Based on observation, staff interviews, clinical record review, and facility document review, the facility staff failed to provide a resident with food prepared in a form designed to meet the individual needs for 1 of 6 sampled residents. (Resident #3) The findings include: For Resident #3, the facility staff failed to ensure meat was ground as indicated for a mechanical soft diet as ordered by a medical provider to meet the resident's dietary needs. Resident #3's diagnosis list indicated diagnoses that included, but were not limited to, Congestive Heart Failure, Dysphagia, Transient Cerebral Ischemic Attack, Glaucoma, Anemia, Peripheral Vascular Disease, Chronic Kidney Disease-Stage 3, Unspecified Dementia, and History of Falling. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/2/25, assigned the resident a brief interview for mental status (BIMS) summary score of 7 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A review of Section K (Swallowing/Nutritional Status) was coded in section K0520. Nutritional Approaches with C-Mechanically altered diet and D-Therapeutic diet. A review of the clinical record revealed the following documentation: A speech therapy patient referral and history note dated 5/28/25 read in part, .Reason for referral .referred to ST (speech therapy) via nursing as patient's family is requesting diet downgrade . A Diet Order & Communication form dated 5/28/25, which read in part, .Diet Change .Texture .Mechanical Soft . A review of the comprehensive care plan disclosed a focus that read in part, .Resident has increased nutrition/hydration risk related to .dysphagia .therapeutic diet, mechanically altered diet .Edited: 06/02/2025 . A review of the interventions read in part, .Provide diet per order . A medical provider orders with a start date of 6/9/25 read in part, .Dietary .Cardiac, Mech Soft (mechanical soft) . On 6/10/25 at 12:34 PM, surveyor observed Resident #3 in her room with her lunch tray. The plate contained a regular pork chop with gravy cut into a few large strips and a piece of custard pie with crust. Certified nursing assistant #3 (CNA#3) was present in the room. Surveyor requested to see the resident's tray ticket and it read in part, .Cardiac-Mech Soft (mechanical soft) .Ground Smothered Pork Chop .Sweet Potato Pie (no crust) .NURSING TO ASSIST TO CHOP MEAT . CNA#3 informed surveyor she was assisting Resident #3 with eating and agreed the pork chop should have been ground. On 6/10/25 at 12:37 PM, dietary manager accompanied this surveyor to Resident #3's room and observed the plate and the resident's tray ticket. She agreed the resident should have received ground meat with gravy and the pie should not have crust. She informed surveyor the daughter wants the resident's diet to be upgraded. She stated she would get Resident #3 a new tray. On 6/10/25 at 1:05 PM, surveyor spoke via phone conversation with Resident #3's responsible party and she informed surveyor speech therapy is working with her mother, and she is supposed to be on a mechanical soft diet and her meat is supposed to be ground. On 6/11/25 at 8:10 AM, surveyor observed Resident #3 with her breakfast meal in her room and other staff #3 (OS#3) was present in the room. Surveyor reviewed the tray ticket and resident had the appropriate items remaining on her tray. OS#3 stated resident had already eaten her eggs and sausage. On 6/11/25 at 9:16 AM, surveyor interviewed CNA#4 and she informed surveyor she assists Resident #3 with her meals at times and the resident is supposed to be on a mechanical soft diet. On 6/11/25 at 9:28 AM, surveyor spoke with CNA#5 and she informed surveyor she assists Resident #3 with eating at times and resident eats chopped meats. On 6/11/25 at 10:47 AM in an interview with administrative staff #4 (AS#4), she stated Resident #3's family is not agreeing with the resident's diet, and they did not want her on puree, the family wants a regular diet with chopped meats. Surveyor and AS#4 discussed Resident #3's tray ticket and AS#4 informed surveyor the mechanical soft diet tray tickets default to ground meats in the tray tracker system and that's what prints on the tray ticket, so that is why nursing to assist to chop meat was put on the bottom of the tray ticket, because they were trying to give the resident a liberalized diet. On 6/11/25 at 10:53 AM, surveyor interviewed the speech therapist, and she agreed the pork chop served at lunch yesterday (6/10/25) should have been ground from a safety standpoint. She stated the resident's two daughters do not agree on the resident's diet, one brings regular food and the other brings mechanical soft foods. This concern was reviewed on 6/11/25 at 11:49 AM during the pre-exit meeting with the administrator, interim director of nursing, and regional director of clinical services. Surveyor requested and received a facility policy titled, Diet Orders Policy with a revision date of 3/18/24, which read in part, .The facility will ensure residents are provided meals as ordered by their healthcare provider .the Food and Nutrition Services Manager will utilize a tray card identification system to ensure that each resident receives his or her diet as ordered . Surveyor was provided with a Diet Descriptions document that read in part, .Mechanical Soft .The regular ground diet is for adults who have difficulty chewing .Foods that are difficult to chew are replaced with foods that have been altered into a form that can be easily chewed. Foods that may be modified because they are tough and difficult to chew include meats . No further information was provided to the survey team prior to exit on 6/11/25.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to report an incident of visitor-to-resident abuse within two (2) hours of the observed abuse for one (1) of four (4) residents sampled. (Resident #1) The findings were: For Resident #1, facility staff failed to report an incident of visitor-to-resident sexual abuse within two (2) hours of the incident. On 11/10/24 at 3:08 p.m., three (3) staff members observed a visitor (another resident's family member) and resident touching each other inappropriately while together in an alcove off the main hallway. The incident was reported on 11/11/24, over two (2) hours after the incident. Resident #1's diagnoses list included but was not limited to unspecified dementia, major depressive disorder, and cognitive communication deficit. The most recent minimum data set (MDS) with an assessment reference date of 10/16/24 assigned the resident a brief interview for mental status summary score of 03 (three) out of 15 in Section C (Cognitive Patterns) indicating severely impaired cognition. Section GG (Functional Abilities) coded Resident #1 had no impairments for upper or lower extremities and did not use any mobility devices. Resident #1 was coded as independently being able to eat, perform oral hygiene, dress her upper and lower body, and putting on/taking off footwear. Resident #1's care plan included a problem area of Behavioral Symptoms. The problem area read, Resident exhibits the following inappropriate behaviors: makes overly affectionate advances toward male residents such as kissing and hugging, continues to have affectionate behaviors, At {sic} risk for inappropriate advances from male residents or visitors on 11/10-24 {sic}. Actual allegation of sexual encounter from a visitor. Resident #1's clinical record included a progress note written by the director of nursing (DON), dated 11/11/24 at 4:53 p.m. which was documented as a late entry on 11/18/24 at 4:55 p.m. The note read, Resident was asked if she felt safe in the facility, responded yes. Resident states she does not recall incident from 11/10/24 that involved a visitor inappropriately touching resident. Resident was safeguarded from the individual in question and charges were taken out at the RP's [responsible party] request. MD aware and evaluation completed. The assistant director of nursing (ADON) documented an interdepartmental team (IDT) progress note dated 11/14/24 which read, in part, .FRI [facility reported incident] investigation for sexual abuse pending determination . The initial FRI report was dated 11/11/24 with the incident date being 11/10/24 with the details of Resident #1 and a visitor related to another resident observed, by staff, touching each other inappropriately in the cutaway area near the break room. The resident and visitor separated after being seen by staff. The follow up investigation was concluded on 11/18/24 and read in part, . the facility is substantiating sexual abuse from a visitor, (name omitted) he has been banned from the facility. The facility, after thorough investigation could not determine if this action was consensual. (Resident #1) has experienced no negative outcome, her behavior has remained at baseline. Resident was assessed by MD and was found to have no injuries, and reported to the MD that she had not been hurt . The FRI document read that on 11/11/24, the responsible party, physician, adult protective services, and law enforcement were notified of the incident. The surveyor requested and the DON provided a timeline of the facility staff's reporting of the alleged abuse incident: • Video footage showed the incident happened between 3:08 p.m. and 3:11 p.m. on 11/10/24. • At 3:12 p.m. on 11/10/24 a certified nursing assistant (CNA #6) unsuccessfully attempted to reach the DON and did not leave a message. • The DON attempted to return the CNA #6's call on 11/10/24 at 8:02 p.m. with no answer. • On 11/11/24 at 8:00 a.m., the DON spoke with the CNA #6 who told the DON to look at the camera video. The DON spoke with the housekeeping/maintenance director who had been the manager-on-duty on 11/10/24 who stated it was reported to him the resident and visitor were hugging inappropriately. The DON did not receive a call from the manager on duty (housekeeping/maintenance director) on 11/10/24. CNA #6 was interviewed via phone on 12/10/24 at 4:36 p.m. The nursing assistant acknowledged she attempted to call the DON after the incident on 11/10/24 but was unable to reach her. The CNA's written statement indicated she reported the incident to the manager on duty. In the morning of 11/11/24 the DON asked CNA #6 about the occurrence. On 12/10/24 at 11:35 a.m., Resident #1 was interviewed by a surveyor. The resident reported feeling safe in the facility and reported the staff were nice to her. The resident was walking around her room, smiling and pleasant. The facility policy titled Virginia Resident Abuse Policy with an effective date of May 2008 and a last revision date of 07/11/24 was provided by the DON on 12/09/24 and reviewed. The policy read in part, 6) Initial Reports a. Timing. All allegations of Abuse, Neglect, Involuntary Seclusion, injuries of Unknown Source, and Misappropriation of resident property must be reported immediately* to the Administrator, Director of Nursing (DON) and to the applicable State Agency. If the event that caused the allegation involves an allegation of Abuse or serious bodily injury, it should be reported to the DOH immediately, but not later than 2 hours after the allegation is made The DON and regional director of clinical services (RDCS) were interviewed on 12/10/24 at 5:10 p.m. with the concern for the abuse incident reporting timing discussed. The DON reported the facility staff substantiated the incident based on the video footage and the fact Resident #1 was unable to recall the incident when interviewed, She was unable to say either way about consent. The DON acknowledged the facility staff reported this abuse incident more than two (2) hours after it occurred; it was reported the following day. No further information was provided prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one (1) of four (4) residents sampled. (Resident #1) The findings were: The facility staff failed to ensure Resident #1's clinical record included a medical resident's evaluation of the resident following an abusive incident observed by staff members which occurred on 11/10/24. Resident #1's diagnoses list included but was not limited to unspecified dementia, major depressive disorder, and cognitive communication deficit. The most recent minimum data set (MDS) with an assessment reference date of 10/16/24 assigned the resident a brief interview for mental status summary score of 03 (three) out of 15 in Section C (Cognitive Patterns) indicating severely impaired cognition. Section GG (Functional Abilities) coded Resident #1 had no impairments for upper or lower extremities and did not use any mobility devices. Resident #1 was coded as independently being able to eat, perform oral hygiene, dress her upper and lower body, and putting on/taking off footwear. Resident #1's care plan included a problem area of Behavioral Symptoms. The problem area read, Resident exhibits the following inappropriate behaviors: makes overly affectionate advances toward male residents such as kissing and hugging, continues to have affectionate behaviors, At {sic} risk for inappropriate advances from male residents or visitors on 11/10-24 {sic}. Actual allegation of sexual encounter from a visitor. Resident #1's clinical record included a progress note written by the director of nursing (DON), dated 11/11/24 at 4:53 p.m. which was documented as a late entry on 11/18/24 at 4:55 p.m. The note read, Resident was asked if she felt safe in the facility, responded yes. Resident states she does not recall incident from 11/10/24 that involved a visitor inappropriately touching resident. Resident was safeguarded from the individual in question and charges were taken out at the RP's [responsible party] request. MD aware and evaluation completed. The surveyor requested the medical provider's evaluation mentioned in the progress note. On 12/10/24 at 4:55 p.m. the DON and regional director of clinical services (RDCS) were interviewed. The DON reported there were medical residents who work under Resident #1's primary medical provider. The residents come to the facility daily to see that primary medical provider's patients who may need a new prescription or have changes, for example. The residents do not act on anything without notifying the primary medical provider. The DON stated one of these residents evaluated Resident #1 on 11/11/24 following the visitor-to-resident abuse incident which occurred on 11/10/24. The evaluation was not documented. The DON acknowledged there was no evidence of the resident's evaluation in the clinical record or elsewhere. During a meeting with the DON and RDCS on 12/10/24 at 6:05 p.m., the concern regarding Resident #1 receiving a medical resident evaluation which was not documented was discussed. No further information was provided prior to the exit conference.

