/23 at 6:00 pm, as the MAR was left blank, surveyor was unable to locate a corresponding blood sugar for this administration. Resident #75's current comprehensive person-centered care plan included a focus area stating in part .The resident is at risk for complications and blood glucose fluctuations related to diagnosis of diabetes mellitus with: insulin use with an intervention dated 10/10/22 to administer insulin as ordered. On 4/11/23 at 4:32 pm, the survey team met with the interim administrator, director of nursing, and regional director of clinical services and discussed the concern of staff failing to administer Novolin 70/30 according to physician's orders. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/13/23. 2. For Resident #30 the facility staff failed to administer insulin per the physician's order. Resident #30's face sheet listed diagnoses which included but not limited to type 2 diabetes mellitus. The most recent minimum data set with an assessment reference date of 01/16/23 assigned the resident a brief interview for mental status score of 12 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #30's comprehensive care plan was reviewed and contained a care plan for Diabetes Mellitus: The resident is at risk for complications and blood glucose fluctuations related to diagnosis of diabetes mellitus with: insulin use. Interventions for this care plan included administer insulin as ordered. Resident #30's clinical record was reviewed and contained a physician's order summary for the month on April 2023, which read in part Humalog KwikPen Solution Pen-injector 100 unit/ml (Insulin Lispro (1 Unit Dial)) Inject 5 unit subcutaneously with meals related to TYPE 2 DIABETES MELLITUS WITH DIABETIC POLY NEUROPATHY (E11.42) and Humalog KwikPen Solution Pen-injector 100 unit/ml (Insulin Lispro (1Unit Dial)) Inject 8 unit subcutaneously one time a day related to DIABETES MELLITUS WITH DIABETIC POLY NEUROMPATHY (E11.42). Resident #30's medication administration record for the month of April 2023 was reviewed and contained entries as above. The entry for Humalog 5 units with meals was coded 5 on 04/09/23 at 12 pm, which is equivalent to Hold/see progress notes. Resident #30's nurse's progress notes were reviewed and contained a progress note dated 04/09/23, which read in part pt (patient) BS (blood sugar) was 128 at 1130 and he/she was given 8 units. Second 5 units was held due to BS. Surveyor spoke with director of nursing (DON) on 04/12/23 at 10:20 am regarding Resident #30's insulin. Surveyor asked DON to review resident's physician's order summary and medication administration record. DON confirmed that insulin was not administered as ordered. Surveyor asked if insulin should have been held, and DON stated, Not without calling the physician and getting an order to hold. I will start education immediately. The concern of holding the resident's insulin without a physician's order was discussed with the administrator, DON, and regional director of clinical services on 04/12/23 at 4:15 pm. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to provide laboratory services to meet the needs of the resident for 1 of 25 residents, Resident #94. The findings included: For Resident #94, the facility staff failed to obtain the provider ordered labs TSH (thyroid stimulating hormone) and LFT (liver function test). Resident #94's diagnosis included, but were not limited to, adult failure to thrive, hyperlipidemia, and chronic kidney disease. Section C (cognitive patterns) of Resident #94's quarterly MDS (minimum data set) assessment with an assessment reference date (ARD) of 02/15/23 included a brief interview for mental status (BIMS) summary score of 11 out of a possible 15 points. Resident #94's clinical record included a pharmacy recommendation dated 01/16/23 for a LFT and TSH due to the residents Amiodarone therapy. 02/08/23, Family Nurse Practitioner ordered LFT and TSH laboratory tests due to Amiodarone therapy. During the clinical record review, the surveyor was unable to locate any results for the ordered laboratory tests. 04/11/23 11:20 a.m., Unit Manager stated they were unable to find any evidence that the laboratory tests were obtained. 04/12/23 4:14 p.m., the Administrator, Director of Nursing, and Regional Nurse Consultant were made aware of the missing laboratory tests. No further information regarding the missing laboratory tests was provided to the survey team prior to the exit conference.

Based on interviews, clinical record review, and facility document review, the facility staff failed to maintain a complete and accurate clinical record for one (1) of 25 residents (Resident #100). The findings include: Resident #100's clinical record included a list of diagnoses. End Stage Renal Disease (ESRD) was incorrectly listed as one of Resident #100's diagnoses. No medical provider documentation was found to support the diagnosis of ESRD. Resident #100's Minimum Data Set (MDS) assessment, with an Assessment Reference date (ARD) of 2/26/23, was dated as completed on 3/4/23. Resident #100 was assessed as able to make self understood and as able to understand others. Resident #100's Brief Interview for Mental Status (BIMS) summary score was documented as a 13 out of 15; this indicated intact and/or borderline cognition. Resident #100 was assessed as requiring assistance with bed mobility, transfers, toilet use, and personal hygiene. Resident #100 discharge documentation, from a local hospital, included the medical problem of Acute Renal Failure. This discharge document was dated 2/20/23 at 2:12 p.m. On 4/12/23 at 11:15 a.m., Staff Member (SM) #1 (a nurse practitioner) reviewed Resident #100 clinical documentation. SM #1 confirmed Resident #100 had the diagnosis of Acute Renal Failure; SM #1 stated they were hopeful for Resident #100's kidney function to return. On 4/12/23 at 11:20 a.m., the surveyor discussed, with the facility's Director of Nursing (DON) and Regional Director of Clinical Services, Resident #100's diagnoses list containing the incorrect renal disease diagnosis. The following information was obtained from a policy named Documentation Summary (with an effective date of 11/1/19): Document all of the facts and pertinent information related to an event, course of treatment, patient condition, response to care, and deviations from standard treatment along with the reason for the deviation. On the afternoon of 4/12/23, Resident #100's clinical documentation was reviewed. It was noted the diagnosis of ESRD had been struck out due to a data entry error. On 4/12/23 at 4:14 p.m., the survey team met with the facility's Administrator, DON, and Regional Director of Clinical Services. Resident #100 having the diagnosis of ESRD documented when the resident was experiencing Acute Renal Failure was discussed.

Based on staff interview, facility document review, and during the course of a medication pass and pour observation, the facility staff failed to maintain an infection prevention and control program to provide a safe, sanitary environment to help prevent the development and transmission of communicable disease and infections on one of two facility units, unit 1. The findings include: During a medication pass and pour observation, Licensed Practical Nurse (LPN) #1 failed to change gloves and perform hand hygiene after administering eye drops to resident #9. On 4/11/23 at 08:39 AM surveyor observed LPN #1 during a medication pass and pour observation administer Artificial Tears eye drops to resident #9. After administering the eye drops, LPN #1 gave the resident their pills by using their fingers to pick each pill out of the medication cup individually, place the pill onto a spoon with pudding then put in the resident's mouth. LPN #1 did not change their gloves or perform hand hygiene after administering the eye drops. Surveyor asked LPN #1 what the facility policy was for hand hygiene when administering eye drops, they stated, I should have changed my gloves before I gave the pills. Surveyor requested and received the policy entitled, Handwashing Requirements, with an effective date of 2/6/20. The policy read in part, Under Section A. Hand Hygiene The following is a list of some situations that require hand hygiene, Under section k. Upon and after coming into contact with a patient's intact skin, and Under Section D. Gloves, Remove gloves after caring for a patient, and Change gloves during patient care when moving from a contaminated body site to a clean body site. Surveyor also received the Pharmscript policy with a revision date of 8/2020 entitled, Administration Procedures for all Medications, which read in part under IV. Administration #3. Cleanse hands using antimicrobial soap and water or facility- approved hand sanitizer before beginning a med pass, before handing medication and before contact with a resident. The survey team met with the Administrator, Director of Nursing and Regional Nurse Consultant on 4/11/23 at 4:30 PM and discuss this concern. No further information was provided to the survey team prior to exit on 4/13/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, the facility staff failed to accurately complete DDNR's for 2 of 25 residents, Residents #34 and #97. The findings included: 1. Resident #34's clinical record included the diagnoses of of diabetes, depression, and hypertension. Section C (cognitive patterns) of Resident #34's quarterly MDS (minimum data set) assessment with an (ARD) assessment reference date of [DATE] included a BIMS (brief interview for mental status) summary score of 13 out of a possible 15 points. Resident #34's clinical record included a DDNR order form from the Virginia Department of Health. This form was dated [DATE] and read in part. Under section 1 I further certify [must check 1 or 2]: 1. The patient is CAPABLE of making an informed decision . 2. The patient is INCAPABLE of making an informed decision . Neither box had been checked. Section 2 read, If you checked 2 above, check A, B, or C below . All three boxes had been left blank. [DATE] 8:40 a.m., LPN (licensed practical nurse) #1 was interviewed and stated that the DDNR was incomplete. [DATE] 1:30 p.m., the administrator, DON (director of nursing), and nurse consultant were made aware of the incomplete DDNR. No further information was provided regarding the incomplete DDNR prior to the exit conference. 2. Resident #97's minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], was completed on [DATE]. Resident #97 was assessed as able to make self understood and as able to understand others. Resident #97's BIMS (Brief Interview for Mental Status) summary score was a 10 out of 15 (indicating moderate cognitive impairment). Resident #97's provider orders included active orders for comfort care and DNR (do not resuscitate). Resident #97's clinical documentation included a signed Virginia Department of Health DDNR Order form dated [DATE]. This form included two (2) areas that had to be completed by a medical provider. The first area required the medical provider to certify if the individual was capable of making an informed decision related to initiating the DDNR order. The medical provider indicated Resident #97 was incapable of making such a decision. By indicating Resident #97 was not capable of making an informed decision about initiating the DDNR, the medical provider was required to complete the second area of the DDNR Order form. The second area required the medical provided to select one (1) of three (3) options to document how the decision to implement the DDNR Order was made due to the resident not currently being capable of making an informed decision. This second part was not completed. The incomplete DDNR Order form had been signed by a medical provider. The following information was found in a facility policy titled Do Not Resuscitate (with an effective date of [DATE]): A Virginia Department of Health Durable Do Not Resuscitate (DNR) Order form is a valid order. A licensed nurse verifies that the individual in question is the patient for whom the order is issued, and that the document is the original, or a legible copy of the DDNR form, that it has not been altered, that the form has been filled in completely, and that no signature(s) are missing. If the said DDNR form is not intact or has been altered, or has not been filled out completely, it is not considered valid for withholding CPR. If there is any question about the validity of a Virginia DDNR Order form, resuscitative measures should be administered until the validity of the order is established. During a survey team meeting with the facility's Administrator, Director of Nursing (DON) and Regional Nurse Consultant (RNC) on [DATE] at 12:10 p.m., the failure of the facility staff to ensure Resident #97's DDNR form was correctly completed was discussed.