Based on staff interview and clinical record review, facility staff failed to administer an an antibiotic medication per provider orders for 1 of 14 sampled current residents (Resident 30). The findings include: Resident 30 was admitted to the facility with diagnoses including type 2 diabetes mellitus, hypertension, cerebral palsy, obesity, spinal stenosis, obstructive uropathy, and benign prostatic hypertrophy. On the most recent Minimum Data Set assessment, the resident scored 15/15 on the brief interview for mental status and was assessed without signs of delirium or psychosis. The resident exhibited rejecting care 1-3 days of the week prior to the assessment. Clinical record review for antibiotic use revealed a provider order dated 9/20/24 for urinalysis with culture and sensitivity and Ceding 300 mg twice per day for 7 days. On 9/27/24, the laboratory results revealed lactose fermenting gram negative rods. The provider ordered Ertapenem 1 gram intramuscularly daily for 5 days. An Infection control Infection tracker note dated 10/2/24 indicated provider made aware resident previously on Cefdinir x 7 days. Per MD stop Ceftriaxone. On further record review, the surveyor found no order for Ceftriaxone. The resident received 14 doses of Cefdinir as ordered. For Ertapenem, staff documented: 9/28, 9/29- not administered: discontinued; 9/30 not administered: time changed; then administered 9/30 at a later time; 10/1 not administered: medication has not arrived from the pharmacy MD made aware; 10/2 administered. On 10/15/24 at 1:53 PM, the surveyor spoke with the director of nursing (DON) who stated Ceftriaxone was an erroneous entry. The stop order on 10/2 was for Ertapenem. Per Omnicare (pharmacy) invoice, 4 doses of Ertapenem were delivered on 9/29, but did not arrive with the Lidocaine to be used to administer the antibiotic. The Lidocaine arrived on 9/30. The resident received a dose of Ertapenem on 9/30 and another on 10/2/24. There is no explanation for the missed dose on 10/2/24. During a summary meeting on 10/16/24, the administrator, DON, and others were notified of the concern.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure the medical provider documented the action and/or rationale for the action on a pharmacy recommendation, as part of a medication regimen review for (1) one of (5) five residents sampled for medication regimen reviews, Resident #9. The findings included: Resident #9's diagnosis list indicated diagnoses, which included, but not limited to Parkinson's disease, hyperlipidemia, essential (primary) hypertension, chronic respiratory failure, chronic obstructive pulmonary disease, hypothyroidism, atrial fibrillation, schizophrenia, anxiety disorder, major depressive disorder, and bipolar disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/13/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. Progress notes within Resident #9's clinical record indicated a drug regimen review was completed on 6/12/24 with recommendations. Surveyor was unable to locate the recommendation reports in the resident's clinical record. Surveyor requested and received the medication regimen review recommendation report completed by the pharmacist for Resident #9 from the regional director of clinical services on 10/11/24. The 6/12/24 Consultation Report read in part .[resident name omitted] receives Buspropion 100 mg (milligrams) every OTHER day. Psych (psychiatric) provider note dated 6/9/24 suggests a trial discontinuation. Recommendation: Please discontinue Buspropion . Review of the Psychiatry Progress Note, dated 6/9/24, read in part, .Patient is being seen today by request to consider GDR (gradual dose reduction) .Recommend to discontinue Wellbutrin (buspropion) .Orders for this visit .Recommend to discontinue Wellbutrin . Further review of the Consultation Report, revealed the medical provider signed the report at the bottom of the report, however, the medical provider did not indicate a Physician's Response to the recommendations. The report was also signed by the DON (director of nursing) on 6/13/24. A review of the active provider orders indicated the recommendation was not addressed, as the medication was active on the order with a start date of 4/4/24. A review of the MARs (medication administration records) for June 2024 through August 2024, indicated Resident #9 continued to receive Buspropion medication as ordered by the physician with no indications of dose reduction or discontinuation. The pharmacist recommended a GDR for Buspropion again on the Consultation Report dated 8/7/24 and the NP (nurse practitioner) declined this recommendation, the report read in part, .because the GDR was clinically contraindicated for this individual as indicated .1. Continued use in accordance with the current standard of practice and a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability . This concern was discussed at the end of day meeting on 10/11/24 at 12:15 PM with the administrator, director of nursing, regional director of clinical services, and regional vice president of operations. Surveyor requested and received the facility policy titled, Medication Regimen Review which read in part, .6. Facility should independently review each resident's medication regimen .9. Facility should encourage physician/prescriber .receiving the MRR (medication regimen review) and the director of nursing to act upon the recommendations contained in the MRR. 9.1 For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected, as outlined in the State Operations Manual Appendix PP .9.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it .10. Facility should alert the medical director where MRRs are not addressed by the attending physician .The attending physician/prescriber should address the consultant pharmacist's recommendations no later than their next scheduled visit to the facility to assess the resident, per facility policy and state or federal regulations . No further information regarding this concern was presented to the survey team prior to the exit conference on 10/16/24.

Based on staff interviews and facility document review the facility staff failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for one agency staff member working in the facility. The findings include: On 10/11/24, surveyors requested employee records of a selection of facility employees and contracted staff for review for compliance with regulations. On 10/15, the administrator reported that staff pulled the licenses of contracted nursing staff over the weekend and discovered that one contracted licensed practical nurse's license (LPN 1) was revoked by the board of nursing on 8/9/2024. The nurse had not notified the facility. A facility investigation was conducted over the weekend. The nurse will not return to the facility. The administrator stated that the company would no longer use that agency as it had not fulfilled requirements of the contract to only provide licensed staff to the facility. The nurse had worked 11 shifts after the license was revoked. Staff interviewed and assessed each resident on the nurse's assignment and reviewed records to determine whether any resident had been negatively impacted by receiving care from this nurse. No negative incidents were found attributable to the nurse's care. The administrator, DON, and others were notified of the concern during a summary conference on 10/16/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, family interview, and clinical record review, the facility staff failed to ensure the highest practicable physical well-being for 1 of 4 Residents (Resident #2). The facility staff failed to identify an injury of unknown origin. The findings included: The facility staff failed to identify an injury of unknown origin. Resident #2's family member identified injuries to the residents lower extremities when visiting and brought it to the attention of the facility nursing staff. Resident #2 was sent to a local hospital and a CT scan identified a mildly displaced acute right intertrochanteric femur fracture. The facility was unable to determine how this injury occurred. Resident #2's diagnoses included, but were not limited to, muscle weakness, cognitive communication deficit, edema, depressive disorder, anxiety disorder, restless leg syndrome, and other chronic pain. The only completed minimum data set (MDS) assessment for Resident #2 was a discharge assessment with an assessment reference date (ARD) of 09/24/22. Section C (cognitive patterns) was not assessed due to the residents discharge. Section G (functional status) was only complete for self-performance. Bed mobility, transfers, dressing, toilet use, and personal hygiene were all coded with a 3 for extensive assistance. Walk in room/corridor was coded with an 8 to indicate the activity did not occur. Section G0300 (Balance) and section G0600 (mobility devices) is not part of a discharge MDS assessment. The residents care plan included the following focus areas has a psychiatric disorder, has activities of daily living (ADL) self-care deficit, is on antianxiety therapy, at risk for falls characterized by history of falls, injury and/or multiple risk factors, potential for pain, and history of false allegations, stating they have not had meds or meals when both have been provided. Interventions included, but were not limited to, encourage resident to express feelings, establish and maintain a trusting relationship with the resident, maintain a calm no threatening manner while working with the resident, assist with ADL's, refer to therapy, assist with mobility, eating, toileting, and transfers. Administer medications as ordered, educate resident/family regarding preventative fall interventions/safety devices as appropriate, implement preventative fall interventions/devices, maintain call bell within reach, and maintain residents items in reach. The Director of Nursing (DON) provided the surveyor with a fall risk assessment completed on admission indicating Resident #2 was a high risk for falls. 09/26/23 1:45 p.m., the Nurse Consultant and MDS nurse were asked what kind of fall preventions were put in place. These staff stated, this resident was seen by therapy, offered grippy socks, bed was placed in lowest locked position, and they were educated on call bell use. A review of the residents provider orders indicated this resident wore a Lidocaine patch 4% daily for pain, was administered Tylenol 650 mg on 09/19/22 for a pain level of 2 and Ibuprofen 800 mg on 09/23/22 for a pain level of 7. The facility nursing staff were documenting the residents pain level every shift from 09/19/22-09/23/22 all the blocks on the administration page were documented as a 0 except for 09/23/22 for the evening shift when the nursing staff documented a 4. When Resident #2 was admitted to the facility Registered Nurse (RN) #2 documented the following in the clinical record, Resident arrived at the center in a wheelchair being transported by a medical transportation service. One technician accompanied resident. Resident alert and oriented to person and situation. Very restless and anxious .Skin assessment performed Skin tear on right shin measuring 2 cm X 2.5 cm. Cleaned with normal saline and covered with dry dressing. Scab noted on left knee measuring 0.5 cm X 0.5 cm. Purple discoloration left shin . On 09/25/23 11:45 a.m., during an interview with RN #2 this nurse stated they had just got to work (09/23/22) and received report from RN #3. Resident #2's family member was at the facility and asked what had happened to Resident #2. RN #2 stated Resident #2 had an abrasion on their leg and was complaining of pain in their back and leg. RN #3 stated nothing had happened, but they had them go in Resident #2's room with them. RN #2 stated no one had said anything, the resident was hollering, and they thought the provider ordered X-rays, this resident ended up going out to the hospital later and the X-rays showed a fracture. RN #2 stated no one ever reported anything to them but the family member stated Resident #2 stated they had fallen. The clinical record included the following progress notes. On 09/23/22 2:44 p.m., RN #3 documented, Resident noted to be crying at times and difficult to understand speech. Resident was in bed with the head sat up .Resident in no acute distress. RN #3 no longer worked at the facility. 09/23/22 5:00 p.m., RN #3 documented Resident c/o (complained of) knee pain. Left knee noted to be swollen and bruised. Resident stated, a white woman picked me up this morning. Resident was never observed or told that resident was on the floor at any time. This nurse did not witness, and it was not reported that resident was on the floor. Resident did not voice c/o anything until this time. The clinical record included the following documentation made by Licensed Practical Nurse (LPN) #2. 09/23/22 at 11:03 p.m., .resident has some complaints of pain in back and knees that was unrelieved by repositioning .did state .prn (as needed) med did help to alleviate .pain. vitals have been stable .is alert and oriented x 2, with some intermittent periods of confusion . 09/24/22 at 12:29 a.m., MD gave order for resident to be sent to ER for eval and treatment due to back pain. X-rays reviewed by MD showed fracture to vertebrae in spine .Resident has been oriented/prepared for transfer .The resident RP was notified of the transfer . 09/24/22 at 4:01 a.m., called ER (emergency room) .resident is being admitted .for a hip fracture. The clinical record included a late entry documented by RN #2 on 09/24/22 at 12:56 p.m., Late Entry: Note pertaining to happenings on Friday, September 23, 2022. At 1630 (4:30 p.m ) resident's ____ (family member) asked nurse what had happened to _____ Resident #2's leg. Nurse went in room noted left knee positive for purplish discoloration, swelling, and a scar under [NAME]. Right thigh was positive for swelling and a purplish discoloration. Resident stated .had fallen. Stat X-ray obtained. Based on these results an order was given to transfer resident to the ER for further evaluation. The Administrative staff were able to provide the surveyor with the following hospital records. X-ray results from the local hospital with an exam date of 09/24/22. Left knee-severe septennial. There is soft tissue edema. No evidence for acute fracture or dislocation. Moderate degenerative changes. Right knee-severe septennial. No evidence for acute fracture or dislocation. There is soft tissue edema. CT head comparison date 10/01/20-No acute intractability findings. CT pelvis-Mildly displaced acute right intertrochanteric femur fracture is identified. There is chronic fracture of the pubic symphysis. There is mild soft tissue edema. Right hip comparison date 09/20/20-Nondisplaced right intertrochanteric femur fracture. CT lumbar spine without contrast comparison date 10/04/21-Chronic compression fractures of T 11 and L2. No acute findings. History and Physical dated 09/24/22 5:40 a.m. Presented to the emergency room due to right leg pain. The provider documented that Resident #2 answered all questions appropriately when they arrived and stated that they had pain on right thigh and back. Patient was brought by EMS due to pain. Due to lack of history, they were unable to obtain whether not patient had a mechanical ground level fall, syncopal episode, seizure activity or how long patient was on the floor if they had fallen. The provider documented this Resident had multiple lacerations and ecchymosis (bruises) bilaterally on lower extremities. On 09/26/23 10:55 a.m., the surveyor placed a call to the family member of Resident #2. This family member was at the facility when the injury was discovered. This family member stated they had come to the facility to visit, and they saw a bruise on Resident #2's leg, they went up to the male nurse and asked to speak to the nurse that was over Resident #2. This staff was identified as RN #3, the family member stated RN #3 stated they could not tell me what had happened, and it did not happen on their shift. The family member stated they then talked to a female nurse, and they told them if something had happened there should be a record and stated they would take care of it. The family member stated the female nurse told her it wasn't documented, and they did not know why. They stated Resident #2 was hurting on their side. This family member stated they felt like Resident #2 fell out of the bed because they drugged them up. Somebody in that nursing home had to pick them up and put them back in the bed. Somebody should have told us that. There was no documentation. I had to find Resident #2 like that, and the male nurse said it did not happen on their shift. 