Based on staff interview, employee record review, and facility document review, the facility staff failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of resident and misappropriation of resident property as evidenced by failure to pre-screen 5 of 25 new hire employees (LPN (licensed practical nurse) #1, LPN #4, LPN #16, LPN #17, and LPN #20). The findings included: The facility staff failed to obtain reference checks for agency LPNs #1, #4, #16, #17 and #20. A review of the employee records provided by the facility for agency LPNs #1, #4, #16, #17, and #20 revealed the following documentation: LPN #1 was employed through (name omitted) staffing agency on 10/11/21. LPN #1's employee record did not contain documentation of a reference check review. LPN #4 was employed through (name omitted) staffing agency on 9/13/21. LPN #4's employee record did not contain documentation of a reference check review. LPN #16 was employed through (name omitted) staffing agency on 10/14/21. LPN #16's employee record did not contain documentation of a reference check review. LPN #17 was employed through (name omitted) staffing agency on 9/08/21. LPN #17's employee record did not contain documentation of a reference check review. LPN #20 was employed through (name omitted) staffing agency on 11/11/21. LPN #20's employee record did not contain documentation of a reference check review. On 11/19/21 at 9:24 am, the administrator was interviewed and stated for the (name omitted) agency staff that is all I will have for them. The facility policy entitled Prevention/Screening/Training stated in part criminal background and reference checks are performed on all employees. On 11/19/21 at 1:30 pm, during a meeting with the administrator, director of nursing, and regional nurse consultant, surveyor discussed the concern of the missing reference check reviews for agency LPNs #1, #4, #16, and #17 and #20. No further information regarding these issues was presented to the survey team prior to the exit conference on 11/19/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure an accurate MDS (minimum data set) for 1 of 25 residents in the survey sample, Resident #103. For Resident #103, the facility staff coded the resident as being discharged to an acute hospital when in fact the resident had been discharged home. The findings included: Resident #103's diagnosis list indicated diagnoses, which included, but not limited to Unspecified Dementia without Behavioral Disturbance, Muscle Weakness, Adult Failure to Thrive, and Bipolar Disorder. The most recent discharge MDS with an ARD (assessment reference date) of 10/09/21 assigned the resident a BIMS (brief interview for mental status) score of 7 out of 15 in section C, Cognitive Patterns. Resident #103 was coded as being discharged to an acute hospital in section A, Identification Information. A review of Resident #103's clinical record revealed a physician's order stating in part discharge date : [DATE], Home Health Agency (name omitted) PT (physical therapy) - OT (occupational therapy) - NSG (nursing), Equipment Needs: N/A. Res (resident) may d/c (discharge) home with remaining narcotics. A nursing progress note dated 10/09/21 11:41 am stated in part, Resident discharged home today. On 11/17/21 at 12:27 pm, the MDS RN (registered nurse) #1 was interviewed and asked if the MDS was coded for discharge to an acute hospital when the resident was discharged home. The MDS RN #1 stated I believe it does say that. On 11/18/21 at 12:10 pm, the administrator, director of nursing, and the regional nurse consultant were notified of the inaccurate Discharge MDS assessment for Resident #103. No additional information regarding this concern was presented to the survey team prior to the exit conference on 11/19/21.

Based on staff interview and clinical record review, the facility staff failed to review and revise comprehensive care plans for 3 of 25 residents, Residents #1, #104, and #42. For Resident #1, the facility staff failed to review and revise the residents care plan when a PICC line was discontinued. For Resident #104, the care plan included the focus area for enhanced droplet precautions when Resident #104 was not on enhanced droplet precautions. Resident #42's care plan failed to address the resident's significant weight loss. The findings included: 1. Resident #1's diagnoses included, but were not limited to, hypertension, gastro-esophageal reflux disease, chronic atrial fibrillation, acute kidney failure, and peripheral vascular disease. Section C (cognitive patterns) of Resident #1's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 08/20/21 included a BIMS (brief interview for mental status) summary score of 12 out of a possible 15 points. Resident #1's current CCP (comprehensive care plan) included the focus area PICC line Left arm. with a revision date of 03/19/21. On 11/18/21 at 8:11 a.m., two agency nurses were asked about the resident's CCP's and stated they were not aware where the care plans were located. The unit manager reviewed Resident #1's CCP and stated the PICC line had been discontinued and identified themselves and the MDS coordinator as the staff responsible for updating care plans. A review of Resident #1's clinical record on 11/18/21 revealed that the resident's PICC line had been discontinued in April 2021. On 11/19/21 at 1:30 p.m., the administrator, DON (director of nursing), and nurse consultant were made aware of the issue regarding the residents PICC line remaining on the CCP months after it had been discontinued. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. Resident #104's clinical record included the diagnoses of muscle weakness, end stage renal disease, dependence on renal dialysis, and gastro-esophageal reflux disease. Section C (cognitive patterns) of Resident #104's admission (readmit) MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/11/21 included a BIMS (brief interview for mental status) summary score of 7 out of a possible 15 points. Resident #104's current care plan included the focus area The resident is enhanced droplet r/t (related to) admit. Created date 10/19/20 revision date 11/09/20. Interventions included, Enhanced Droplet and Contact precautions. Resident #104's clinical record did not include an order for droplet or contact precautions. On 11/18/21 at 10:26 a.m., the nurse consultant verified that Resident #104 had received their second dose of the COVID-19 vaccine on 11/02/21 and stated Resident #104 meet the criteria for being fully vaccinated, did not need to be on isolation, and that they had pulled the old care plan across from a previous admit. On 11/18/2021 at 10:45 a.m., the nurse consultant provided the policy titled COVID-19. This policy read in part, .New Admissions/Readmissions/Return to Center from outside visits (including hemodialysis patients): Place new admission/readmission in a designated area of the Center. Quarantine is not recommended for patients who are being admitted if they are fully vaccinated . On 11/19/21 at 1:30 p.m., the administrator, DON (director of nursing), and nurse consultant were made aware of the issue regarding the residents care plan in regards to isolation. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. Resident #42's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/2/21, was completed on 10/5/21. Resident #42 was assessed as able to understand others and as able to make themselves understood. Resident #42's Brief Interview for Mental Status (BIMS) summary score was documented as a five (5) out of 15 (this indicated severe cognitive impairment). Resident #42 was documented as requiring assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #42's diagnoses included, but were not limited to: pneumonia, thyroid disorder, osteoporosis, dementia, and lung disease. Resident #42's clinical documentation included the following weights: 9/9/21 - 105.5 lbs (pounds), 9/25/21 - 99.4 lbs, 10/3/21 - 96.2 lbs, and 11/18/21 - 89.8 lbs The difference in the 9/9/21 and 10/3/21 weight was 9.3 lbs, a greater than 8% weight loss. Resident #42's care plan included the following focus area: Nutritional Risk: recent hospitalization, dementia, COPD, PNA (pneumonia), aspiration risk. Therapeutic diet-receives nutritional supplements to provide extra kcals/protein. (history of weight) fluctuation, (resident) is on diuretic therapy. The goal for this focused area was: The resident will maintain adequate nutritional status (as evidenced by) no significant weight change by next review. This nutritional care plan failed to address Resident #42's actual significant weight loss. The last revision to this focus area's interventions was dated 6/2/21 with Provide and serve supplements as ordered being the intervention added. The following information was found in a facility policy/procedure titled Weight Monitoring and Tracking (with an effective date of 11/1/19): The Center has a system in place to weigh, monitor, and track patient's weights on a timely schedule. Weights are tracked and monitored by way of the interdisciplinary Weight Variance Committee .An interdisciplinary weight variance committee will meet at least monthly to discuss patients with significant weight change. Weekly weight meetings are encouraged and may be incorporated into other interdisciplinary team meetings .Significant weight changes will be identified and discussed by the interdisciplinary team using the table below . (information on the table indicated a 5% weight change in one (1) month and a 7.5% weight change in three (3) months were significant weight changes). During an interview with the Director of Nursing (DON) on 11/18/21 at 4:59 p.m., the DON reported no documentation was found to provide evidence of the care plan being revised to address Resident #42's aforementioned weight loss. The following information was found in a facility policy/procedure titled Resident Assessment & Care Planning (with an effective date of 11/1/19): A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individual care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient. During a survey team meeting with the facility's Administrator, DON, and Regional Nurse Consultant (RNC) on 11/18/21 at 5:16 p.m., the failure of the facility's staff members to review and revise Resident #42's care plan to address the resident's significant weight loss was discussed. No additional information related to this issue was provided to the survey team.