09/26/23 1:55 p.m. during a meeting with the Administrator, DON, and Nurse Consultant the Administrator stated there was no camera footage and they had investigated the incident. They ruled out abuse but could never say what had happened. These staff stated the resident did say they fell, there were no medication errors reported, and no grievances involving Resident #2. 09/26/23 8:45 a.m., the DON provided the surveyor with over 30 statements from staff regarding the incident involving this resident. The DON stated they had a turnover in staff an only a few of the staff were still employed at the facility. The DON also provided the surveyor with a copy of the working schedule for 09/23/22 (Friday). Only a few nursing and/or direct care staff that were listed on this schedule were still employed at the facility. C.N.A. #3 was interviewed on 09/25/23 at 3:18 p.m. and stated they did not remember any incident involving this resident. C.N.A. #3 looked at the schedule and stated the staff (C.N.A. #5) that was assigned these rooms on day shift was now retired. C.N.A. #5 had written up a statement that indicated they had worked with this resident on 09/23/22 from 6:00 a.m. until 2:00 p.m. they did not notice any bruising; the nurse had helped pull this resident up in the bed and administered their medications and the resident had fallen asleep. Per the working schedule C.N.A. #1 was working day shift on 09/23/22 but was not assigned the room Resident #2 resided in. C.N.A. #1 no longer was employed at the facility. C.N.A. #1 provided a statement to the facility that stated they had never provided care for this resident. C.N.A. #4 was on the working schedule as working second shift 3:00 p.m. until 11:00 p.m. on the day of the incident and was still employed at the facility. During an interview with this staff on 09/26/23 at 9:05 a.m. this staff stated they did not remember this resident. The DON identified C.N.A. #6 as the staff person assigned to these rooms on 9/23/22 on 2nd shift. This staff was no longer employed at the facility. This staff had written up a statement that indicated when they entered the residents room on 09/23/22 the resident was upset and saying they had back pain they had told the nurse. C.N.A. #6 stated they changed her up and was gentle. The second time they entered the room was to take in the residents supper and they were sitting on the side of the bed. The last time was after X-rays had been completed and the resident complained of pain in their back. There was nothing in this written statement to indicate the resident had stated they had fallen or to indicate this staff observed the resident fall. RN #3 was the assigned nurse on day shift. RN #3 no longer worked at the facility but provided the facility with their written statement. This statement indicated Resident #2 was in their room for the entire time they had worked. From 7 until 4 p.m. resident had no complaints of knee or hip pain. Resident did state they wanted to sit on the side of the bed, but they were never observed on the floor or never stated to them they had fallen. RN #3 stated the resident took all their medications and requested specific items for lunch, they had worn a gown and did not attempt to get up at any point to the best of their knowledge. RN #3 transcribed the resident was not seen ambulating or attempting to ambulate and no incidents were reported to them. On 09/26/23 10:10 a.m., the Nurse Consultant stated they had substantiated that Resident #2 had a fracture, injury of unknown origin, no abuse/neglect, and who knows it may have been that way before they were admitted . No further information regarding this issue was provided to the surveyor prior to the exit conference.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 12 residents in the survey sample, Resident #22. For Resident #22, the facility staff failed to secure the resident's cigarettes and lighter. The findings included: Resident #22's diagnosis list indicated diagnoses, which included, but not limited to Dementia with Behavioral Disturbance, Anxiety Disorder, Osteoarthritis of Hip, Thoracic, Thoracolumbar and Lumbosacral Intervertebral Disc Disorder, Peripheral Vascular Disease, History of Falling, Muscle Weakness, and Nicotine Dependence. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 2/02/22 assigned the resident a BIMS (brief interview for mental status) summary score of 10 out of 15 indicating the resident was moderately cognitively impaired. Resident #22 was coded as being independent with bed mobility, transfers, walking, bathing and required supervision only with dressing, eating, toileting, and personal hygiene. Resident #22's current comprehensive person-centered plan of care included a focus area stating Resident is a smoker / nicotine dependent with an intervention initiated 10/12/16 and revised 1/30/20 stating cigarettes, lighters, and matches are to be kept by appropriate staff only and an intervention dated 8/11/20 stating Notify staff immediately if it is suspected or observed that the resident is violating smoking policy. On 3/15/22 at 2:20 pm, surveyor spoke with Resident #22 in the day room, he/she stated they could smoke outside on the side porch anytime. Surveyor asked where their cigarettes and lighter were kept and Resident #22 showed the surveyor a pack of cigarettes in their shirt pocket and removed a red lighter from their pants pocket. On 3/15/22 at 2:31 pm, surveyor spoke with RN (registered nurse) #1 regarding resident smoking times and storage of smoking supplies. RN #1 stated if a resident is a safe smoker, they can go anytime and can keep cigarettes and lighters with them. RN #1 stated only one resident in the facility required supervision while smoking, this was not Resident #22. Surveyor reviewed Resident #22's clinical record and the most recent smoking assessment was dated 12/12/20. This assessment stated in part that Resident #22 may smoke unsupervised in designated smoking area and resident/representative/family have been informed of smoking policies/procedures. Resident #22's clinical record also included a smoking contract signed by the resident on 9/28/21 stating in part supervision not required at this time, there were no specific time for designated smoking times, and Residents residing in the long-term care units are prohibited from keeping smoking materials in their rooms or in their possession and smoking materials, cigarettes and lighters must be kept secured by facility. Surveyor requested and received the facility policy entitled Resident Smoking Policy effective 7/01/08 and last revised 1/10/22 which read in part: A) Upon admission to the facility, all residents who smoke will have a Safe Smoking Evaluation completed by the Social Worker/Designee and be asked to sign a Smoking Contract. 1. The evaluation will be completed with readmission, quarterly, and with any significant change in the resident's condition. C) Resident smoking materials will be retained and distributed by the facility staff to the residents during the designated smoking times and/or when independent resident choses to smoke. 1. No resident is permitted to maintain or store smoking materials on their person or in their room On 3/15/22 at 4:41 pm, surveyor met with the administrator and DON (director of nursing) and discussed the concern of the observation of Resident #22 with cigarettes and a lighter on their person. Administrator stated this has been addressed multiple times with Resident #22 and they become very aggressive and at times will put themselves in the floor. On 3/16/22 at 11:24 am, surveyor again observed Resident #22 sitting in the day room and asked the resident if they had their cigarettes and lighter, the resident stated yes and showed surveyor a pack of cigarettes in their shirt pocket and removed a red lighter from their pants pocket. Surveyor spoke with the facility social worker on 3/16/22 at 1:00 pm regarding resident smoking. Social worker stated they only do the smoking contracts with the residents. Surveyor asked if residents were allowed to keep smoking materials on their person and they stated yes, as far as I know. Social worker further stated Resident #22 gets extremely hostile if you try to take theirs. On 3/16/22 at 1:02 pm, surveyor spoke with CNA (certified nursing assistant) #1 and asked where residents keep their cigarettes and lighters, CNA #1 stated on themselves. On 3/16/22 at 1:06 pm, surveyor spoke with the DON who stated resident smoking assessments were not being done and they initiated the process of smoking assessments being completed by nursing on admission and quarterly on 12/06/21. On 3/16/22 at 1:15 pm, surveyor notified the administrator and DON of Resident #22 again having cigarettes and a lighter on their person. On 3/16/22 at 6:24 pm, survey team met with the administrator and DON and discussed of concern of Resident #22 keeping smoking materials in their possession and the administrator stated they are planning to sit down with all residents that smoke and go over with them that smoking supplies will be kept at the nurse's station. Resident #22's clinical record included a social services progress note dated 3/17/22 9:31 am stating in part writer and administrator (name omitted) reviewed smoking policy with resident. Res (resident) understands policy and agrees to terms: cigarettes and lighter to be given to (administrator) to be kept at nurse's station for res. No further information regarding this concern was presented to the survey team prior to the exit conference on 3/17/22.

Based on staff interview, Resident interview and clinical record review the facility staff failed to ensure a complete and accurate clinical record for 4 out of 12 residents, Resident #8, Resident #14, Resident #28 and Resident #37. For Resident #8 the facility staff failed to document blood sugar levels and the administration of insulin on one occasion and failed to document a weekly ordered weight on one occasion. For Resident #14 the facility staff failed to document the administration of the medications Prevacid and Neurontin for one occasion and failed to document tube feeding water flushes for one occasion. For Resident #28 the facility staff failed to document the administration of the medications Levothyroxine and Prilosec on one occasion, and failed to document blood sugar levels and insulin administered on two occasions. For Resident #37 the facility staff failed to document the administration of the medication Ascorbic Acid on one occasion, the medication iron tablet on two occasions, the nutritional supplements Magic cup and Pro Stat AWC for one occasion each. The facility staff also failed to document the application of skin prep on two occasions, treatment for a pressure ulcer for three occasions, application of zinc oxide ointment on six occasions, and the application of a heel boot on 3 occasions. The findings included: 1. Resident #8's face sheet listed diagnoses which included but not limited to dysphagia, type 2 diabetes mellitus, heart failure, morbid obesity, hypertension, acute respiratory failure, depression and atrial fibrillation. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 01/07/22 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 #8's clinical record was reviewed and contained a physician's order summary for the month of March 2022 which read in part, Weigh once a week. Call MD if resident has a weight gain of 5 lbs. in one week one time a day every WED for MONITORING, Accuchecks AC (before meals), HS (bedtime) before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9) and Humalog Solution Cartridge 100 UNIT/ML (Insulin Lispro) Inject 6 unit subcutaneously before meals related to TYPE 2 DIABETES MELLITUS WITH FOOT ULCER (E11.621). Resident #8's eMAR (electronic medication administration record) for the month of March 2022 was reviewed and contained entries as above. The entry for weigh weekly was blank on 03/09/22. The entry for Humalog insulin was blank on 03/10/22 at 4:30 pm, and the entry for accuchecks was blank on 03/10/22 at 4:00 pm. Surveyor spoke with Resident #8 on 03/16/22 at 5:10 pm regarding medications. Surveyor asked Resident #8 if they received their insulin like they should, and Resident #8 stated, Oh yeah, they check my sugar and give me my insulin every day. Surveyor then asked Resident #8 about weights, and Resident stated, I don't like to be weighed. Surveyor spoke with the DON (director on nursing) on 03/16/22 at 5:30 pm regarding blanks on Resident #8's eMAR's. DON stated there should not be any blanks on the eMAR. DON also stated they would look for the information on the daily report sheets and provide it to the surveyor. DON also stated they were bringing in the nurse who worked that day to re-educate on signing eMARs. The concern of the resident's eMARs not being signed was discussed with the administrator and DON on 03/16/22 at 6:10 pm. On 03/17/22 the DON provided the survey team with a daily report sheet for 03/10/22, which contained Resident #8's blood sugar readings for the day. DON also provided the survey team with a copy of a Disciplinary Action Form dated 03/17/22 which read in part Written warning. Detailed description of incident-Failure to complete documentation as required-Holes on MARS/TARS (medication administration record/treatment administration record) .Description of counseling received by Employee: Education one-on-one on important responsibility of care and documentation of such. Notify supervisor immediately if unable to complete task. This form was signed by the DON, administrator and LPN (licensed practical nurse). No further information was provided prior to exit. 2. Resident #14's face sheet listed diagnoses which included but not limited to dysphagia, hypertension, gastroesophageal reflux disease, anxiety, gastrostomy, depression and heart failure. Resident #14's admission MDS (minimum data set) with an ARD (assessment reference date) of 01/17/22 assigned the resident a BIMS (brief interview for mental status) score of 9 out of 15 in section C, cognitive patterns. This indicates that the resident moderately cognitively impaired. Resident #14's clinical record was reviewed and contained a physician's order summary for the month of March 2022, which read in part Flush tube with 60 cc of H2O (water) every 4 hours for hydration via pump, Neurontin Capsule 100 mg (Gabapentin) Give 1 tablet via PEG (percutaneous endoscopic gastrostomy)-tube three times a day for neuropathy, and Prevacid Capsule Delayed Release 30 mg (Lansoprazole) Give 1 capsule via PEG-tube in the morning for GERD (gastroesophageal reflux disease). Resident #14's eMAR (electronic medication administration record) for the month of March 2022 was reviewed and contained entries as above. The entries for Prevacid 30 mg and Neurontin 100 mg were blank on 03/13/22 at 6 am. The entry for 60 cc water was blank on 03/10/22 at 5 pm. Surveyor observed Resident #14 on 03/15/22 at 1:25 pm. Resident's tube feeding was running with correct formula and rate, with correct water flushes. Surveyor observed Resident #14 again on 03/16/22 at 10:30 am. Tube feeding was running with water flushes correct. Surveyor spoke with the DON (director on nursing) on 03/16/22 at 5:30 pm regarding blanks on Resident 14's eMAR's. DON stated there should not be any blanks on the eMAR. DON also stated they would look for the information on the daily report sheets and provide it to the surveyor. DON also stated they were bringing in the nurse who worked that day to re-educate on signing eMARs. The concern of the resident's eMARs not being signed was discussed with the administrator and DON on 03/16/22 at 6:10 pm. On 03/17/22 the DON provided the survey team with a copy of Resident #14's narcotics sign out sheet for Neurontin. This form indicated that the Neurontin was signed out on 03/13/22 at 5:16 am. DON also provided the survey team with a copy of a Disciplinary Action Form dated 03/17/22 which read in part Written warning. Detailed description of incident-Failure to complete documentation as required-Holes on MARS/TARS (medication administration record/treatment administration record) .Description of counseling received by Employee: Education one-on-one on important responsibility of care and documentation of such. Notify supervisor immediately if unable to complete task. This form was signed by the DON, administrator and LPN (licensed practical nurse). No further information was provided prior to exit. 3. Resident #28's face sheet listed diagnoses which included but not limited to metabolic encephalopathy, hypothyroidism, type 2 diabetes mellitus, hypertension, depression, dementia, and Parkinson's disease. Resident #28's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 02/04/22 assigned the resident a BIMS (brief interview