Based on staff interview, clinical record review, facility document review, and during a medication pass and pour observation, the facility staff failed to provide services to meet professional standards of practice for 1 of 25 residents, Resident #37. For Resident #37, the facility staff signed that they had administered the medication Lexapro 10 mg, when it had not been administered. The findings included: Resident #37's face sheet listed diagnoses which included but not limited to depression, schizophrenia, hypertension, and insomnia. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 08/24/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #37's comprehensive care plan was reviewed and contained a care plan, which read in part The resident uses psychotropic medications r/t depression, suicidal ideation schizophrenia, insomnia. Interventions for this care plan included administer meds as ordered. LPN (licensed practical nurse) #1 was observed on 11/17/21 at 8:45 am during a medication pass and pour. LPN #1 prepared and administered the medications Colace 100 mg, Lexapro 5 mg, Miralax 17 gm, Claritin 10 mg and Azelastine HCl nasal spray, 2 sprays per nostril to Resident #37. LPN #1 did not administer Lexapro 10 mg to Resident #37. Resident #37's clinical record was reviewed and contained a physician's order summary for the month of November 2021, which read in part Lexapro Tablet 10 mg (Escitalopram Oxalate). Give 1 tablet by mouth in the morning for Depression and, Lexapro Tablet 5 mg (Escitalopram Oxalate). Give 1 tablet in the morning for Depression. Resident #37's eMAR (electronic medication administration record) was reviewed and contained entries as above. Both of the entries had been initialed as being administered on 11/17/21 for the 9:00 am dose. Resident #37's medications were reconciled on 11/17/21. Upon reconciliation of medications, LPN #1 was asked if they had administered Resident #37's Lexapro 10 mg. LPN #1 stated they had misunderstood about the Lexapro, that they had pulled a 10 mg card, put it back and pulled a 5 mg card, since that was correct dose. LPN #1 was asked to confirm the order, and LPN #1 stated that Resident #37 was supposed to receive both doses. LPN #1 pulled the 10 mg dose and administered at this time (11:48 AM). LPN #1 was asked if they realized they had signed for both doses, but had actually only administered one. LPN #1 stated they did and was sorry. The DON (director of nursing) was interviewed on 11/17/21 at 12:20 pm and asked for the facility standard of practice in regards to medication administration. On 11/17/21 at 12:40 pm, DON provided the facility policy entitled General Guidelines for Medication Administration, which read in part Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer. 6. At a minimum, the 5 Rights-right resident, right drug, right dose, right route, and right time-should be applied to all medication administration and reviewed at three steps in the process of preparation: (1) when medication is selected, (2) when the dose is removed from the container, and (3) after the dose is prepared and medication is put away. 7. Always employ the MAR (medication administration record) during medication administration. Prior to the administration of any medication, the medication and dosage schedule on the resident's MAR are compared with the medication label. The DON was asked if this was their standard of practice, and DON stated that it was. The concern of not following professional standards of practice for the administration of medications was discussed with the administrative staff (administrator, director of nursing, regional nurse consultant) during an end of day meeting on 11//17/21 at 4:15 pm. No further information was provided prior to exit.

Based on observation, staff interview, resident interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure that residents who were unable to carry out ADL's (activities of daily living) received the necessary care and services to maintain personal hygiene for 3 of 25 Residents, Residents #62, #1 and #104. The facility staff failed to provide incontinence care for Resident #62. For Resident #1 and #104, the facility staff failed to provide nail care. Resident #1 and #104's toenails were observed long and jagged. The findings included: 1. Resident #62's diagnoses included, but were not limited to, muscle weakness, diabetes, anxiety disorder, and chronic kidney disease. Section C (cognitive patterns) of Resident #62's annual 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. Section G (functional status) was coded 3/2 extensive assistance of one person for toilet use and personal hygiene. Section H (bladder and bowel) was coded to indicate the resident was frequently incontinent of urine. Resident #62's comprehensive care plan included the focus areas for ADL self-care performance deficit and bladder incontinence. Interventions included, but were not limited to, personal hygiene provide set up and assist with hygiene needs as indicated. Clean peri-area with each incontinence episode. On 11/16/21 at 2:59 p.m., Resident #62 stated I was last changed (brief) before breakfast and indicated they were in need of incontinence care. On 11/16/21 3:31 p.m., CNA (certified nursing assistant) #1 provided incontinence care. CNA #1 stated Resident #62 was changed after breakfast. Resident #62 again stated it was before breakfast. Resident #62's brief and pad were observed saturated with urine. On 11/18/21 at 9:05 a.m., Resident #62 stated they had not been changed since last night around 10:30 p.m. Resident #62 stated a staff came in around 3:30 a.m. and they had asked them to come back and no one ever came back. Resident #62 added that they had fallen asleep during that timeframe and they were a heavy wetter. On 11/18/21 at 9:18 a.m., CNA #2 entered the room to change Resident #62. Resident #62's pad and brief were observed saturated with urine. CNA #2 confirmed the pad and brief were saturated. The administrator, DON (director of nursing), and nurse consultant were notified of the issue of Resident #62 being left wet for an extended period of time on 11/17/21 and again on 11/19/21 at 1:30 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. Resident #1's diagnoses included, but were not limited to, hypertension, gastro-esophageal reflux disease, chronic atrial fibrillation, acute kidney failure, and peripheral vascular disease. Section C (cognitive patterns) of Resident #1's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 08/20/21 included a BIMS (brief interview for mental status) summary score of 12 out of a possible 15 points. Section G (functional status) was coded to indicate the resident required (3/2) extensive assistance of one person for personal hygiene and had limited range of motion in the upper and lower extremities. Resident #1's comprehensive care plan included the focus area of has an ADL self-care performance deficit. Interventions included, but were not limited to, personal hygiene/oral care provide set up and assist with oral/dental care and hygiene needs as indicated. On 11/17/21 at 2:35 p.m., Resident #1's toenails on right foot were observed long and jagged. Resident #1 stated they were supposed to have had them cut by the doctor but maybe the facility staff forgot. On 11/17/21 during a meeting with the administrator, DON (director of nursing), and nurse consultant, the DON stated the staff cut the resident's nails unless they are a diabetic. The nurse consultant stated they did not have a policy specific to nail care. The administrator, DON, and nurse consultant were notified of the issue of Resident #1's toenails on 11/17/21 and again on 11/19/21 at 1:30 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. Resident #104's clinical record included the diagnoses of muscle weakness, end stage renal disease, dependence on renal dialysis, gout, and gastro-esophageal reflux disease. Section C (cognitive patterns) of Resident #104's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/11/21 included a BIMS (brief interview for mental status) summary score of 7 out of a possible 15 points. Section G (functional status) was coded to indicate the resident required limited assistance (2/2) of one person for personal hygiene and used a wheelchair for mobility. Resident #104's current care plan included the focus area of has an ADL performance self-care deficit, has limited physical mobility, and pain related to gout. Interventions included, but were not limited to, personal hygiene provide set up and assist with oral/dental care and hygiene needs as indicated. On 11/17/21 at 3:00 p.m., Resident #104's toenails were observed long and jagged. Resident #104 also stated that their fingernails needed to be trimmed. On 11/17/21 during a meeting with the administrator, DON (director of nursing), and nurse consultant the DON stated the staff cut the resident's nails unless they are a diabetic. The nurse consultant stated they did not have a policy specific to nail care. On 11/19/21 at 1:30 p.m., the administrator, DON, and nurse consultant were made aware of the issue regarding the residents nails. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on resident interview, staff interview, and clinical record review the facility staff failed to follow physician's orders for 3 of 25 residents, Resident #79, Resident #68, and Resident #10. For Resident #79 the facility staff failed to check resident's blood pressure prior administering the medication Metoprolol, per the physician's order. For Resident #68 the facility staff failed to follow physician's orders for the administration of prn (as needed) medications for constipation. For Resident #10, the facility staff failed to follow physician ordered parameters when administering blood pressure medications. The findings included: 1. Resident #79's face sheet listed diagnoses which included, but not limited to dementia, anemia, anxiety, gastroesophageal reflux disorder, insomnia, psychotic disorder, and hypertension. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 10/27/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out of 15. This indicated that the resident was severely cognitively impaired. Resident #79's comprehensive care plan was reviewed and contained a care plan for, The resident has hypertension (HTN) r/t (related to) lifestyle choices, history of Smoking, HLD (hyperlipidemia). Interventions for this care plan included Meds as ordered and Vital signs as needed. Resident #79's clinical record was reviewed on 11/18/21 and contained a signed physician's order summary for the month of November 2021, which read in part Metoprolol Succinate ER Extended Release 24 Hour 25 MG. Give I tablet by mouth one time a day for HTN (hypertension). Hold if BP (blood pressure) is 115 or less or pulse is less than 60. Resident #79's eMAR (electronic medication administration record was reviewed and contained an entry, which read , Metoprolol Succinate ER Extended Release 24 Hour 25 MG. Give I tablet by mouth one time a day for HTN (hypertension). Hold if BP (blood pressure) is 115 or less or pulse is less than 60. This entry did not have an area to record the resident's blood pressures. The RNC (regional nurse consultant) was interviewed on 11/18/21 at 3:40 pm regarding the resident's blood pressure. The RNC was asked if staff should be checking and recording the resident's blood pressures prior to the administration of the medication. The RNC stated, That would be my expectation. The RNC stated to check under vital signs tab in the electronic medical record to see if blood pressures were being record there. There were only two blood pressures recorded in this area for Resident #10 for the month of November. The concern of the facility staff not checking the resident's blood pressures prior to the administration of the medication, Metoprolol, per the physician's order was discussed with the administrative team (administrator, director of nursing, regional nurse consultant) during an end of day meeting on 11/18/21 at 5:15 pm. No further information was provided prior to exit. 2. Resident #68's face sheet listed diagnoses which included but not limited to chronic obstructive pulmonary disease, dementia, depression, anxiety, chronic kidney disease, gastroesophageal reflux disease, and constipation. Resident #68's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 10/22/21 assigned the resident a BIMS (brief interview for mental status) score of 10 out 15 is section C, cognitive patterns. This indicated that the resident was moderately cognitively impaired. Resident #68's comprehensive care plan was reviewed and contained a care plan for, The resident has risk for constipation r/t (related to) decreased mobility. The goal for this care plan was, The resident will have a normal bowel movement at least every 3rd day through the review date. Interventions for this care plan include adm (administer) meds as ordered. Resident #68's clinical record was reviewed on 11/17/21 and contained a physician's order summary for the month of November 2021, which read, Dulcolax Milk of Magnesia Suspension (Magnesium Hydroxide). Give 30 ml by mouth every 8 hours as needed for constipation and Dulcolax Tablet Delayed Release (Bisacodyl). Give 10 mg by mouth every 24 hours as needed for constipation. Resident #68's eMAR (electronic medication administration record) for the month of November 2021 was reviewed and contained entries as above. The entry for Milk of Magnesia was initialed as being given on 11/06/21 at 2030 (9:30 pm), and coded with I meaning ineffective. The order for Dulcolax had not been initialed for the month of November. Resident #68 was interviewed on 11/17/21 at 2:25 pm. Resident #68 stated, I can't poop. It hurts so bad. Resident #68's bowel movement record in the electronic record was reviewed on 11/17/21. The bowel movement record indicated that Resident #68 had a bowel movement on 11/03/21 and did not have another bowel movement until 11/10/21, for a total of 6 days with no bowel movement. The DON stated they would print off the bowel movement report for Resident #68. As of 12 pm on 11/19/21, this had not been received. No further information was provided prior to exit. 3. Resident #10's clinical record included the diagnoses hypertension, congestive heart failure, dementia, and anxiety. Section C (cognitive patterns) of Resident #10's significant change MDS (minimum data set) assessment with an ARD (assessment reference date) of 09/01/21 included a BIMS (brief interview for mental status) summary score of 4 out of a possible 15 points. Resident #10's clinical record included orders for following hypertensive medications: Amlodipine Besylate 5 mg 1 tablet by mouth at bedtime hold if heart rate is less than 55 or SBP (systolic blood pressure), (top number) is less than 100. Start date 11/16/20. Hydralazine 100 mg 1 tablet by mouth three times a day for hypertension hold if heart rate is less than 55 of SBP less than 100. Start date 11/16/20. Metoprolol Tartrate 12.5 mg two times a day for hypertension hold if heart rate is less than 55 or SBP less than 100. Start date 11/16/20. A review of Resident #10's eMARs (electronic medication administration records) revealed that the nursing staff had documented a 15 for the medication Metoprolol Tartrate on 11/06/21 at 9:00 p.m. for a BP (blood pressure) of 115/72 and a heart rate of 58, on 11/11/21 at 9:00 p.m. for a BP of 107/60 and a heart rate of 72, and on 11/15/21 for a BP of 121/76 and a heart rate of 55. Per the preprinted code on the eMAR a 15 meant No coverage required. On 11/17/21 at 11:53 a.m., the nurse consultant stated they were unable to find any further information in regards to the blood pressure medication metoprolol being held. Further review of the eMARs revealed that the nursing staff had also held the hypertensive medications Hydralazine and Amlodipine Besylate. For the hypertensive medication Hydralazine the nursing staff had documented a 15 No coverage required on 11/06/21 at 9:00 p.m. for a BP of 115/72 and a heart rate of 58, on 11/11/21 at 1:00 p.m. for a BP of 103/57 and a heart rate of 69, at 9:00 p.m. for a BP of 107/60 and heart rate of 72, and on 11/15/21 at 9:00 p.m. for a BP of 121/76 and heart rate of 55. For the medication Amlodipine Besylate on 11/11/21 at 9:00 p.m, the nursing staff had documented a BP of 107/60 and a heart rate of 72. There was no documentation for a BP or heart rate on 11/06/21 or on 11/15/21 at 9:00 p.m., the medication boxes were marked with an X. The nursing staff had documented a 15 on the eMAR for both of these dates. The administrator, DON (director of nursing), and nurse consultant were made aware that the facility staff had not followed the physician ordered parameters in regards to BP medications on 11/17/21 and again on 11/19/21 at 1:30 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on interviews and the review of documents, the facility staff failed to provide respiratory services and/or care for two (2) of 25 residents, Resident #42 and Resident #158. The facility staff failed to ensure Resident #42's oxygen was provided when the resident was transported outside to the facility's gazebo for a family visit. The facility staff failed to consistently complete respiratory assessments every shift as detailed in Resident #158's COVID-19 care plan. The findings include: 1. Resident #42's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/2/21, was completed on 10/5/21. Resident #42 was assessed as able to understand others and as able to make themself understood. Resident #42's Brief Interview for Mental Status (BIMS) summary score was documented as a five (5) out of 15 (this indicated severe cognitive impairment). Resident #42's diagnoses included, but were not limited to: pneumonia, thyroid disorder, osteoporosis, dementia, and lung disease. A family member of Resident #42 (FM #1) was interviewed on 11/17/21. FM #1 reported, on 11/12/21, Resident #42 was being visited by family members. FM #1 reported that Resident #42 was brought outside the facility to the gazebo, while the family members made their way to the gazebo. When the family members arrived at the gazebo, Resident #42 was found unattended without their oxygen. On 11/17/21 at 3:20 p.m., the facility's Administrator and Regional Nurse Consultant (RNC) was informed that FM #1 reported Resident #42 was placed in the facility's gazebo without their oxygen. No documentation was found in Resident #42's clinical record related to the 11/12/21 family visit. A SERVICE CONCERN REPORT addressing the aforementioned concern, partially completed on 11/17/21 by the facility's Director of Nursing (DON), was provided to the survey team. The DON's investigation into this concern identified via staff interviews that Resident #42 was transported to the gazebo by a nursing student. The family visiting Resident #42 contacted the facility's receptionist requesting the resident's oxygen. The resident's oxygen was taken to the resident in the gazebo, as a result of the family's request. The following provider order was found in Resident #42's clinical record: Oxygen Therapy - Oxygen at 3L Liters per minute via nasal cannula every shift for COPD. This order was dated 9/25/2021. Resident #42's care plan included the following focus area: The resident has altered respiratory status/difficulty breathing (related to) COPD, chronic respiratory failure, Bronchiectasis [sic]. This focus area included the intervention of OXYGEN SETTING: (oxygen) via (nasal cannula). On 11/19/21 at 1:30 p.m., the facility's Administrator, Director of Nursing (DON), and RNC were part of a survey team meeting. During this meeting, the failure of facility staff to ensure Resident #42's oxygen was provided, as ordered, during a family visit was discussed. 2. Resident #158's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 11/5/21, was completed on 11/11/21. Resident #158 was assessed as being able to sometimes make themself understood by others and sometimes able to understand others. Resident #158's Brief Interview for Mental Status (BIMS) summary score was documented as a three (3) out of 15 (this indicated severe cognitive impairment). Resident #158's diagnoses included, but were not limited to: high blood pressure, kidney disease, dementia, and depression. Review of Resident #158's clinical documentation on 11/18/21 failed to provide evidence of a respiratory assessment being completed every shift. On 11/18/21 at 3:35 p.m., the facility's Director of Nursing (DON) was interviewed about the missing respiratory assessments. The DON confirmed the resident assessments were not completed as care planned. The survey team was provided evidence of the completion of three (3) Respiratory Evaluations completed on 11/10/21 at 5:03 a.m.; 11/13/21 at 2:30 a.m.; and 11/14/21 at 12:39 a.m. Resident #158's care plan included the focus area statement of: The resident is Positive for COVID-19. Goals for this focus were: The resident will be free of complications related to COVID-19 through next review .The resident will be free of symptom of respiratory distress through next review. Resident #158 was care planned with the intervention of: Respiratory Assessment (every) shift and (as needed). The failure of facility staff members to complete Resident #158's care planned respiratory assessments/evaluations was discussed with the facility's Administrator, Director of Nursing (DON), and RNC on 11/19/21 at 1:30 p.m.