for mental status) score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #28's clinical record was reviewed and contained a physician's order summary for the month of March 2022, which read in part Levothyroxine Sodium Tablet 50 mcg. Give 1 tablet by mouth one time a day for Hypothyroidism, Novolog FlexPen Solution Pen-Injector 100 unit/ml (Insulin Aspart). Inject as per sliding scale .subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9) hold less than 100 call md > (greater than) 400 and Prilosec Capsule Delayed Release 20 mg (Omeprazole). Give 1 capsule by mouth one time a day for GERD (gastroesophageal reflux disease). Resident #28's eMAR (electronic medication administration record) for the month of March 2022 was reviewed and contained entries as above. The entries for Levothyroxine and Prilosec were blank on 03/13/22 at 6 am. Then entry for Novolog was blank on 03/10/22 at 4 pm and 03/13/22 at 6 am. Surveyor spoke with the DON (director on nursing) on 03/16/22 at 5:30 pm regarding blanks on Resident 28's eMAR's. DON stated there should not be any blanks on the eMAR. DON also stated they would look for the information on the daily report sheets and provide it to the surveyor. DON also stated they were bringing in the nurse who worked that day to re-educate on signing eMARs. The concern of the resident's eMARs not being signed was discussed with the administrator and DON on 03/16/22 at 6:10 pm. On 03/17/22 the DON provided the survey team with a copy of the daily report sheets for 03/10/22 and 03/13/22 with Resident #28's blood sugars listed. DON also provided the survey team with a copy of a Disciplinary Action Form dated 03/17/22 which read in part Written warning. Detailed description of incident-Failure to complete documentation as required-Holes on MARS/TARS (medication administration record/treatment administration record) .Description of counseling received by Employee: Education one-on-one on important responsibility of care and documentation of such. Notify supervisor immediately if unable to complete task. This form was signed by the DON, administrator and LPN (licensed practical nurse). No further information was provided prior to exit. 4. Resident #37's face sheet listed diagnoses which included but not limited to anemia, hypothyroidism, depression, insomnia, peripheral vascular disease, chronic obstructive pulmonary disease, and dementia. Resident #37's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/03/22 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 clinical record was reviewed and contained a physician's order summary for the month of March 2022, which read in part HHL Magic Cup one time a day for supplement to be served on dinner tray, Pro-Stat AWC (advance wound care) two times a day for Give 30 ml p.o. (by mouth) wound healing, Apply skin prep to left toes every day shift for protection, Apply zinc oxide cream to buttocks and scrum every shift for protection every shift for redness, Cleanse stage 4 ulcer to left heel with NS (normal saline). Pat dry. Cover with calcium alginate plus silver, apply foam dressing with adhesive border OR secure with kerlix every day shift for wound, Heel boot to left heel at all times as resident allows. Check for placement and encourage use every shift for wound care, Ascorbic Acid Tablet 500 mg. Give 1 tablet by mouth one time a day for Supplement and Iron (Ferrous Sulfate) Tablet 325 mg (65 Fe) MG (Ferrous Sulfate). Give 1 tablet by mouth two times a day for Anemia. Resident #37's eMAR (electronic medication record) for the month of March 2022 was reviewed and contained entries, which read in part HHL Magic Cup one time a day for supplement to be served on dinner tray, Pro-Stat AWC (advance wound care) two times a day for Give 30 ml p.o. (by mouth) wound healing, Ascorbic Acid Tablet 500 mg. Give 1 tablet by mouth one time a day for Supplement and Iron (Ferrous Sulfate) Tablet 325 mg (65 Fe) MG (Ferrous Sulfate). Give 1 tablet by mouth two times a day for Anemia. The entry for HHL Magic Cup was blank on 03/10/22 at 5 pm. The entries for Pro-Stat, Ascorbic Acid and Iron were blank on 03/11/22 at 9:00 am. Resident #37's eTAR (electronic treatment administration record was reviewed and contained entries, which read in part Apply skin prep to left toes every day shift for protection, Apply zinc oxide cream to buttocks and scrum every shift for protection every shift for redness, Cleanse stage 4 ulcer to left heel with NS (normal saline). Pat dry. Cover with calcium alginate plus silver, apply foam dressing with adhesive border OR secure with kerlix every day shift for wound, and Heel boot to left heel at all times as resident allows. Check for placement and encourage use every shift for wound care. The entry for skin prep was blank on 03/11/22 and 03/15/22 for day shift. The entries for cleanse stage 4 pressure ulcer, zinc oxide, and heel boot were blank on 03/09/22, 03/11/22, and 03/15/22 for day shift. Surveyor spoke with Resident #37 on 03/15/22 at 12:40 pm. Surveyor asked resident about the wound on their heel, and resident stated, They come in here every day and change that dressing. I see the wound care doctor couple of times a week. It's getting better. Surveyor observed heel boot in place at this time. Surveyor spoke with Resident #37 again on 03/16/22 at 10:30 am. Surveyor asked resident if they received the medications as they should, and resident stated, I always get my pills. Surveyor observed heel boot in place at this time. Surveyor spoke with the DON (director on nursing) on 03/16/22 at 5:30 pm regarding blanks on Resident 37's eMAR's. DON stated there should not be any blanks on the eMAR. DON also stated they would look for the information on the daily report sheets and provide it to the surveyor. DON also stated they were bringing in the nurse who worked that day to re-educate on signing eMARs. The concern of the resident's eMARs not being signed was discussed with the administrator and DON on 03/16/22 at 6:10 pm. On 03/17/22 the DON provided the survey team with a copy of a Disciplinary Action Form dated 03/17/22 which read in part Written warning. Detailed description of incident-Failure to complete documentation as required-Holes on MARS/TARS (medication administration record/treatment administration record) .Description of counseling received by Employee: Education one-on-one on important responsibility of care and documentation of such. Notify supervisor immediately if unable to complete task. This form was signed by the DON, administrator and LPN (licensed practical nurse). No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to ensure the Virginia Department of Health Durable Do Not Resuscitate (DDNR) form was complete for 1 of 22 residents (Resident #154). The findings included: The facility staff failed to ensure the Virginia Department of Health DDNR was accurate for Resident #154. The clinical record of Resident #154 was reviewed 5/29/19 through 5/31/19. Resident #154 was admitted to the facility 5/22/19 with diagnoses that included but not limited to fracture of parts of lumbosacral spine and pelvis, muscle weakness, gait and mobility abnormalities, cognitive communication deficit, anxiety, major depressive disorder, age-related osteoporosis, rheumatoid arthritis, hypertension, Vitamin D deficiency, kyphosis, atherosclerotic heart disease, and chronic pain. Resident #154's admission minimum data set (MDS) had not been completed. The clinical record contained a Virginia Department of Health Durable Do Not Resuscitate form dated 5/22/19. Section 1 and Section 2 were blank. Section 1 of the DDNR read in part, 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 . The boxes beside #1 and #2 were blank. Section 2 read If you checked 2 above, check A, B, or C below: The three boxes below were blank. The surveyor asked licensed practical nurse #1 to review Resident #154's DDNR on 5/29/19 at 12:38 p.m. L.P.N. #1 stated nothing was marked on the DDNR. The surveyor informed the administrator, the director of nursing, the corporate registered nurse and the chief executive officer of the incomplete DDNR on 5/30/19 at 4:50 p.m. and again prior to exit on 5/31/19 at 6:20 p.m. No further information was provided prior to the exit conference on 5/31/19.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure a clean and comfortable homelike environment for 1 of 22 residents (Resident #41). The findings included: The facility staff failed to ensure Resident #41's privacy curtain and air conditioning unit were clean. Resident #41 was admitted to the facility 1/26/18 with diagnoses that included but not limited to frostbite, anxiety, depression, and dementia. Resident #41's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 5/15/19 assessed the resident with a BIMS (brief interview for mental status) as 9/15. The surveyor interviewed Resident #41 on 5/29/19 at 11:34 a.m. Resident #41 was observed sitting up in bed during the interview. The surveyor sat in a folding chair and the privacy curtain was pulled to separate Resident #41 from the roommate. When the surveyor sat down, a large orange stain was observed at the end of the curtain as well as dark marks throughout the remainder of the curtain. At the end of the interview, Resident #41 asked the surveyor to close the window and turn the air conditioner on 68 degrees. When the surveyor turned the air conditioner on, the surveyor noticed an accumulation of dust on top of the air conditioner in the grill. The surveyor showed the director of nursing of the above concerns on 5/29/19 at 2:00 p.m. The DON stated she would inform the housekeeping staff of the above issue. The surveyor informed the administrator, the director of nursing, the corporate registered nurse and the chief executive officer of the above concern during the end of the day meeting on 5/30/19 at 4:50 p.m. and requested a copy of the housekeeping job duties and informed the administrative staff again on 5/31/19 at 6:20 p.m. of the above concern. No further information was provided prior to the exit conference on 5/31/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure the PASSARs (Pre-admission Screening and Resident Review) were complete for 2 of 22 residents (Resident #45 and Resident #7). The findings included: 1. The facility staff failed to ensure the PASSAR was complete for Resident #45. The clinical record of Resident #45 was reviewed 5/29/19 through 5/31/19. Resident #45 was admitted to the facility 10/1/18 and readmitted [DATE] with diagnoses that included but not limited to schizophrenia, osteomyelitis in ankle and foot, type 2 diabetes mellitus, morbid obesity, obstructive and reflux uropathy, hypertension, hyperlipidemia, peripheral vascular disease, and chronic kidney disease, stage 3. Resident #45's significant change in assessment minimum data set (MDS) with an assessment reference date (ARD) of 5/16/19 assessed the resident with a BIMS (brief interview for mental status) as 13/15. During the survey process, the record review asked if a Level II PASSAR had been completed. All sections of the PASSAR had been completed except there was no signature or date as to who completed the assessment. The surveyor was informed by the director of nursing on 5/30/19 that the social worker was responsible for the completion of the form. The surveyor interviewed the facility social worker on 5/30/19 at 11:14 a.m. The social worker reviewed the form and stated she completed the form but just didn't sign it. The surveyor informed the administrator, the director of nursing, the corporate registered nurse, and the chief executive officer of the above concern on 5/30/19 at 4:50 p.m. and again on 5/31/19 at 6:20 p.m. No further information was provided prior to the exit conference on 5/31/19. 2. The facility staff failed to ensure the Pre-admission Screening and Resident Review (PASSAR) was competed for Resident #7. The clinical record of Resident #7 was reviewed 5/28/19 through 5/31/19. Resident #7 was admitted to the facility 7/29/16 with diagnoses that included but not limited to anemia, anxiety, depression, dementia, psychosis, diabetes mellitus, pneumonia, hypertension, orthostatic hypotension, and obstructive uropathy. Resident #7's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/10/19 assessed the resident with a BIMS (brief interview for mental status) as 12/15. During the clinical record review, the long-term care process asked about PASSARs. The surveyor reviewed the PASSAR in the clinical record. Under Section 5, it stated either a or b must be checked. Neither one of these were checked. The surveyor informed the director of nursing of the above concern on 5/30/19 at 11:10 a.m. At 11:25 a.m., the surveyor interviewed the social worker and informed the social worker of the concern. The social worker circled 5b and stated, I just made a mistake. The surveyor informed the administrator, the director of nursing, the corporate registered nurse, and the chief executive officer of the above concern on 5/30/19 at 4:50 p.m. and again on 5/31/19 at 6:20 p.m. No further information was provided prior to the exit conference on 5/31/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to develop care plans for psychotropic medication (Zyprexa and Restoril) and insomnia for 1 of 22 residents (Resident #40). The findings included: The facility staff failed to develop a care plan for the use of psychotropic medications, failed to develop a care plan for insomnia, and failed to develop a care plan for diabetes for Resident #40. The clinical record of Resident #40 was reviewed 5/29/19 through 5/31/19. Resident #40 was admitted to the facility 2/28/19 and readmitted [DATE] with diagnoses that included but not limited to symbolic dysfunction, insomnia, muscle weakness, hypertension, atherosclerotic heart disease, unspecified dementia with behavioral disturbances, cerebrovascular disease, anxiety disorder, major depressive disorder, hyperlipidemia, type 2 diabetes mellitus, and unspecified psychosis. Resident #40's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/15/19 assessed the resident with a BIMS (brief interview for mental status) as 3/15. Resident #40 was not interviewable. The May 2019 physician's orders were reviewed and included orders that read Restoril 15 mg (milligrams) Give 1 capsule by mouth at bedtime for insomnia, Seroquel Tablet 25 mg Give 1 tablet at bedtime for BPSD (bipolar disorder) and Zyprexa 2.5 mg give 1 tablet by mouth one time a day for psychosis. In addition, Resident #40 had physicians orders for Lantus15 units at bedtime-start date 5/11/19 and Novolog FlexPen Inject as per sliding scale: If 150-200=2 units; 201-250=4 units; 251-300=6 units; 301-350=8 units, 351-400=10 units, subcutaneously before meals and at bedtime for DM II (diabetes mellitus type 2). If BS (blood sugar) > (greater than) 400, call MD (medical doctor). Start Date 5/11/19. Resident #40's current comprehensive care plan initiated 3/4/19 did not include a care plan for behaviors and the use of psychotropic medications or a care plan for insomnia. Resident #40 does have a care plan initiated 3/8/19 for a focus area of chronic/progressive decline in intellectual functioning characterized by deficit in memory, judgement, decision making and thought processes, per family and through interviews related to dx (diagnosis) of dementia/hx (history of) CVA (cerebrovascular accident) AEB (as evidenced by) inability to participate on BIMS/PHQ sections of MDS. Interventions: Break tasks/activities into manageable subtasks. In addition, the current comprehensive care plan did not have a care plan for the care and management of the diabetic resident. The surveyor informed the administrator, director of nursing, the corporate registered nurse and the chief executive officer of the above concern on 5/30/19 at 4:50 p.m. and again on 5/31/19 at 6:20 p.m. The surveyor requested the facility policy on psychotropic medication management. No further information was provided prior to the exit conference on 5/31/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility staff failed to review and revise the comprehensive plan of care for 2 of 22 Residents in the survey sample, Resident # 31 and Resident # 7. The findings included 1. The facility staff failed to review and revise the plan of care for Resident # 31 to reflect refusal of insulin. Resident # 31 was a [AGE] year-old-female who was originally admitted to the facility on [DATE], with a readmission date of 1/21/19. Diagnoses included but were not limited to; type 2 diabetes mellitus, hypertension, anemia, and heart failure. The clinical record for Resident # 31 was reviewed 5/30/19 at 3:38 pm. The most recent MDS (minimum data set) assessment for Resident # 31 was an annual assessment with an ARD (assessment reference date) of 5/5/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 31 had a BIMS (brief interview for mental status) score of 13 out of 15, which indicated that Resident # 31 was cognitively intact. The current plan of care for Resident # 31 was reviewed and revised on 5/10/19. The facility staff documented a focus area for Resident # 31 as, At risk for skin breakdown related to: decreased mobility, weakness, edema, diagnosis of DM (diabetes mellitus), O2 (oxygen) tubing prn (as needed). Interventions included but were not limited to, Notify MD (medical doctor) prn with any changes. The surveyor did not observe any documentation of insulin refusals on the care plan for Resident # 31. Resident # 31 had orders that included but were not limited to, Lantus SoloStar Solution Pen-injector 100 unit/ml (milliliter) Inject 35 unit subcutaneously at bedtime for diabetes, which was initiated by the physician on 3/9/19. The surveyor reviewed the clinical record for Resident # 31 and observed that the facility staff had documented that Resident # 31 had refused Lantus 35 units at 8:00 pm, and the physician had not been notified. The dates identified were: 5/5/19 5/11/19 5/14/19 5/15/19 5/17/19 5/18/19 5/20/19 5/21/19 5/22/19 5/24/19 5/25/19 5/26/19 5/29/19 On 5/31/19 at 6:30 pm, the administrative team was made aware of the findings as stated above, and agreed that the plan of care for Resident # 31 did not reflect that Resident # 31 refused insulin at times. No further information regarding this issue was presented to the survey team prior to the exit conference on 5/31/19. The findings included 2. The facility staff failed to review and revise the plan of care to include Resident specific behaviors of depression associated with the use of Remeron for Resident # 7. Resident # 7 was an [AGE] year-old-female who was originally admitted to the facility on [DATE], with a readmission date of 11/5/17. Diagnoses included but were not limited to; major depressive disorder, anxiety, heart failure, and type 2 diabetes mellitus. The clinical record for Resident # 7 was reviewed on 5/30/19 at 11:00 am. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 3/10/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 7 had a BIMS (brief interview for mental status) score of 12 out of 15, which indicated that Resident # 7's cognitive status was moderately impaired. The current plan of care for Resident # 7 was reviewed and revised on 1/14/19. The facility staff documented a focus area for Resident # 7 as, At risk for adverse effects r/t (related to) psychoactive medication use: anxiety, depression, BSPD (behavioral and psychological symptoms of dementia), psychosis. Interventions included but were not limited to, Monitor of s/s (signs and symptoms) of depression, Monitor medications for effectiveness, and Monitor for med side effects: sedation, hypotension, EPS (extrapyramidal symptoms), anticholinergic sx (symptoms) H/A (headache), insomnia, anorexia, constipation. The surveyor did not observe and Resident specific documented behaviors of depression on the plan of care for Resident # 7. Resident # 7 had orders that included but were not limited to, Remeron tablet 30 mg (milligram) Give 1 tablet by mouth at bedtime for depression, which was initiated by the physician on 12/13/18. On 5/31/19 at 9:42 am, the surveyor reviewed the May 2019 medication administration record for Resident # 7. The surveyor did not observe behavior monitoring, or monitoring for side effects and effectiveness associated with the use of Remeron for Resident # 7. On 5/31/19 at 6:20 pm, the administrative team was made aware of the findings as stated above, and agreed that the facility failed to review and revise the care plan for Resident # 7 to include Resident specific behaviors associated with the use of Remeron . No further information regarding this issue was presented to the survey team prior to the exit conference of 5/31/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview, Resident interview, and facility document review, the facility staff failed to provide services to prevent urinary tract infections for 1 of 22 Residents in the survey sample, Resident 34. The findings included The facility staff failed to ensure that Foley catheter tubing for Resident # 34 was secured. Resident # 34 was an [AGE] year-old-male who was originally admitted to the facility on [DATE], with a readmission date of 7/19/18. Diagnoses included but were not limited to; obstructive and reflux uropathy, chronic kidney disease, hypertension, and type 2 diabetes mellitus. The clinical record for Resident # 34 was reviewed on 5/29/19 at 11:44 am. The most recent MDS (minimum data set) assessment for Resident # 34 was a quarterly assessment with an ARD (assessment reference date) of 5/9/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 34 had a BIMS (brief interview for mental status) score of 7 out of 15, which indicated that Resident # 34's cognitive status was severely impaired. Section H of the MDS assesses bladder and bowel. In Section H0100, the facility staff documented that Resident # 34 had an indwelling catheter. The current plan of care for Resident # 34 was reviewed and revised on 5/14/19. The facility staff documented a focus area for Resident # 34 as, Resident is at risk for infection r/t (related to) Foley catheter r/t BPH (benign prostatic hyperplasia), obstructive uropathy, peg tube, hx (history) of uti (urinary tract infections), hx pna (pneumonia), hx cellulitis, hx of osteomyelitis, areas to legs and toes. Interventions included but were not limited to; Foley cath care as ordered. Resident # 34 had orders that included but were not limited to; 16F (French) (30cc (cubic centimeter) balloon) indwelling Foley catheter d/t (due to) obstructive uropathy, which was signed by the physician on 5/2/19. On 5/30/19 at 9:18 am, the surveyor was in Resident # 34's room conducting a Resident interview. The surveyor asked Resident # 34 if she could observe his Foley catheter. Resident # 34 pulled back his bed covers, and the surveyor observed that Resident # 34's Foley catheter tubing was not secured. On 5/30/19 at 10:34 am, the surveyor and LPN # 1 (licensed practical nurse) went into Resident # 34's room to observed his Foley catheter. The surveyor and LPN # 1 observed Resident # 34's Foley catheter tubing was not secured. The surveyor asked LPN # 1 if the catheter should be secured. LPN # 1 replied, Yes he used to have one but he keeps pulling them off. We tried both kinds. The surveyor asked Resident # 34 if he would like to have something on his leg that would help keep his catheter from pulling. Resident # 34 stated, You can try it if you want to. On 5/30/19 at 10:45 am, the surveyor reviewed the clinical record for Resident # 34. The surveyor did not observe any documentation in Resident # 34's clinical record that stated that Resident # 34 would pull off or refuse supplies utilized to secure his Foley catheter. On 5/31/19 at 11:05 am, the director of nursing provided the surveyor with the facility standard of practice for Management of the Patient with an Indwelling (self-retaining) Catheter and Closed Drainage system. The standard of practice contained documentation that included but was not limited to; .Nursing Action 2. Secure the indwelling catheter to the patient's thigh using tape, strap, adhesive anchor, or other securement device. [NAME], S. M., & Brunner, L. S. (2019). [NAME] manual of nursing practice (10th ed.). Philadelphia: Wolters Kiuwer. On 5/31/19 at 6:30 pm, the administrative team was made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 5/31/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to utilize non-pharmacological interventions prior to the use of pain medication for 1 of 22 residents (Resident #154). The findings included: The facility staff failed to utilize non-pharmacological interventions prior to the use of pain medication for Resident #154. The clinical record of Resident #154 was reviewed 5/29/19 through 5/31/19. Resident #154 was admitted to the facility 5/22/19 with diagnoses that included but not limited to fracture of parts of lumbosacral spine and pelvis, muscle weakness, gait and mobility abnormalities, cognitive communication deficit, anxiety, major depressive disorder, age-related osteoporosis, rheumatoid arthritis, hypertension, Vitamin D deficiency, kyphosis, atherosclerotic heart disease, and chronic pain. Resident #154's admission minimum data set (MDS) had not been completed. Resident #154's careplan initiated 5/23/19 identified actual pain as a focus area r/t (related to) decreased mobility/function and weakness, dx (diagnosis) chronic pain, spinal compression fracture with long history of back issues including multiple kyphoplastys, RA (rheumatoid arthritis), sacral fracture, lumbar fracture, and abdominal pain. Interventions: Assist with positioning for comfort, provide distractions prn (as needed) such as television, or activities, interaction with others, reading material as able, assess for increase or decrease in pain, and meds (medications) as ordered. Resident #154's May 2019 admission physician's orders included Oxycodone 5 mg (milligram) 1 tablet by mouth every 6 hours as needed for pain and Tylenol 1000 mg every 8 hours as needed for pain fever. A review of the May 2019 electronic medication administration record revealed Resident #154 was administered oxycodone 5 mg eighteen times and Tylenol 1000 mg twice since admission on [DATE]. A review of the May 2019 progress notes did not reveal any non-pharmacological interventions were utilized prior to the administration of each of the Oxycodone 5 mg tablets or Tylenol. Resident #154's pain assessment each shift ranged from 0-8 with 0 being no pain and 8 being the highest. The surveyor informed the administrator, the director of nursing, the corporate registered nurse and the chief executive officer of the above concern during the end of the day meeting on 5/31/19 at 6:20 p.m. No further information was provided prior to the exit conference on 5/31/19.

Based on observation and staff interview, the facility staff failed to dispose of expired medications on two of two halls. The findings included: The facility staff failed to dispose of expired medications. On 05/29/19 at 9:35 a.m., the surveyor checked medication cart #2 on the 100 hall with LPN (licensed practical nurse) #1. This cart included an opened bottle of 1000-tablet multivitamins with an expiration date of 03/19 and a victoza (insulin) flex pen with an open date of 04/14/19. The label on this flex pen read to discard after 30 days. LPN #1 checked the medications with the surveyor, confirmed they were out of date disposed of the flex pen, and returned the bottle of multivitamins to the medication room to be returned to the pharmacy. On 05/29/19 at 10:10 a.m., the surveyor checked medication cart #1 on the 200 hall with LPN #2. This cart included an opened bottle of 100-tablet zinc sulfate 220 mg with a use by date of 09/18 and a victoza flex pen dated 04/28/19. The label on this flex pen read to discard after 30 days. LPN #2 checked the medications with the surveyor confirmed they were out of date and stated she would dispose of them. On 05/29/19 at 12:30 p.m., the DON (director of nursing) and corporate nurse were made aware of the issues regarding the expired medications. No further information regarding this issue was shared with the surveyor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record, the facility staff failed to obtain a physician ordered laboratory test for 1 of 22 residents (Resident #40). The findings included: The facility staff failed to obtain a CMP (comprehensive metabolic panel) for Resident #40. The clinical record of Resident #40 was reviewed 5/29/19 through 5/31/19. Resident #40 was admitted to the facility 2/28/19 and readmitted [DATE] with diagnoses that included but not limited to symbolic dysfunction, insomnia, muscle weakness, hypertension, atherosclerotic heart disease, unspecified dementia with behavioral disturbances, cerebrovascular disease, anxiety disorder, major depressive disorder, hyperlipidemia, type 2 diabetes mellitus, and unspecified psychosis. Resident #40's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/15/19 assessed the resident with a BIMS (brief interview for mental status) as 3/15. Resident #40 was not interviewable. The surveyor reviewed the March 2019 physician's orders. The 3/2/19 orders read Hgb, A1C, CMP, Lipid panel, urine micro albumin one time only for 1 day. A review of the laboratory section revealed no results for the CMP ordered. The surveyor informed the director of nursing of the above laboratory test results not found. After researching the order, the DON stated the nurse had not marked the lab test (CMP) on the lab requisition sheet. The surveyor informed the administrator, director of nursing, the corporate registered nurse and the chief executive officer of the above concern on 5/30/19 at 4:50 p.m. and again on 5/31/19 at 6:20 p.m. No further information was provided prior to the exit conference on 5/31/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record, the facility staff failed to obtain a physician order prior to obtaining laboratory tests for 1 of 22 residents (Resident #40). The findings included: The facility staff failed to obtain a physician order before obtaining an albumin level, a urine and urine for culture and sensitivity, and a CBC (complete blood count) for Resident #40 on 3/4/19. The clinical record of Resident #40 was reviewed 5/29/19 through 5/31/19. Resident #40 was admitted to the facility 2/28/19 and readmitted [DATE] with diagnoses that included but not limited to symbolic dysfunction, insomnia, muscle weakness, hypertension, atherosclerotic heart disease, unspecified dementia with behavioral disturbances, cerebrovascular disease, anxiety disorder, major depressive disorder, hyperlipidemia, type 2 diabetes mellitus, and unspecified psychosis. Resident #40's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/15/19 assessed the resident with a BIMS (brief interview for mental status) as 3/15. Resident #40 was not interviewable. The surveyor reviewed the March 2019 physician's orders. The 3/2/19 orders read Hgb, A1C, CMP, Lipid panel, urine micro albumin one time only for 1 day. A review of the laboratory section revealed the results for the CBC, albumin level and a urine and urine for culture and sensitivity dated 3/4/19 but a physician order was unable to be located. The surveyor informed the director of nursing of the above laboratory test results found but unable to find a physician order. After researching the order, the DON stated the nurse had marked the lab tests on the lab requisition sheet incorrectly. CBC, Albumin, urine and urine culture were marked incorrectly but not ordered by the physician. The surveyor informed the administrator, director of nursing, the corporate registered nurse and the chief executive officer of the above concern on 5/30/19 at 4:50 p.m. and again on 5/31/19 at 6:20 p.m. No further information was provided prior to the exit conference on 5/31/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to clean scissors before use or after use for 1 of 22 residents (Resident #45). The findings included: The facility staff failed to clean the scissors used in wound care for Resident #45. The clinical record of Resident #45 was reviewed 5/29/19 through 5/31/19. Resident #45 was admitted to the facility 10/1/18 and readmitted [DATE] with diagnoses that included but not limited to schizophrenia, osteomyelitis in ankle and foot, type 2 diabetes mellitus, morbid obesity, obstructive and reflux uropathy, hypertension, hyperlipidemia, peripheral vascular disease, and chronic kidney disease, stage 3. Resident #45's significant change in assessment minimum data set (MDS) with an assessment reference date (ARD) of 5/16/19 assessed the resident with a BIMS (brief interview for mental status) as 13/15. Section K Skin Conditions assessed the resident with a surgical wound and surgical wound care. Resident #45's current comprehensive care plan initiated 10/4/18 and revised 5/22/19 identified the resident to be at risk for skin breakdown related to weakness, decreased mobility, diagnosis of DM (diabetes mellitus), incontinent of bowel, PVD (peripheral vascular disease), actual surgical area to scrotum/penis. Interventions: meds/labs/treatment (medications/laboratory) as ordered. During the interview with Resident #45 on 5/29/19 at 10:46 a.m., the resident was asked if the surveyor could observe doing wound care. Resident #45 stated yes. The surveyor observed wound care to Resident #45 on 5/30/19 at 2:44 p.m. with licensed practical nurse #2. L.P.N. #2 washed hands, returned to the treatment cart, removed a bottle of Saf-Clens from cart, and sprayed gauze with saf-clens. L.P.N. #2 pulled an ABD pad and opened it. L.P.N. #2 put gloves on, removed one q-tip from a multi-package, and placed the qtip in a cup. L.P.N. #2 pulled a strip of iodoform from the cart, opened the bottle and cut a long strip. Scissors were not cleaned before cutting the strip. L.P.N. #2 placed the scissors on the top of the uncleaned cart. Knocked on door and entered room. Placed wax paper on over the bed table. Washed hands and put gloves on. Old dressing removed (had seen urologist today). Gloves off and washed hands. New gloves on and cleaned scrotal area with safe clens soaked gauze. Gloves off and hands washed. Gloves on and placed iodoform gauze in scrotal area. Placed ABD over scrotum and covered the resident with a sheet. Removed soiled trash can lining and discarded. Gloves off and washed hands. L.P.N. #2 placed the scissors in the uniform pocket and left the room. In the end of the day meeting on 5/30/19 at 4:50 p.m., the surveyor requested the facility policy on dressing changes. The surveyor reviewed the competency checklist for Clean Dressing Application provided by the director of nursing on 5/31/19 at 2:55 p.m. The competency read in part 6. Remove and discard gloves. Wash bandage scissors with soap and water if used during soiled part of procedure. 