Based on staff interview, clinical record review, and facility document review and during a medication pass and pour observation the facility staff failed to ensure the medications Cymbalta 30 mg and Tylenol 325 mg were available for administration for 1 of 25 residents, Resident #8. The findings included: Resident #8's diagnoses included but were not limited to multiple sclerosis, depression, insomnia, hypertension, and quadriplegia. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 09/03/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns. This indicated that the resident was cognitively intact. Resident #8's comprehensive care plan was reviewed and contained a care plan for pain. Interventions for this care plan included Medicate as ordered. LPN (licensed practical nurse) #2 was observed during a medication pass and pour on 11/17/21 at 8:30 am. LPN #2 prepared Resident #8's medications, but stated that they could not locate the resident's Cymbalta 30 mg or Tylenol 325 mg. LPN #2 stated they would contact the pharmacy to get the medications and let surveyor know when the medications arrived. On 11/17/21 at 11:50 am LPN #3 stated that they had gotten an order from the facility FNP (family nurse practitioner) to hold the resident's Cymbalta and Tylenol for the day. Resident #8's progress notes were reviewed and contained a note, which read in part 11/17/21 11:50. New order: Hold Cymbalta 30 MG x1 day and Tylenol 325 mg hold x 1 day . The facility policy entitled Unavailable Medications documented, Medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. This may be due to the pharmacy being temporarily out of stock of a particular product, a drug recall, or manufacturer's shortage of an ingredient, or may be a permanent situation due to the medication no longer being produced. The facility must make every effort to ensure that medications are available to meet the needs of each resident. Procedures: The nursing staff shall: 1. Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy(ies) available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction. 2. Obtain a new order and cancel/discontinue the order for the non-available medication. 3. Notify the pharmacy of the replacement order. The concern of the resident's medications not being available for administration was discussed with the administrative team (administrator, director of nursing, regional nurse consultant) during an end of day meeting on 11/17/21 at 4:15 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review, facility document review, and during a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5%. There were two errors in 26 opportunities for a medication error rate of 7.69%. The findings included: Resident #37's diagnoses included but were not limited to, depression, schizophrenia, hypertension, and insomnia. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 08/24/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident was cognitively intact. LPN (licensed practical nurse) #1 was observed on 11/17/21 at 8:45 am during a medication pass and pour. LPN #1 prepared and administered the medications Colace 100 mg, Lexapro 5 mg, Miralax 17 gm, Claritin 10 mg and Azelastine HCl nasal spray, 2 sprays per nostril, to Resident #37. LPN #1 did not administer Lexapro 10 mg to Resident #37. Resident #37's clinical record was reviewed and contained a physician's order summary for the month of November 2021, which read, Lexapro Tablet 10 mg (Escitalopram Oxalate). Give 1 tablet by mouth in the morning for Depression, Lexapro Tablet 5 mg (Escitalopram Oxalate). Give 1 tablet in the morning for Depression and Azelastine HCl solution 0.1% 1 spray in both nostrils one time a day for nasal congestion Resident #37's medications were reconciled on 11/17/21. Upon reconciliation of medications, LPN #1 was asked if they had administered Resident #37's Lexapro 10 mg. LPN #1 stated that they had misunderstood about the Lexapro, that they had pulled a 10 mg card, then put it back and pulled a 5 mg card, since that was correct dose. LPN #1 was asked to confirm the order. LPN #1 stated that resident was supposed to receive both doses. LPN #1 pulled the 10 mg dose and administered it at this time (11:48 AM). LPN #1 was interviewed on 11/17/21/ at 12:23 pm regarding how many sprays per nostril of the Azelastine HCL nasal spray they had administered to Resident #37. LPN #1 stated Two. LPN #1 was asked to confirm the order. LPN #1 confirmed that they should have only administered one spray per nostril per the physician's order. The facility policy entitled General Guidelines for Medication Administration, which read in part Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer. 6. At a minimum, the 5 Rights-right resident, right drug, right dose, right route, and right time-should be applied to all medication administration and reviewed at three steps in the process of preparation: (1) when medication is selected, (2) when the dose is removed from the container, and (3) after the dose is prepared and medication is put away. 7. Always employ the MAR (medication administration record) during medication administration. Prior to the administration of any medication, the medication and dosage schedule on the resident's MAR are compared with the medication label. The concern of not ensuring a medication error rate of less than 5% was discussed with the administrative team during an end of day meeting on 11/17/21 at 4:15 pm. No further information was provided prior to exit.

Based on staff interview and facility document review, the facility staff failed to ensure the dietary manager for the facility possessed the required education and/or certification. The findings include: On 11/19/21 at approximately 11:20 a.m., the facility's administrator acknowledged the facility's dietary manager did not have a certification or the education required for the position of dietary manager. The administrator explained the dietary manager was currently enrolled in an online training course and had one year to complete the course. The administrator provided a document which indicated the Dietary Manager Training pathway had been ordered (with the employee's name) however he/she denied knowing when that training pathway had been ordered. The only date on the document was 11/19/21, 11:14 a.m., which the administrator stated was the date/time the document was printed. The administrator provided a letter which indicated the facility's previous certified dietary manager had resigned in September 2021 with a last work day for the contracted dietary service being 10/10/2021. The administrator referred to the current dietary manager as their interim dietary manager for the first time during the survey and stated the facility had plans to offer the interim dietary manager a permanent position since this contracted employee had been an internal employee in dietary services for approximately four years previously. The dietary manager was interviewed on 11/19/21 at 11:45 a.m. He/She reported having enrolled in the online course two weeks ago but had not started the course because the student identification number, needed to begin the course, had not been sent. The dietary manager acknowledged having one year to complete the course. The administrator also acknowledged that although the facility's dietitian worked full-time for the contracted dietary service, the dietitian was not at the facility full-time. No further information was provided prior to the exit conference.

Based on staff interview and facility document review, the facility staff failed to conduct routine COVID-19 testing for 1 of 3 sampled employees (Staff Member #2) and 2 agency nurses. The findings included: 1. On 11/17/21, the administrator provided a signed document stating We have remained in high community transmission rate since 10/01/21. A review of SM #2's COVID-19 testing since 10/01/21, included documentation of testing performed on 10/04/21, 10/14/21, 10/21/21, 10/28/21, 11/08/21, and 11/12/21 each with negative results. A copy of SM #2's COVID-19 Vaccination Record Card documented they received their first dose of the (name omitted) COVID-19 vaccine on 9/17/21 but had not received the second dose. The facility policy entitled, COVID-19 Testing documented: 1. Routine testing of employees .b. Unvaccinated employees are to be routinely tested based on the center's county level of community transmission. On 11/18/21 at 5:15 pm, the administrator, director of nursing, and the regional nurse consultant were notified of the missing routine COVID-19 testing for SM #2. The following morning on 11/19/21, the administrator provided documentation of additional COVID-19 testing for SM #2 for 10/07/21, 11/04/21, and 11/18/21 each with negative results. Following review of the additional test results, SM #2 still had four missing COVID-19 test results. No further information regarding this issue was presented to the survey team prior to the exit conference on 11/19/21. 2. On 11/18/21 at approximately 10:55 a.m., agency nurse #1 and #2 were asked about testing for COVID-19 and stated they were tested outside of the facility on 11/17/21. The results of these tests were not provided. On 11/18/21 at 12:10 p.m., the administrator, DON (director of nursing) and nurse consultant were asked for evidence of COVID-19 testing and vaccination status for the two agency nurses currently working in the building. On 11/18/21 at 2:20 p.m., the administrator stated they did not have a tracking system in place for vaccines for agency employees, that they were testing employees twice a week, and they did not have a COVID-19 outbreak related to agency staff. On 11/18/21 at 2:22 p.m., the staff development coordinator stated agency staff should be tested for COVID-19 prior to being allowed to work in the facility. On 11/18/21 at 2:30 p.m., the administrator stated they would work the agency staff into the scheduled testing routine. It would be good for them to be tested but not required. On 11/19/21 at 9:32 a.m., the IP (infection preventionist) stated they should know the vaccination status and COVID-19 status of agency employees prior to allowing them to work in the building. On 11/19/21 at 10:13 a.m., the IP stated they swabbed the agency nurses late yesterday. The facility provided evidence of negative COVID-19 testing for both these employees dated 11/18/21. These tests were completed after the survey team requested information regarding testing for agency employees. On 11/19/21 at 10:17 a.m., human resource employee #1 stated they did not complete anything in regards to agency staff. The facility did not provide any evidence to the survey team indicating the agency nurses were fully vaccinated. The facility provided the policy titled, COVID-19 Testing which read in part, .Outbreak testing will occur immediately, and be conducted by two options: Contact tracing/focused testing approach .Broad-based testing approach, in which the center tests all employees and patients when a new case is identified, regardless of vaccination status .Testing-Others: Unvaccinated consultants, contractors, volunteers, students, transportation staff and anyone else who 'provide services under arrangement and volunteers' should be tested. These individuals must be tested using the timeframe that corresponds to the centers testing frequency. If the individual has been tested from another source, the center must obtain documentation of the results, including the date and the test results, and keep a copy of the result on file. If the individual has not been previously tested the center can perform a POC (antigen) test, if available and document the results . No further information regarding this issue was provided to the survey team prior to the exit conference.