10. Wash hands. Wash bandage scissors, if used. The surveyor interviewed L.P.N. #2 on 5/31/19 at 2:37 p.m. about the wound care observations. L.P.N. #2 was informed that the scissors were not cleaned prior to cutting the iodoform strip. L.P.N. #2 stated she always cleans her scissors. L.P.N. #2 stated the scissors were cleaned before the surveyor's observations. However, the surveyor did not observe scissors cleaned before or after use. The surveyor informed the administrator, the director of nursing, the corporate registered nurse, and the chief executive officer of the above concern on 5/31/19 at 6:20 p.m. No further information was provided prior to the exit conference on 5/31/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to notify the physician of refusal of insulin for Resident # 4. Resident # 4 was an [AGE] year-old-male who was originally admitted to the facility on [DATE], and was readmitted to the facility on [DATE]. Diagnoses included but were not limited to; type 2 diabetes mellitus, heart failure, hypertension, and end stage renal disease. The clinical record for Resident # 4 was reviewed on 5/30/19 at 9:25 am. The most recent MDS (minimum data set) assessment for Resident # 4 was a quarterly assessment with an ARD (assessment reference date) of 3/13/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 4 had a BIMS (brief interview for mental status) score of 12 out of 15, which indicated that Resident # 4's cognitive status was moderately impaired. Section N of the MDS assesses medications. In Section N0350, the facility staff documented that Resident # 4 had insulin injections on 2 days during the look back period for the 3/13/19 ARD. The current plan of care for Resident # 4 was reviewed and revised on 2/25/19. The facility staff documented a focus area for Resident # 4 as, The resident is at times resistive to care r/t (related to) noncompliance with taking medication and daily routine AEB (as evidenced by) refusing medication and getting out of bed. Interventions included but were not limited to; Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care. Resident # 4 had orders that included but were not limited to; Levemir Solution 100 unit/ml (milliliter) Inject 12 unit subcutaneously one time a day for DM II (type 2 diabetes mellitus), which was initiated by the physician on 1/30/19, and Levemir Solution 100 unit/ml Inject 5 unit subcutaneously at bedtime for DM II, which was initiated by the physician on 1/30/19. On 5/31/19 at 8:02 am, the surveyor reviewed the May 2019 medication administration record for Resident # 4. The surveyor observed that the facility staff documented that Resident # 4 had refused Levemir Solution 100 unit/ml Inject 12 unit subcutaneously one time a day on the following dates for the 6:00 am dose, 5/1/19 5/2/19 5/3/19 5/4/19 5/5/19 5/6/19 5/7/19 5/8/19 5/9/19 5/10/19 5/11/19 5/12/19 5/13/19 5/14/19 5/16/19 5/17/19 5/18/19 5/19/19 5/20/19 5/21/19 5/22/19 5/23/19 5/24/19 5/25/19 5/26/19 5/27/19 5/28/19 5/29/10 5/30/19 The surveyor observed that the facility staff documented that Resident # 4 had refused Levemir Solution 100 unit/ml Inject 5 unit subcutaneously at bedtime on the following dates for the 8:00 pm dose, 5/2/19 5/5/19 5/8/19 5/9/19 5/12/19 5/13/19 5/15/19 5/16/19 5/17/19 5/18/19 5/19/19 5/21/19 5/24/19 5/25/19 5/27/19 5/29/19 5/30/19 The surveyor reviewed the clinical record further for Resident # 4 and did not observe documentation that the physician and had been made aware that Resident # 4 had refused Levemir on the dates and times listed above. On 5/31/19 at 11:08 am, the surveyor informed the director of nursing that there was no documentation that the physician had been made aware of Resident # 4's refusal of Levemir on the dates and times listed above. The director of nursing stated that she would look into it. The facility Change in Resident Condition policy contained documentation that included but was not limited to; . 5. The Resident/Physician/Family/Responsible Party will be notified when there has been: f. Refusal of treatment or medications for on 3 consecutive times. On 5/31/19 at 6:30 pm, the administrative team was made aware of the findings as stated above and agreed that the physician had not been made aware of Resident # 4's refusals of Levemir. No further information regarding this issue was presented to the survey team prior to the exit conference on 5/31/19. 3. The facility staff failed to notify the physician of blood sugar levels above 450 for Resident # 19. Resident # 19 was an [AGE] year-old-male who was originally admitted to the facility on [DATE], with a readmission date of 5/29/19. Diagnoses included but were not limited to; type 2 diabetes mellitus, hypertension, cognitive communication deficit, and peripheral vascular disease. The clinical record for Resident # 19 was reviewed on 5/29/19 at 11:51 am. The most recent MDS (minimum data set) assessment for Resident # 19 was a quarterly assessment with an ARD (assessment reference date) of 4/4/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 19 had a BIMS (brief interview for mental status) score of 5 out of 15, which indicated that Resident # 19's cognitive status was severely impaired. Section N of the MDS assesses medications. In Section N0350, the facility staff documented that Resident # 19 had insulin injections for 7 days during the look back period for the 4/4/19 ARD. The current plan of care for Resident # 19 was reviewed and revised on 3/15/19. The facility staff documented a focus area for Resident # 19 as, At risk for skin breakdown related to decreased mobility, weakness, diagnosis of DM (diabetes mellitus) edema, incontinent of bowel and bladder, PVD (peripheral vascular disease), application of prosthetic to left leg, surgical wound to right leg. Interventions included but were not limited to, Meds/labs/treatment as ordered. Resident # 19 had orders that included but were not limited to; Call MD (medical doctor) if bs (blood sugar) greater than 450, which was initiated by the physician on 4/26/19, and Novolog flexpen solution pen-injector 100 unit/ml (milliliter) Inject 15 unit subcutaneously before meals for dm (diabetes mellitus), which was initiated by the physician on 4/26/19. On 5/30/19 at 2:42 pm, the surveyor reviewed the May 2019 medication administration record for Resident # 19. The surveyor observed that Resident # 19 had blood sugar levels above 450 on the following dates and times: 5/2/19 at 4:30 pm - 454 5/3/19 at 4:30 pm - 477 5/5/19 at 4:30 pm - 472 5/11/19 at 4:30 pm - 452 5/16/19 at 4:30 pm - 493 5/18/19 at 4:30 pm - 497 5/26/19 at 4:30 pm - 494 The surveyor reviewed the clinical record for Resident # 19 and did not observe any documentation that reflected that the physician was made aware of blood sugars levels greater than 450 on the dates and times listed above. On 5/31/19 at 11:08 am, the director of nursing was made aware that the surveyor did not locate documentation that supported that the physician had been made aware of blood sugars greater than 450 on the dates and times listed above. On 5/31/19 at 6:30 pm, the administrative team was made aware of the findings as stated above and agreed that the physician was not notified of blood sugars greater than 450 for Resident # 19. No further information regarding this issue was presented to the survey team prior to the exit conference on 5/31/19. 4. The facility staff failed to notify the physician of insulin refusals for Resident # 34. Resident # 34 was an [AGE] year-old-male who was originally admitted to the facility on [DATE], with a readmission date of 7/19/18. Diagnoses included but were not limited to; obstructive and reflux uropathy, chronic kidney disease, hypertension, and type 2 diabetes mellitus. The clinical record for Resident # 34 was reviewed on 5/29/19 at 10:59 am. The most recent MDS (minimum data set) assessment for Resident # 34 was a quarterly assessment with an ARD (assessment reference date) of 5/9/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 34 had a BIMS (brief interview for mental status) score of 7 out of 15, which indicated that Resident # 34's cognitive status was severely impaired. Section N of the MDS assesses medications. In Section N0350, the facility staff documented that Resident # 34 had insulin injections on 5 days during the look back period for the 5/9/19 ARD. The current plan of care for Resident # 34 was reviewed and revised on 5/14/19. The facility staff documented a focus area for Resident # 34 as, Resident is noncompliant with taking his insulin in the a.m. R/T (related to) his right of choice. Interventions included but were not limited to, Inform MD (medical doctor)/physician, if applicable of non-compliance. Resident # 34 had orders that included but were not limited to, Lantus Solution 100 unit/ml (milliliter) Inject 14 unit subcutaneously at bedtime for diabetes, which was initiated by the physician on 7/19/18, and Lantus Solution 100 unit/ml Inject 16 unit subcutaneously in the morning for diabetes before breakfast, which was initiated by the physician on 7/19/18. On 5/29/19 at 11:44 am, the surveyor reviewed the May 2019 medication administration record for Resident # 34. The surveyor observed that the facility staff documented that Resident # 34 refused Lantus 100 unit/ml 16 unit subcutaneous for the 6:30 am dose, and the physician was not notified on the following dates: 5/1/19 5/2/19 5/3/19 5/5/19 5/6/19 5/7/19 5/8/19 5/9/19 5/10/19 5/11/19 5/12/19 5/13/19 5/16/19 5/17/19 5/19/19 5/20/19 5/21/19 5/22/19 5/23/19 5/24/19 5/25/19 5/26/19 5/27/19 5/29/19 The surveyor observed that Lantus 100 unit/ml Inject 14 unit subcutaneously at bedtime for the 8:00 pm was refused by Resident # 34 and the physician was not notified on the following dates: 5/2/19 5/6/19 5/9/19 5/12/19 5/15/19 5/16/19 5/17/19 5/19/19 5/21/19 5/28/19 The facility Change in Resident Condition policy contained documentation that included but was not limited to; . 5. The Resident/Physician/Family/Responsible Party will be notified when there has been: f. Refusal of treatment or medications for on 3 consecutive times. On 5/31/19 at 6:30 pm, the administrative team was made aware of the findings as stated above and agreed that the physician had not been made aware of Resident # 34's refusals of Lantus. No further information regarding this issue was presented to the survey team prior to the exit conference on 5/31/19. 5(a). The facility staff failed to notify the physician of insulin refusals for Resident # 31. Resident # 31 was a [AGE] year-old-female who was originally admitted to the facility on [DATE], with a readmission date of 1/21/19. Diagnoses included but were not limited to; type 2 diabetes mellitus, hypertension, anemia, and heart failure. The clinical record for Resident # 31 was reviewed 5/30/19 at 3:38 pm. The most recent MDS (minimum data set) assessment for Resident # 31 was an annual assessment with an ARD (assessment reference date) of 5/5/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 31 had a BIMS (brief interview for mental status) score of 13 out of 15, which indicated that Resident # 31 was cognitively intact. The current plan of care for Resident # 31 was reviewed and revised on 5/10/19. The facility staff documented a focus area for Resident # 31 as, At risk for skin breakdown related to: decreased mobility, weakness, edema, diagnosis of DM (diabetes mellitus), O2 (oxygen) tubing prn (as needed). Interventions included but were not limited to, Notify MD (medical doctor) prn with any changes. The surveyor did not observe any documentation of insulin refusals on the care plan for Resident # 31. Resident # 31 had orders that included but were not limited to, Lantus SoloStar Solution Pen-injector 100 unit/ml (milliliter) Inject 35 unit subcutaneously at bedtime for diabetes, which was initiated by the physician on 3/9/19. The surveyor reviewed the clinical record for Resident # 31 and observed that the facility staff had documented that Resident # 31 had refused Lantus 35 units at 8:00 pm, and the physician had not been notified. The dates identified were: 5/5/19 5/11/19 5/14/19 5/15/19 5/17/19 5/18/19 5/20/19 5/21/19 5/22/19 5/24/19 5/25/19 5/26/19 5/29/19 The facility Change in Resident Condition policy contained documentation that included but was not limited to; . 5. The Resident/Physician/Family/Responsible Party will be notified when there has been: f. Refusal of treatment or medications for on 3 consecutive times. On 5/31/19 at 6:30 pm, the administrative team was made aware of the findings as stated above, and agreed that the physician was not notified that Resident # 31 had refused Lantus on the dates and times listed above. No further information regarding this issue was presented to the survey team prior to the exit conference on 5/31/19. 5(b). The facility staff failed to obtain a urinalysis within a timely manner for Resident # 31. On 5/30/19 at 3:21 pm, the surveyor observed a nursing note in Resident # 31's clinical record dated 5/24/19 at 10:47 pm. The nursing note was documented as, Seen by (Physician's name withheld) today orders given to start loratadine 10 mg (milligram) by mouth daily and collect UA/C&S (urine analysis with culture and sensitivity). The surveyor observed that the urinalysis was to be obtained on the next available void. Upon review of the lab results, the surveyor observed that the urinalysis was not obtained until 5/27/19. The surveyor asked the regional nurse consultant if she could look into why the urinalysis was not obtained until 3 days later when it was to be obtained on the next available void. On 5/31/19 at 6:30 pm, the administrative team was made aware of the findings as stated above, and agreed that the facility staff did not obtain the physician ordered urinalysis for Resident # 31 within a timely manner. No further information regarding this issue was presented to the survey team prior to the exit conference on 5/31/19.Based on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to ensure the highest practicable well-being for 7 of 22 Residents, Resident #43, #31, #19, #34, #4, #40, and #22. The findings included: 1. For Resident #43, the facility staff failed to administer the Residents medication per the physician's orders. The medication renvela was not administered with meals or any food item. The clinical record review revealed that Resident #43 had been admitted to the facility 09/29/16 and was readmitted [DATE]. Diagnoses included, but were not limited to, hypertension, end stage renal disease, gout, gastro-esophageal reflux disease, cognitive communication deficit, and metabolic encephalopathy. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 05/15/19 included a BIMS (brief interview for mental status) summary score of 12 out of a possible 15 points. The Residents clinical record included a physicians order for renvela 800 mg give by mouth with meals. On 05/29/19 beginning at approximately 11:10 a.m., the surveyor observed LPN (licensed practical nurse) #2 prepare and administer Resident #43's renvela for administration. This medication was not administered with a meal or with any type of food. When interviewing LPN #2, LPN #2 stated the order pops up at 11:00 a.m. I think we are going to tweak the order. On 05/29/19 at 12:30 p.m., the DON (director of nursing) and corporate nurse were made aware of the issues regarding the Residents medication. Per the website www.renvela.com this medication is known as a phosphate binder. It should be taken three times a day with meals to help control phosphorous levels in your body. No further information regarding this issue was shared with the surveyor. 6. The facility staff failed to follow the physician's orders for insulin administration that included holding of long acting insulin (Lantus) without a physician order, not following physician's orders to obtain accuchecks, and no notification to physician when Resident #40 refused both Humalog (short-acting insulin) and Lantus (long-acting insulin). The clinical record of Resident #40 was reviewed 5/29/19 through 5/31/19. Resident #40 was admitted to the facility 2/28/19 and readmitted [DATE] with diagnoses that included but not limited to symbolic dysfunction, insomnia, muscle weakness, hypertension, atherosclerotic heart disease, unspecified dementia with behavioral disturbances, cerebrovascular disease, anxiety disorder, major depressive disorder, hyperlipidemia, type 2 diabetes mellitus, and unspecified psychosis. Resident #40's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/15/19 assessed the resident with a BIMS (brief interview for mental status) as 3/15. Resident #40 was not interviewable. There was not a comprehensive care plan that addressed diabetes. The surveyor reviewed the April 2019 physician's orders and the May 2019 physician's orders. Resident #40 had insulin orders that read Humalog Inject 5 units subcutaneously one time a day for DM (diabetes mellitus)-start date 3/3/19 and Lantus (Insulin Glargine) Inject 25 units one time a day for DM II (diabetes mellitus type 2) start date-3/1/19. A review of the April 2019 electronic medication administration record (eMAR) revealed the following: In the entry for Lantus on 4/4/19 at 0600-There was an X in the box for the blood sugar at 0600 and the number 19 and initials ls. In the entry for Lantus on 4/6/19, there was an X in the box for blood sugar at 0600 and the number 12 and initials ls. In the entry for Lantus on 4/8/19, there was an X in the box for blood sugar at 0600 and the number 12 and initials ls. In the entry for Humalog on 4/6/19 at 0630, there was a 12 and the initials ls. In the entry for Humalog on 4/8/19 at 0630, there was a 12 and the initials lc. In the entry for Humalog on 4/9/19 at 0630, there was a 19 and the initials vhc. In the entry for Humalog on 4/12/19 at 0630, there was a 12 and the initials ls. In the entry for Humalog on 4/15/19 at 0630, there was a 16 and the initials vhc. Based on the chart codes/follow-up codes, 12=drug refused, 16=Hold/See Nurse Notes, 17=hospitalized , and 19=Other/See Nurse Notes. The 4/4/19 06:51 progress note read Lantus SoloStar Solution pen-injector 100 unit/ml (milliliter) Inject 25 unit subcutaneously one time a day for DM II rsd (resident) BS (blood sugar) 133 insulin not given. The surveyor was unable to locate a physician order to hold the insulin, physician notification that the insulin was held, or any physician orders with hold parameters. The 4/6/19 05:14 progress note read Lantus SoloStar Solution pen-injector 100 unit/ml (milliliter) Inject 25 unit subcutaneously one time a day for DM II rsd (resident) BS (blood sugar) 133 insulin not given. The surveyor was unable to locate a physician order to hold the insulin, physician notification that the insulin was held, or any physician orders with hold parameters. The 4/6/19 05:35 progress note read, Humalog KwikPen Solution Pen-injector 100 unit/ml Inject 5 units subcutaneously one time a day for DM rsd refused admin. (administration) of insulin. The surveyor was unable to physician notification that the insulin was refused by the resident. There was not a progress note for 4/8/19 as to the reason Humalog and Lantus were not administered at 0630. The 4/9/19 05:35 progress note read, Humalog KwikPen Solution Pen-injector 100 unit/ml Inject 5 units subcutaneously one time a day for DM held, long acting insulin given. Unable to determine resident appetite at this time. Resting quietly with eyes closed, refused snack at this time. The surveyor was unable to locate a physician order to hold the Humalog insulin and physician notification that the insulin was not administered by the nurse. There was not a progress note for 4/12/19 as to the reason Humalog was not administered at 0630. The chart code for Lantus not administered on 4/12/19 at 0600 was refusal by the resident per the chart codes. However, there was no documentation that the physician had been made aware of the insulin refusal. The 4/15/19 05:59 progress note read, Humalog KwikPen Solution Pen-injector 100 unit/ml Inject 5 units subcutaneously one time a day for DM blood sugar 126, fast acting insulin held. The surveyor was unable to locate a physician order to hold the Humalog insulin and physician notification that the insulin was not administered by the nurse. The May 2019 physician's orders read Lantus Inject 10 unit subcutaneously one time a day for Diabetes-start date 5/6/19. The entry for Lantus on 5/9/19 at 0600 read 3 and initials l1s. The entry for Lantus on 5/10/19 at 0600 read 12 and initials l1s. The chart codes for 3=No insulin required and 12=drug refused. The surveyor was unable to locate a blood sugar result for 5/9/19 at 0600. The progress note dated 5/10/19 at 06:53 read Lantus SoloStar Solution Pen-injector 100 unit/ml Inject 10 unit subcutaneously one time a day for DM II rsd refused insulin d/t (due to) BS (blood sugar) 113. However, there was no documentation that the physician had been made aware of the insulin refusal. The May 2019 physician's orders, in addition, included orders for Novolog Flex Pen subcutaneously before meals and at bedtime for DM II. Inject as per sliding scale: If 151-200=2 units 201-250=4 units 251-300=6 units 301-350=8 units 351-400=10 units If BS > (greater than) 400, call MD (medical doctor). Start dated 5/11/19. On 5/17/19 at 0600, there was no recorded blood sugar. The box read 7 and initials of C1M. The chart codes for 7=vitals outside of parameters. The progress noted dated 5/17/19 at 05:47 did not have a documented blood sugar result. The 5/18/19 2000 (8:00 p.m.) blood sugar was 404. The box had 19 and the initials HC. The chart code for 19=Other/See Nurse Note. The 5/18/19 at 19:29 (7:29 p.m.) did not have documentation the physician was notified of the 404 blood sugar. On 5/20/19 at 2000, there was no recorded blood sugar. The box read X and initials of JCM. There was not a progress note dated 5/20/19 for blood sugars. The 5/25/19 4:00 p.m. (1600) blood sugar was 443 and the chart code 19. 19=Other/See Nurse Notes. The 5/25/19 8:00 p.m. blood sugar was 419 and the chart code 19. The chart code for 19=Other/See Nurse Notes. The surveyor reviewed the 5/25/19 nurses notes and found no documentation that the physician was informed of the blood sugar greater than 400. The 5/26/19 4:00 p.m. (1600) blood sugar was 427 and the chart code 19. 19=Other/See Nurse Notes. The 5/26/19 8:00 p.m. blood sugar was 433 and the chart code 19. The chart code for 19=Other/See Nurse Notes. The surveyor reviewed the 5/26/19 nurses notes and found no documentation that the physician was informed of the blood sugar greater than 400. The surveyor informed the director of nursing of the above concern on 5/31/19 at 11:24 a.m. and requested the facility policy on diabetes management and physician notification. The surveyor reviewed the facility policy titled Caring for the Diabetic Date Revised October 15, 2015 on 5/31/19. The policy read in part PROCEDURE: g) The physician will authorize pertinent periodic evaluations such as ophthalmology and nephrology, as indicated. The physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. i. The staff will incorporate such parameters into the Medication Administration Record and care plan. The surveyor reviewed the facility policy titled Change in Resident Condition Date Revised: July 2015. The policy read in part 5. The Resident/Physician/Family/Responsible Party will be notified when there has been: e. A need to alter the resident's medical treatment. The surveyor informed the administrator, the director of nursing, and the corporate registered nurse of the above issue on 5/31/19 at 6:20 p.m. No further information was provided prior to the exit conference on 5/31/19. 7. The facility staff failed to follow the physician's orders for medication administration for Resident #22. The facility staff failed to administer Humalog and Lantus as ordered by the physician and failed to notify the physician of insulin refusals. The clinical record of Resident #22 was reviewed 5/28/19 through 5/31/19. Resident #22 was admitted to the facility 4/26/11 and readmitted [DATE] with diagnoses that included but not limited to type 2 diabetes mellitus, end-stage renal disease, morbid obesity, post-menopausal bleeding, hypertension, hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, contracted elbow, contracted left hand, and chronic pain. Resident #22's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 4/13/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #22's current comprehensive care plan date initiated 8/18/2015 and revised 5/14/19 identified non-compliance with medication/insulin. Interventions: Notify MD (medical doctor) of non-compliance per routine and prn (whenever necessary). The May 2019 physician's orders were reviewed. Resident #22 had orders for Humalog (Insulin Lispro) Inject 12 units subcutaneously three times a day for DM (diabetes mellitus) and Lantus (insulin Glargine) Inject 62 units subcutaneously at bedtime for DM. The surveyor reviewed the May 2019 electronic medication administration records (eMARs). The entry that read Humalog (insulin Lispro) Inject 12 unit subcutaneously three times a day for DM revealed Resident #22 was not administered Humalog on the following days/times: 5/2/19 at 0600 (chart code 12), 1100 (chart code=14), and 1700 (5:00 p.m.)(chart code=3). Chart codes: 3=No insulin required 12=Drug refused 14=Absent from home 15-Away from home with meds A review of the 5/2/19 progress notes did not have documentation as to why the medication was not administered or the physician had been informed of the insulin refusal. 5/3/19 at 0600=12 marked 5/3/19 at 1100=12 marked 5/4/19 at 0600=12 marked 5/4/19 at 1100=13 marked 5/7/19 at 0600=12 marked 5/7/19 at 1100=14 marked 5/8/19 at 0600=12 marked 5/8/19 at 1100=15 marked 5/9/19 at 0600=12 marked 5/9/19 at 1100=13 marked 5/9/19 at 1700=3 marked 5/10/19 at 0600=12 marked 5/10/19 at 1100=12 marked 5/11/19 at 1100=14 marked 5/11/19 at 1700=12 marked 5/12/19 at 0600=12 marked 5/14/19 at 0600=12 marked 5/14/19 at 1100=13 marked 5/14/19 at 1700=12 marked 5/15/19 at 0600 and 1100=12 marked 5/16/19 at 0600=12 marked 5/16/19 at 1100=13 marked 5/16/19 at 1700=12 marked 5/17/19 at 0600=3 marked 5/18/19 at 0600=12 marked 5/19/19 at 0600=12 marked 5/20/19 at 0600=12 marked 5/20/19 at 1100=14 marked 5/21/19 at 0600-12 marked 5/22/19 at 0600=12 marked 5/22/19 at 1700=14 marked 5/23/19 at 0600=12 marked 5/23/19 at 1100=13 marked 5/24/19 at 0600=12 marked 5/25/19 at 0600 and 1700=12 marked 5/25/19 at 1100=14 marked 5/26/19 at 0600=12 marked 5/27/19 at 0600 and 1100=12 marked 5/28/19 at 0600 and 1700=12 marked 5/28/19 at 1100=13 marked 5/29/19 at 0600=12 marked 5/30/19 at 0600=12 marked 5/30/19 at 1100=14 marked 5/31/19 at 1100=12 marked The entry for Lantus Inject 62 unit subcutaneously at bedtime for DM-start date 4/27/19 was reviewed. The entry for 5/22/19 at 2000 (8:00p.m.) was marked with 12 (drug refused). The May 2019 progress notes were reviewed. Only two progress notes (one dated 5/19/19 at 0604 and a second one dated 5/20/19 at 0559) had documentation why the resident refused the insulin. However, there was no documentation the physician was notified of Resident #22's insulin refusals and the physician orders for insulin not followed. The surveyor informed the MDS/RN (registered nurse) of the above concern on 5/31/19 at 4:42 p.m. and requested the facility policy on diabetes management and physician notification. The surveyor reviewed the facility policy titled Caring for the Diabetic Date Revised October 15, 2015 on 5/31/19. The policy read in part PROCEDURE: g) The physician will authorize pertinent periodic evaluations such as ophthalmology and nephrology, as indicated. The physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. i. The staff will incorporate such parameters into the Medication administration Record and care plan. The surveyor reviewed the facility policy titled Change in Resident Condition Date Revised: July 2015. The policy read in part 5. The Resident/Physician/Family/Responsible Party will be notified when there has been: e. A need to alter the resident's medical treatment. The surveyor informed the administrator, the director of nursing, and the corporate registered nurse of the above issue on 5/31/19 at 6:20 p.m. No further information was provided prior to the exit conference on 5/31/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4(a). The facility staff failed to document appropriate rationale for prn (as needed) Lorazepam for Resident # 19 that exceeded 14 days. 4(b). The facility staff failed to implement non-pharmacological interventions prior to the use of prn Lorazepam for Resident # 19. Resident # 19 was an [AGE] year-old-male who was originally admitted to the facility on [DATE], with a readmission date of 5/29/19. Diagnoses included but were not limited to; type 2 diabetes mellitus, hypertension, cognitive communication deficit, and peripheral vascular disease. The clinical record for Resident # 19 was reviewed on 5/29/19 at 11:51 am. The most recent MDS (minimum data set) assessment for Resident # 19 was a quarterly assessment with an ARD (assessment reference date) of 4/4/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 19 had a BIMS (brief interview for mental status) score of 5 out of 15, which indicated that Resident # 19's cognitive status was severely impaired. The current plan of care for Resident # 19 was reviewed and revised on 3/21/19. The facility staff documented a focus area for Resident # 19 as, Resident has a psychosocial well being issue (potential) r/t (related to) recent health issues/additional amputation of right stump AEB (as evidenced by) loss of independence. Interventions included but were not limited to; Administer meds as ordered by physician, monitor for effectiveness. Report adverse reactions/ineffectiveness to physician for further f/u (follow up), and Encourage activity distraction. Resident # 19 had orders for Lorazepam tablet 1 mg (milligram) Give 1 tablet by mouth as needed for agitation two times daily, which was initiated by the physician on 5/11/19. On 5/29/19 at 12:02 pm, the surveyor reviewed the May 2019 medication administration record for Resident # 19. The surveyor observed that Resident # 19 had a prn order for Lorazepam that had been active for 18 days. The surveyor reviewed the clinical record and did not observe any documentation from the physician to provide a rationale that warranted the use of prn Lorazepam for longer than 14 days. The surveyor also did not observe any documentation of non-pharmacological interventions attempted prior to the administration of prn Lorazepam for Resident # 19. The facility policy for Psychotropic Medication Documentation and Review contained documentation that included but was not limited to, . Policy: All residents receiving psychotropic medication will have their behaviors, effectiveness of interventions (pharmacological and non-pharmacological) and potential for gradual dose reduction of psychotropic medication monitored and documented. On 5/31/19 at 6:30 pm, the administrative team was made aware of the findings as stated above, and agreed that there was no documentation to support the use of prn Lorazepam for more than 14 days for Resident # 19. The administrative team also agreed that there were no non-pharmacological interventions documented prior to the use of prn Lorazepam for Resident # 19. No further information regarding this issue was provided to the survey team prior to the exit conference on 5/31/19. 