3. Resident #49's diagnoses included but were not limited to, diabetes mellitus II, chronic kidney disease, anorexia, hypertension, hypothyroidism, insomnia, constipation, depression, dementia and anxiety. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 10/08/21 assigned the resident a BIMS (brief interview for mental status) score of 0 out of 15. This indicated that the resident was severely cognitively impaired. Resident #49's clinical record was reviewed on 11/18/21. The medication regimen review for the month of July 2021 was not located. On 11/18/21 the DON (director of nursing) was notified that the medication regimen review could not be located. On 11/19/21 the DON stated that the medication regimen review was not located. The concern of the facility staff not ensuring that the monthly medication regimen review was completed was discussed with the administrative team (administrator, director of nursing, regional nurse consultant) on 11/18/21 at 5:15 pm. No further information was provided prior to exit. 4. Resident #79's face sheet listed diagnoses which included, but not limited to dementia, anemia, anxiety, gastroesophageal reflux disorder, insomnia, psychotic disorder, and hypertension. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 10/27/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out of 15. This indicates that the resident is severely cognitively impaired. Resident #79's clinical record was reviewed on 11/18/21. A medication regimen review for the month of July 2021 was not located. On 11/18/21 the DON (director of nursing) was notified that the medication regimen review could not be located. On 11/19/21 the DON stated that the medication regimen review was not located. The concern of the facility staff not ensuring that the monthly medication regimen review was completed was discussed with the administrative team (administrator, director of nursing, regional nurse consultant) on 11/18/21 at 5:15 pm. No further information was provided prior to exit. Based on staff interview and clinical record review, the facility staff failed to complete drug regimen reviews for 4 of 25 residents and failed to follow up on a pharmacy recommendation for 1 of 25 residents. Residents #10, #34, #49 and #79. The findings included: 1. Resident #10's clinical record included the diagnoses hypertension, congestive heart failure, dementia, and anxiety. Section C (cognitive patterns) of Resident #10's significant change MDS (minimum data set) assessment with an ARD (assessment reference date) of 09/01/21 included a BIMS (brief interview for mental status) summary score of 4 out of a possible 15 points. On 11/18/21 at 4:16 p.m., during a review of the Resident #10's clinical record, the pharmacy drug regimen review for July 2021 was not located. On 11/18/21 at 5:15 p.m., the missing drug regimen review was requested from the administrator, DON (director of nursing), and nurse consultant. The administrative staff stated they had recently changed their pharmacy. On 11/19/21 at 8:58 a.m., the DON stated they were unable to find a pharmacy drug regimen review for July 2021. No further information regarding the missing drug regimen review was provided to the survey team prior to the exit conference. 2. Resident #34's clinical record included the diagnoses of diabetes, depression, and hypertension. Section C (cognitive patterns) of Resident #34's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 10/01/21 included a BIMS (brief interview for mental status) summary score of 13 out of a possible 15 points. During a review of the Resident #34's clinical record, the pharmacy drug regimen review for July 2021 was not located. On the drug regimen review dated 08/06/21, the pharmacist had checked the box beside the statement, See report for any noted irregularities and/or recommendations. No information in regards to this recommendation was located in the clinical record. On 11/18/21 at 5:15 p.m., the administrator, DON (director of nursing), and nurse consultant were made aware of the missing information in regards to a pharmacy recommendation for August 2021 and drug regimen review for July 2021. The administrative staff stated they had recently changed their pharmacy. On 11/19/21 at 8:58 a.m., the DON stated they were unable to locate a drug regimen review for July 2021 and unable to find any information regarding the recommendation from the pharmacist for 08/06/21. No further information regarding the missing recommendation or drug regimen review was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to ensure 1 of 25 residents was free from unnecessary medications, Resident #49. The facility staff failed to hold the blood pressure medication, hydralizine, when it should have been held based on a blood pressure reading/pulse on 6 occassions in the month of November 2021. The findings included: Resident #49's diagnoses included but were not limited to, diabetes mellitus II, chronic kidney disease, anorexia, hypertension, hypothyroidism, insomnia, constipation, depression, dementia and anxiety. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 10/08/21 assigned the resident a BMS (brief interview for mental status) score of 0 out of 15. This indicated that the resident was severely cognitively impaired. Resident #49's clinical record was reviewed on 11/18/21 and contained a physician's order summary for the month of November 2021, which read, hydrALAZINE HCl tablet 50 mg. Give 1 tablet by mouth two times a day for HTN (hypertension). Hold if SBP (systolic blood pressure) is less than 115 or pulse is less than 60. Resident #49's eMAR (electronic medication administration record) for the month of November 2021 was reviewed and contained an entry which read, hydrALAZINE HCl tablet 50 mg. Give 1 tablet by mouth two times a day for HTN (hypertension). Hold if SBP (systolic blood pressure) is less than 115 or pulse is less than 60. This entry was initialed as administered on 11/03/21 at 9:00 am with a SBP of 107, on 11/03/21 at 8:00 pm with a SBP of 100, on 11/04/21 at 9:00 with a SBP of 100, on 11/06/21 at 8:00 pm with a SBP of 113, on 11/09/21 at 8:00 pm with a SBP of 113, and on 11/11/21 at 9:00 am with a SBP of 101 and a pulse of 58. The director of nursing (DON) was interviewed on 11/18/21 at 2:30 pm regarding Resident #49's medications. The DON stated the medication should not have been administered on the above dates/times. The concern of the facility staff failing to ensure the resident was free of unnecessary medications was discussed with the administrative team (administrator, director of nursing, regional nurse consultant) on 11/18/21 at 5:15 pm. No further information was provided prior to exit.

3. On 11/17/21 at 2:13 pm, the past two weeks of daily screenings for COVID-19 signs and symptoms for staff member (SM) #1 were requested. On 11/18/21 at 1:34 pm, the administrator stated that SM #1's last day of employment was 11/01/21. On 11/18/21 at 9:55 am during a meeting with the Infection Preventionist, administrator, and Regional Nurse Consultant (RNC), were asked how staff were screened prior to each shift. The administrator stated the staff have a sign-in book with screening questions and a temperature check. On 11/18/21 at 5:15 pm, the administrator, DON (director of nursing), and the RNC were asked for daily screening for the last two weeks of SM #1's employment. On 11/19/21 at 10:43 am, the administrator provided daily screenings for SM #1 for 10/07/21 and 10/08/21 only. On 11/19/21 at 11:10 am, the HR (human resource) Manager was asked for the dates SM #1 worked in the facility after 10/08/21. The HR Manager stated SM #1 worked in the facility on 10/09/21, 10/10/21, 10/14/21, 10/19/21, 10/23/21, 10/24/21, 10/26/21, and 10/28/21. Surveyor requested and received the facility policy entitled COVID-19 which states in part: 6. Surveillance - Employees a. Screen Center employees prior to beginning shift to include: Positive travel history to locations with sustained community transmission of COVID-19 within the past 14 days. Signs or symptoms of COVID-19 (fever (temperature greater than 99.5 degrees F or 37.5 degrees C), chills, sore throat, cough, nasal congestion, congestion, runny nose, fatigue, myalgia, body aches, shortness of breath, difficulty breathing, headache, nausea, vomiting, diarrhea, or new loss of taste or smell). Has had high risk/prolonged contact with someone who is suspected or positive for COVID-19. On 11/19/21 at 1:30 pm the administrator, DON, and RNC were notified of the missing daily screenings for SM #1. No additional information regarding this concern was presented to the survey team prior to the exit conference on 11/19/21. Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow infection control policies and procedures for preventing the spread of COVID-19 on 1 of 2 units, unit 2 the observation wing, and failed to ensure screening of employees prior to work. The facility staff failed to donn PPE (personal protective equipment) before entering resident rooms that were on droplet/contact precautions, failed to perform any hand hygiene prior to/after exiting these rooms; failed to doff PPE when exiting a resident's room who was on transmission-based precautions; failed to ensure proper infection control signage on Resident #33's and Resident #42's room; and failed to ensure staff were screened for symptoms of COVID-19 prior to working at the facility. The findings included: 1. On 11/16/21 upon entrance to the facility, the administrator confirmed they currently had 20 in house residents and 15 staff that were positive for COVID-19. The facility had a hot unit for positive COVID-19 residents and a warm unit for observation. On 11/16/21 at 1:33 p.m., housekeeper #1 was observed entering a resident room on the observation wing. The housekeeper had an N95 mask in place. Housekeeper #1 did not perform any hand hygiene before entering this room, did not donn any additional PPE, and did not complete any hand hygiene prior to or after exiting the room. Housekeeper #1 was observed opening the closet with their bare hands and placing an item inside. A PPE cart and two signs were observed outside of this room. One sign read in part, Stop Contact Precautions .Perform hand hygiene using soap and water and/or alcohol-based rub before entering and before leaving room. Wear gown and gloves when entering room or cubicle . The second sign read, Stop Droplet Precautions .Perform hand hygiene using soap and water and/or alcohol-based hand rub before entering and before leaving room. Wear gown and mask when entering room . After exiting this room housekeeper #1 went up the hall, returned and at 1:36 p.m., and entered the room directly across from the previous room. The residents in this room were also on TBP (transmission-based precautions). Prior to entering the room, the housekeeper did not perform any hand hygiene and did not donn any additional PPE. The housekeeper was wearing an N95 mask. Upon entering the room housekeeper #1 opened a drawer in the resident's room with their bare hands, placed an item of clothing inside the drawer, and shut the door. The housekeeper exited the room without performing any hand hygiene. Observed outside the room was a PPE cart and two signs posted, one that read in part, Stop Contact Precautions .Perform hand hygiene using soap and water and/or alcohol-based rub before entering and before leaving room. Wear gown and gloves when entering room or cubicle . The second sign read, Stop Droplet Precautions .Perform hand hygiene using soap and water and/or alcohol-based hand rub before entering and before leaving room. Wear gown and mask when entering room . On 11/17/21 at 1:40 p.m., Housekeeper #1 stated they did not put PPE on to enter resident rooms they just ran in and then ran back out. On 11/17/21 at 1:51 p.m., the administrator and nurse consultant were notified that housekeeper #1 entered two isolation rooms without performing hand hygiene or donning PPE and placed clothing items in a closet and drawer. On 11/17/2021 during a meeting with the administrator, DON (director of nursing), and nurse consultant, the administrator stated housekeeping had been in-serviced on the proper use of PPE. The policy titled Transmission Based Precautions (effective date 02/06/20) was provided on 11/18/21. This policy read in part, .Droplet precautions In addition to standard precautions, use droplet precautions, for a patient known or suspected to be infected with microorganisms transmitted by droplets .Contact precautions .Perform hand hygiene before entering room and after removing PPE upon room exit .Wear gloves when entering room and whenever touching the patient's intact skin, surfaces or articles in close proximity .After glove removal and hand hygiene, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room to avoid transfer of microorganisms to other patients or environments . On 11/19/21 at 9:32 a.m., the infection preventionist stated that the housekeeper should not have entered rooms without any PPE in place. The facility provided the survey team with a copies of negative COVID-19 test for housekeeper #1 for 11/03/21, 11/06/21, 11/10/21, 11/12/21, and 11/15/21. The facility also provided information that housekeeper #1 was fully vaccinated. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. The facility policy titled COVID-19 (effective date 09/30/21) documented, It is the policy of the Center to establish standards of practice for prevention of Coronavirus Disease 2019 (COVID-19) and to control activities to protect employees and patients .Surveillance-Employees Screen Center employees prior to beginning shift . On 11/18/21 at 3:47 p.m., CNA (certified nursing assistant) #2 was asked if they were screened for COVID-19 symptoms prior to entering and/or beginning work at the facility. CNA #2 stated they were not screened daily and they came in the side door by therapy. CNA #2 stated they were tested twice a week for COVID-19. On 11/18/21 at 3:50 p.m., CNA #3 stated they were screened daily and tested twice a week for COVID-19. The administrative staff were asked for evidence of screenings for both of these employees. On 11/19/21 at 8:13 a.m., the nurse consultant stated they were unable to find in their kiosk where CNA #2 had signed in for the last few weeks. The nurse consultant stated that CNA #2 shared with them yesterday that they had been coming in the side door entrance and sometimes they got their temperature and sometimes they did not. The nurse consultant stated they have locked the side doors. In regards to CNA #3, the nurse consultant stated they were unable to locate sign in logs for this employee and stated this employee also stated they were using the side entrance. A kiosk for screening was observed in the front lobby; however, there was not a kiosk for employees to use at the side entrance. A white notebook labeled vendors and a thermometer was observed on a table at the side entrance. The facility provided negative COVID-19 tests for both of these employees dated 11/12/21 and a negative test for CNA #3 dated 11/18/21. The facility also provided an EMPLOYEE CORRECTIVE ACTION for CNA #2, Employee failed to sign in on kiosk at start of shift on 11/18/21. You must sign in at the start of any shift. On 11/19/21 at 9:32 a.m., the IP (infection preventionist) was interviewed. The IP stated they were not aware staff were coming in the side door and the staff should either screen at the kiosk or use the book for documentation. On 11/19/21 at 1:30 p.m., the issues regarding staff screening was again reviewed with the administrator, DON (director of nursing), and nurse consultant. No further information was provided to the surveyor team prior to the exit conference. 4. On 11/17/2021 at 1:25 p.m., while observing staff serve lunch trays on Unit 2's observation unit (outside of the COVID unit), the dietary manager was observed donning a gown to take a lunch tray into a resident room. The manager was wearing goggles and a mask. There was a PPE cart and two signs that read Stop Contact Precautions and Stop Droplet Precautions at the entrance of the resident room. When the dietary manager left the room, they did not doff the gown before coming into the hall. Another kitchen staff handed the dietary manager a Styrofoam container which the manager took back into the same room, still wearing the same gown. The dietary manager again left the room without removing the gown, donned gloves and scooped ice from a container on top of a food cart, put the ice in a cup and returned to same room. The dietary manager left the room again and removed the gown in the hall and walked towards the nurse's station with the gown balled up. When the dietary manager returned from the nurse's station, they no longer had the gown. The dietary manager was interviewed and acknowledged being trained to remove the gown before leaving the room, but indicated the trash can within the room was not the type of trash can for PPE so they took the gown up there pointing to the nurse station. The dietary manager acknowledged coming in and out of the room without donning/doffing PPE per policy. The Stop Contact Precautions sign read, Visitors must report to Nursing Station before entering. Perform hand hygiene using soap and water and/or alcohol-based rub before entering and before leaving room. Wear gown and gloves when entering room or cubicle. Bag linen to prevent contamination of self, environment or outside bag. Discard infectious trash to prevent contamination of self, environment or outside bag. The Stop Droplet Precautions sign read the same as above. On 11/17/2021 at 1:51 p.m. the administrator and regional nurse consultant were informed of the infection control observation described above. The facility's policy titled, Transmission Based Precautions (TBPs) with an effective date of 02/06/20 was provided on 11/18/2021. For contact precautions the policy read in part, b. Gloves and Handwashing i. Perform hand hygiene before entering room and after removing PPE upon room exit. ii. Wear gloves when entering room and whenever touching the patient's intact skin, surfaces or articles in close proximity. c. Gown. In addition to standard precautions, wear a gown (a clean non-sterile, water-resistant gown is adequate) when entering the room. Remove the gown before leaving the patient's environment . Disposable gowns are placed in regular trash unless contaminated with infectious material . For Droplet Precautions the policy read in part, In addition to standard precautions, use droplet precautions, for a patient know or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets, larger than 5 micros in size that can be generated during coughing, sneezing, talking or the performance of procedures.) . b. Masks. In addition to standard precautions, wear a mask when working within 3 feet of the patient. No further information was provided prior to the exit conference. 5. Resident #33 and Resident #42 were observed in their room (Unit 2) on the afternoon of 11/16/21 at approximately 3:30 p.m. There were no signs outside the residents' room indicating what personal protective equipment (PPE) needed to be used for infection precaution. There was no storage bin placed outside the residents' room to hold any needed infection precaution PPE and supplies. On 11/16/21 at 4:55 p.m., Resident #33's and Resident #42's room was observed to have a Droplet Precautions sign and a Contact Precautions sign posted outside the room; there was an infection precaution supply storage bin noted to have been placed outside the room. On 11/16/21 at 4:57 p.m., the facility's Infection Preventionist (IP) and Licensed Practical Nurse (LPN) #21 was interviewed about the placement of infection precaution signs and infection precaution supplies storage bin outside of Resident #33's and Resident #42's room. The IP reported they noticed the missing items and placed them outside of the residents' room on 11/16/21 at approximately 4:30 p.m. On 11/16/21 at 5:48 p.m., LPN #21 reported Resident #33 was placed on infection control precautions on 11/13/21 due to COVID-19 exposure. On 11/19/21 at 12:25 p.m., the facility Regional Nurse Consultant (RNC) reported Resident #42 was exposed to COVID-19 on 11/15/21. The RNC reported the IP confirmed the isolation signs and supply storage bin were noted, on the afternoon of 11/16/21, to not be placed outside of Resident #33's and Resident #42's room; the signs and storage bin were placed when they were noted to be missing. The following information was found in a facility policy/procedure titled Transmission Based Precautions (TBPs) (with an effective date of 2/6/20): A combination of droplet and contact precautions may be utilized for diseases that have multiple routes of transmission. When used, they are used in addition to standard precautions. There are also empiric precautions for when an infection is suspected but not yet diagnosed. Place the type of precaution needed into the TELS system and notify Central Supply staff for a storage container with the appropriate supplies. The failure of facility staff members to ensure Resident #33's and Resident #42's room was correctly identified as requiring individuals entering the room to follow Contact Infection Control Precautions and Droplet Infection Control Precautions was discussed for a final time with the facility's Administrator, Director of Nursing (DON), and RNC on 11/19/21 at 1:30 p.m.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to properly prevent COVID-19 by failing to provide evidence of education regarding the benefits and potential risks associated with the COVID-19 vaccine and declination of the vaccine for 5 of 5 sampled residents (#1, #4, #17, #29, and #67) and 2 agency nurses. The findings included: 1. For Resident #1, the facility staff failed to provide evidence of education regarding the benefits and potential risks associated with the COVID-19 vaccine and declination of the vaccine. Resident #1's diagnosis list indicated diagnoses, which included, but not limited to Chronic Atrial Fibrillation, Acute Kidney Failure, Peripheral Vascular Disease, Chronic Diastolic (Congestive) Heart Failure, and Muscle Weakness. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 8/20/21 assigned the resident a BIMS (brief interview for mental status) score of 12 out of 15 in section C, Cognitive Patterns. A review of Resident #1's clinical record revealed documentation located under the Immunization section of the electronic health record stating consent refused for the SARS-COV-2 (COVID-19) (Dose 1) and (Dose 2), neither entry included the date of refusal. On 11/17/21 at 4:56 pm, surveyor requested from the administrator evidence of Resident #1 receiving education regarding the COVID-19 vaccine and declination by the resident or resident representative. On 11/18/21 at 5:15 pm during a meeting with the administrator, director of nursing, and the regional nurse consultant, surveyor discussed the concern of Resident #1's clinical record not including evidence of education provided to the resident and/or resident representative regarding the COVID-19 vaccine and declination of the vaccine. Surveyor requested any additional documentation regarding this issue. Surveyor requested and received the facility policy entitled, COVID-19 Vaccinations which states in part: 3. Prior to administering any COVID-19 Vaccine (and for each dose) complete the following for patients: a. Provide the Emergency Use Authorization (EUA) Fact Sheet for Recipients and Caregivers to patient and/or responsible party and educate regarding benefits and potential side effects. Maintain a copy in the patient's record. c. If contraindicated or refused, document in patient's immunization record, including that the patient and/or responsible party was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. No further information regarding this issue was presented to the survey team prior to the exit conference on 11/19/21. 2. For Resident #4, the facility staff failed to provide evidence of education regarding the benefits and potential risks associated with the COVID-19 vaccine and declination of the vaccine. Resident #4's diagnosis list indicated diagnoses, which included, but not limited to Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease Stage 3, Type 2 Diabetes without Complications, Chronic Diastolic (Congestive) Heart Failure, and Morbid Obesity. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 8/27/21 assigned the resident a BIMS (brief interview for mental status) score of 14 out of 15 in section C, Cognitive Patterns. A review of Resident #4's clinical record revealed documentation located under the Immunization section of the electronic health record stating consent refused for the SARS-COV-2 (COVID-19) (Dose 1) and (Dose 2), neither entry included the date of refusal. On 11/17/21 at 4:56 pm, surveyor requested from the administrator evidence of Resident #4 receiving education regarding the COVID-19 vaccine and declination by the resident or resident representative. On 11/18/21 at 5:15 pm during a meeting with the administrator, director of nursing, and the regional nurse consultant, surveyor discussed the concern of Resident #4's clinical record not including evidence of education provided to the resident and/or resident representative regarding the COVID-19 vaccine and declination of the vaccine. Surveyor requested any additional documentation regarding this issue. Surveyor requested and received the facility policy entitled, COVID-19 Vaccinations which states in part: 3. Prior to administering any COVID-19 Vaccine (and for each dose) complete the following for patients: a. Provide the Emergency Use Authorization (EUA) Fact Sheet for Recipients and Caregivers to patient and/or responsible party and educate regarding benefits and potential side effects. Maintain a copy in the patient's record. c. If contraindicated or refused, document in patient's immunization record, including that the patient and/or responsible party was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. No further information regarding this issue was presented to the survey team prior to the exit conference on 11/19/21. 3. For Resident #17, the facility staff failed to provide evidence of education regarding the benefits and potential risks associated with the COVID-19 vaccine and declination of the vaccine. Resident #17's diagnosis list indicated diagnoses, which included, but not limited to Unspecified Mood Affective Disorder, Mixed Irritable Bowel Syndrome, Diverticulosis of Intestine, Gastro-Esophageal Reflux Disease, and Essential Primary Hypertension. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 9/10/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, Cognitive Patterns. A review of Resident #17's clinical record revealed documentation located under the Immunization section of the electronic health record stating consent refused for the SARS-COV-2 (COVID-19) (Dose 1) and (Dose 2), neither entry included the date of refusal. Resident #17's clinical record included results of a PCR COVID-19 lab test dated 11/13/21 indicating the resident was positive for COVID-19. On 11/17/21 at 4:56 pm, surveyor requested from the administrator evidence of Resident #17 receiving education regarding the COVID-19 vaccine and declination by the resident or resident representative. On 11/18/21 at 5:15 pm during a meeting with the administrator, director of nursing, and the regional nurse consultant, surveyor discussed the concern of Resident #17's clinical record not including evidence of education provided to the resident and/or resident representative regarding the COVID-19 vaccine and declination of the vaccine. Surveyor requested any additional documentation regarding this issue. Surveyor requested and received the facility policy entitled, COVID-19 Vaccinations which states in part: 3. Prior to administering any COVID-19 Vaccine (and for each dose) complete the following for patients: a. Provide the Emergency Use Authorization (EUA) Fact Sheet for Recipients and Caregivers to patient and/or responsible party and educate regarding benefits and potential side effects. Maintain a copy in the patient's record. c. If contraindicated or refused, document in patient's immunization record, including that the patient and/or responsible party was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. No further information regarding this issue was presented to the survey team prior to the exit conference on 11/19/21. 4. For Resident #29, the facility staff failed to provide evidence of education regarding the benefits and potential risks associated with the COVID-19 vaccine and declination of the vaccine. Resident #29's diagnosis list indicated diagnoses, which included, but not limited to Chronic Atrial Fibrillation, Chronic Diastolic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Unspecified Dementia with Behavioral Disturbance, Essential Primary Hypertension, and Hemiplegia and Hemiparesis following Cerebral Infarction. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 9/24/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out of 15 in section C, Cognitive Patterns. A review of Resident #29's clinical record revealed documentation located under the Immunization section of the electronic health record stating consent refused for the SARS-COV-2 (COVID-19) (Dose 1) and (Dose 2), neither entry included the date of refusal. On 11/17/21 at 4:56 pm, surveyor requested from the administrator evidence of Resident #29 receiving education regarding the COVID-19 vaccine and declination by the resident or resident representative. On 11/18/21 at 5:15 pm during a meeting with the administrator, director of nursing, and the regional nurse consultant, surveyor discussed the concern of Resident #29's clinical record not including evidence of education provided to the resident and/or resident representative regarding the COVID-19 vaccine and declination of the vaccine. Surveyor requested any additional documentation regarding this issue. Surveyor requested and received the facility policy entitled, COVID-19 Vaccinations which states in part: 3. Prior to administering any COVID-19 Vaccine (and for each dose) complete the following for patients: a. Provide the Emergency Use Authorization (EUA) Fact Sheet for Recipients and Caregivers to patient and/or responsible party and educate regarding benefits and potential side effects. Maintain a copy in the patient's record. c. If contraindicated or refused, document in patient's immunization record, including that the patient and/or responsible party was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. No further information regarding this issue was presented to the survey team prior to the exit conference on 11/19/21. 5. For Resident #67, the facility staff failed to provide evidence of education regarding the benefits and potential risks associated with the COVID-19 vaccine and declination of the vaccine. Resident #67's diagnosis list indicated diagnoses, which included, but not limited to Seizures, Acute Kidney Failure, Generalized Muscle Weakness, Essential Primary Hypertension, Gastro-Esophageal Reflux Disease, Fibromyalgia, and Atrioventricular Block First Degree. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/06/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, Cognitive Patterns. A review of Resident #67's clinical record revealed documentation located under the Immunization section of the electronic health record stating consent refused for the SARS-COV-2 (COVID-19) (Dose 1) and (Dose 2), neither entry included the date of refusal. On 11/17/21 at 4:56 pm, surveyor requested from the administrator evidence of Resident #67 receiving education regarding the COVID-19 vaccine and declination by the resident or resident representative. On 11/18/21 at 5:15 pm during a meeting with the administrator, director of nursing, and the regional nurse consultant, surveyor discussed the concern of Resident #67's clinical record not including evidence of education provided to the resident and/or resident representative regarding the COVID-19 vaccine and declination of the vaccine. Surveyor requested any additional documentation regarding this issue. Surveyor requested and received the facility policy entitled, COVID-19 Vaccinations which states in part: 3. Prior to administering any COVID-19 Vaccine (and for each dose) complete the following for patients: a. Provide the Emergency Use Authorization (EUA) Fact Sheet for Recipients and Caregivers to patient and/or responsible party and educate regarding benefits and potential side effects. Maintain a copy in the patient's record. c. If contraindicated or refused, document in patient's immunization record, including that the patient and/or responsible party was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. No further information regarding this issue was presented to the survey team prior to the exit conference on 11/19/21. 2. The facility failed to identify the vaccination status of two agency nurses currently working in the facility. As part of the survey process, the survey team requested of the facility the vaccination status of all residents and employees of the facility. When the list was provided to the surveyor it did not include two agency staff (nurses) currently working in the building. 11/18/21 12:10 p.m., the survey team requested information from the administrator, DON (director of nursing) and nurse consultant regarding evidence of testing and vaccination status in regards to COVID-19 for two agency nurses currently working in the building. 11/18/21 2:20 p.m., the administrator stated they did not have a tracking system in place in regards to vaccines for agency employee, that they were testing employees twice a week, and they did not have a COVID-19 outbreak related to agency staff. 11/19/21 9:32 a.m., the IP (infection preventionist) stated they should know the vaccination status and COVID-19 status of agency employees prior to allowing them to work in the building. 11/19/21 10:13 a.m., the IP stated they swabbed the agency nurses late yesterday. The facility provided evidence of negative COVID-19 testing for both these employees dated 11/18/21. These tests were completed after the survey team requested information regarding testing for agency employees. 11/19/21 10:17 a.m., human resource employee #1 stated they did not complete anything in regards to agency staff. The facility policy titled, COVID-19 Vaccinations with an effective date of 11/02/21 read in part, .Vaccination against COVID-19 will be offered to all Center patients and employees, as indicated . Prior to the exit conference the facility did not provide any evidence to the survey team indicating the agency nurses were fully vaccinated or that the vaccine had been offered and declined. No further information regarding this issue was provided to the survey team prior to the exit conference.