5. The facility staff failed to monitor side effects and effectiveness associated with the use of Ambien and Sertraline for Resident # 53. Resident # 53 was a 67-yer-old-male who was originally admitted to the facility on [DATE], with a readmission date of 11/27/15. Diagnoses included but were not limited to; major depressive disorder, anxiety, insomnia, and type 2 diabetes mellitus. The clinical record for Resident # 53 was reviewed on 5/31/19 at 9:35 am. The most recent MDS (minimum data set) assessment for Resident # 53 was a quarterly assessment with an ARD (assessment reference date) of 5/23/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 53 had a BIMS (brief interview for mental status) score of 15 out of 15, which indicated that Resident # 53 was cognitively intact. Section N of the MDS assesses medications. In Section N0410, the facility staff documented that Resident # 53 had hypnotic and antidepressant medications for 7 days during the look back period for the 5/23/19 ARD. The current plan of care for Resident # 53 was reviewed and revised on 5/22/19. The facility staff documented a focus area for Resident # 53 as, At risk for adverse effects r/t (related to) psychoactive medication use, dx (diagnosis) of depression, insomnia, anxiety. Interventions included but were not limited to, Monitor for med side effects: sedation hypotension, EPS (extrapyramidal symptoms), anticholinergic sx (symptoms) H/A (headache) insomnia, anorexia, constipation, and Monitor medications for effectiveness. Resident # 53 had orders that included but were not limited to; Ambien tablet 10 mg (milligram) Give 1 tablet by mouth at bedtime related to insomnia, and Sertraline HCI tablet 50 mg Give 1 tablet by mouth one time a day for depression. On 5/31/19 at 9:43 am, the surveyor observed the May 2019 medication administration record for Resident # 53. The surveyor did not observe any documentation for monitoring of side effects and effectiveness associated with the use of Ambien and Sertraline for Resident # 53. The surveyor interviewed the director of nursing and asked if she could provide documentation of monitoring of side effects and effectiveness associated with the use of Ambien and Sertraline for Resident # 53. The director of nursing informed the surveyor that the facility had not been documenting side effects and effectiveness on antidepressants and hypnotics and that the facility had been focused on monitoring the antipsychotic medications. The facility policy for Psychotropic Medication Documentation and Review contained documentation that included but was not limited to, . Policy: All residents receiving psychotropic medication will have their behaviors, effectiveness of interventions (pharmacological and non-pharmacological) and potential for gradual dose reduction of psychotropic medication monitored and documented. On 5/31/19 at 6:30 pm, the administrative team was made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 5/31/19. 6. The facility staff failed to monitor for side effects and effectiveness and failed to identify and monitor behaviors associated with the use of Remeron for Resident # 7. Resident # 7 was an [AGE] year-old-female who was originally admitted to the facility on [DATE], with a readmission date of 11/5/17. Diagnoses included but were not limited to; major depressive disorder, anxiety, heart failure, and type 2 diabetes mellitus. The clinical record for Resident # 7 was reviewed on 5/30/19 at 11:00 am. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 3/10/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 7 had a BIMS (brief interview for mental status) score of 12 out of 15, which indicated that Resident # 7's cognitive status was moderately impaired. The current plan of care for Resident # 7 was reviewed and revised on 1/14/19. The facility staff documented a focus area for Resident # 7 as, At risk for adverse effects r/t (related to) psychoactive medication use: anxiety, depression, BSPD (behavioral and psychological symptoms of dementia), psychosis. Interventions included but were not limited to, Monitor of s/s (signs and symptoms) of depression, Monitor medications for effectiveness, and Monitor for med side effects: sedation, hypotension, EPS (extrapyramidal symptoms), anticholinergic sx (symptoms) H/A (headache), insomnia, anorexia, constipation. The surveyor did not observe and Resident specific documented behaviors of depression on the plan of care for Resident # 7. Resident # 7 had orders that included but were not limited to, Remeron tablet 30 mg (milligram) Give 1 tablet by mouth at bedtime for depression, which was initiated by the physician on 12/13/18. On 5/31/19 at 9:42 am, the surveyor reviewed the May 2019 medication administration record for Resident # 7. The surveyor did not observe behavior monitoring, or monitoring for side effects and effectiveness associated with the use of Remeron for Resident # 7. The facility policy for Psychotropic Medication Documentation and Review contained documentation that included but was not limited to, . Policy: All residents receiving psychotropic medication will have their behaviors, effectiveness of interventions (pharmacological and non-pharmacological) and potential for gradual dose reduction of psychotropic medication monitored and documented. Procedure: A. Residents receiving psychotropic medication will have a Behavior/Intervention Monthly Flow Record (BFR) (Form 4.11) initiated on admission or whenever psychotropic meds are ordered. b. Resident specific behaviors related to medication use will be entered on BFR. On 5/31/19 at 6:20 pm, the administrative team was made aware of the findings as stated above, and agreed that the facility failed to document Resident specific behaviors and monitor side effects and effectiveness associated with the use of Remeron for Resident # 7. No further information regarding this issue was presented to the survey team prior to the exit conference of 5/31/19. Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure 6 of 22 residents were free of an unnecessary psychotropic medication (Resident #6, Resident #40, Resident #154, Resident #19, Resident #53, and Resident # 7). The findings included: 1. The facility staff failed to identify and monitor resident specific target behaviors and identify non-pharmacological interventions for the administration of prn Ativan for Resident # 154. The clinical record of Resident #154 was reviewed 5/29/19 through 5/31/19. Resident #154 was admitted to the facility 5/22/19 with diagnoses that included but not limited to fracture of parts of lumbosacral spine and pelvis, muscle weakness, gait and mobility abnormalities, cognitive communication deficit, anxiety, major depressive disorder, age-related osteoporosis, rheumatoid arthritis, hypertension, Vitamin D deficiency, kyphosis, atherosclerotic heart disease, and chronic pain. Resident #154's admission minimum data set (MDS) had not been completed. Resident #154's current comprehensive care plan initiated 5/23/19 identified the resident was at risk for adverse effects r/t (related to) psychoactive medication use: Anxiety, Depression. Interventions: Encourage expressions of feelings, interaction with others, oor (out of room) activity, monitor for s/s (signs and symptoms) of anxiousness, monitor for s/s of depression, report changes in mood. Resident #154's May 2019 physician's orders read in part Ativan tablet 0.5 mg (milligrams) (Lorazepam) Give 1 tablet by mouth as needed for anxiety for 14 days. The orders for Paxil and Trazodone (both antidepressants had been discontinued 5/22/19. A review of the May 2019 electronic medication administration record revealed Resident #154 was administered Ativan 0.5 mg 10 times from 5/22/19 through 5/29/19. The surveyor found no non-pharmacological interventions prior to the use of Ativan or specific targeted behaviors identified for the use of the medication or behavior monitoring sheets for Ativan. The surveyor informed the director of nursing (DON) of the above concern on 5/30/19 at 9:54 a.m. The DON stated the nurses fill out the behavior sheets. The DON stated the resident was a readmission and probably already had a care plan that addressed the use of psychotropic medications. The surveyor informed the administrator, the director of nursing, the corporate registered nurse and the chief executive officer of the above concern in the end of the day meeting on 5/30/19 at 4:50 p.m. and requested the facility policy on the management of psychotropic medication, Resident #154's May 2019 physician orders, care plan, May 2019 medication administration record and May 2019 nurse's progress notes. The surveyor reviewed the facility policy titled Psychotropic Medication Documentation and Review revised November 2015. The policy read in part A. Residents receiving psychotropic medication will have a behavior/Intervention Monthly Flow Record (BFR) initiated on admission or whenever psychotropic meds are ordered. a. Each psychotropic medication will be entered on BFR. b. Resident specific behaviors related to medication use will be entered. c. Diagnosis for the reason psychotropic medication is being given will be documented in medical record. d. BFR record will be placed in front of the resident medication administration record (MAR). B. Nurse will document on the following every shift: a. Number of behavior episodes b. Specific non-medication interventions used-entered code as indicated on BFR. c. Outcome of interventions-use code key listed on BFR i. Behavior interventions-individualized non-pharmacological approaches (including direct care and activities) that are provided as part of a supportive physical and psychological environment, and are directed toward preventing, relieving, and/or accommodating a resident's distressed behavior. d. Any side effects (observed) -use code key listed on BFR D. The resident's Plan of Care (POC) will be reviewed and updated with any changes in behavior and/or treatment. No further information was provided prior to the exit conference on 5/31/19. 2. The facility staff failed to identify and monitor resident specific target behaviors and identify non-pharmacological interventions for the administration of Ativan and Zoloft for Resident #6. The clinical record of Resident #6 was reviewed 5/29/19 through 5/31/19. Resident #6 was admitted to the facility 6/7/16 and readmitted [DATE] with diagnoses that included but not limited to metabolic encephalopathy, muscle weakness, dysphagia, hypertension, hypothyroidism, major depressive disorder, gastro-esophageal reflux disease, gastrostomy status, aphasia following cerebral infarction, and hemiplegia and hemiparesis following cerebral infarction. Resident #6's significant change in minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/8/19 assessed the resident with short term memory problems, long term memory problems, and severely impaired cognitive skills for daily decision making. Resident #6's current comprehensive care plan initiated 6/21/16 and revised 3/20/19 identified a focus area that the resident was at risk for adverse effects r/t (related to) psychoactive medications use: depression/anxiety. Interventions: Encourage interaction with others or activity, monitor for s/s (signs/symptoms) of anxiousness, monitor for s/s depression, monitor medications for effectiveness. Resident #6's May 2019 physician's orders read in part Ativan tablet 0.5 mg (milligrams) (Lorazepam) Give 1 tablet via G-tube at bedtime related to anxiety disorder and Zoloft tablet 25 mg (Sertraline HCL) give 12.5 mg via G-tube one time a day for depression. The surveyor was unable to locate specific behavior monitoring sheets for Ativan and Zoloft or identified targeted behaviors for the use of Ativan and Zoloft. The surveyor interviewed licensed practical nurse #2 on 5/30/19 at 3:07 p.m. about behavior monitoring for Resident #6. L.P.N. #2 stated the forms are usually kept in the notebook with the narcotic sheets. The narcotic book was checked and L.P.N. #2 was unable to locate any behavior monitoring sheets. The surveyor informed the administrator and the director of nursing of the above issue. The unit secretary reviewed Resident #6's closed record and stated the record did not have any behavior monitoring sheets for Ativan or Zoloft upon the resident's return from a hospital stay in April 2019. The surveyor informed the administrator, the director of nursing, the corporate registered nurse and the chief executive officer of the above concern in the end of the day meeting on 5/30/19 at 4:50 p.m. and again on 5/31/19 at 6:20 p.m. The surveyor requested the facility policy on the management of psychotropic medications. The surveyor reviewed the facility policy titled Psychotropic Medication Documentation and Review revised November 2015. The policy read in part A. Residents receiving psychotropic medication will have a behavior/Intervention Monthly Flow Record (BFR) initiated on admission or whenever psychotropic meds are ordered. a. Each psychotropic medication will be entered on BFR. b. Resident specific behaviors related to medication use will be entered. c. Diagnosis for the reason psychotropic medication is being given will be documented in medical record. d. BFR record will be placed in front of the resident medication administration record (MAR). B. Nurse will document on the following every shift: a. Number of behavior episodes b. Specific non-medication interventions used-entered code as indicated on BFR. c. Outcome of interventions-use code key listed on BFR i. Behavior interventions-individualized non-pharmacological approaches (including direct care and activities) that are provided as part of a supportive physical and psychological environment, and are directed toward preventing, relieving, and/or accommodating a resident's distressed behavior. d. Any side effects (observed) -use code key listed on BFR D. The resident's Plan of Care (POC) will be reviewed and updated with any changes in behavior and/or treatment. No further information was provided prior to the exit conference on 5/31/19. 3. The facility staff failed to identify and monitor resident specific target behaviors and identify non-pharmacological interventions for the administration of Restoril, Zyprexa and Seroquel for Resident #40. The clinical record of Resident #40 was reviewed 5/29/19 through 5/31/19. Resident #40 was admitted to the facility 2/28/19 and readmitted [DATE] with diagnoses that included but not limited to symbolic dysfunction, insomnia, muscle weakness, hypertension, atherosclerotic heart disease, unspecified dementia with behavioral disturbances, cerebrovascular disease, anxiety disorder, major depressive disorder, hyperlipidemia, type 2 diabetes mellitus, and unspecified psychosis. Resident #40's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/15/19 assessed the resident with a BIMS (brief interview for mental status) as 3/15. Resident #40 was not interviewable. The May 2019 physician's orders were reviewed and included orders that read Restoril 15 mg (milligrams) Give 1 capsule by mouth at bedtime for insomnia, Seroquel Tablet 25 mg Give 1 tablet at bedtime for BPSD (bipolar disorder) and Zyprexa 2.5 mg give 1 tablet by mouth one time a day for psychosis. Resident #40's current comprehensive care plan initiated 3/4/19 did not include a care plan for behaviors and the use of psychotropic medications. Resident #40 does have a care plan initiated 3/8/19 for a focus area of chronic/progressive decline in intellectual functioning characterized by deficit in memory, judgement, decision making and thought processes, per family and through interviews related to dx (diagnosis) of dementia/hx (history of) CVA (cerebrovascular accident) AEB (as evidenced by) inability to participate on BIMS/PHQ sections of MDS. Interventions: Break tasks/activities into manageable subtasks. The clinical record did reveal a behavior monitoring sheet for May 2019 for the use of Seroquel. The behavior sheet identified verbal and physical aggression but no identified interventions or outcomes. However, there were no behavior monitoring sheets for the use of Zyprexa or Restoril, identified target behaviors or a care plan developed and implemented for either Zyprexa or Restoril. The surveyor informed the administrator, director of nursing, the corporate registered nurse and the chief executive officer of the above concern on 5/30/19 at 4:50 p.m. and again on 5/31/19 at 6:20 p.m. The surveyor requested the facility policy on psychotropic medication management. The surveyor reviewed the facility policy titled Psychotropic Medication Documentation and Review revised November 2015. The policy read in part A. Residents receiving psychotropic medication will have a behavior/Intervention Monthly Flow Record (BFR) initiated on admission or whenever psychotropic meds are ordered. a. Each psychotropic medication will be entered on BFR. b. Resident specific behaviors related to medication use will be entered. c. Diagnosis for the reason psychotropic medication is being given will be documented in medical record. d. BFR record will be placed in front of the resident medication administration record (MAR). B. Nurse will document on the following every shift: a. Number of behavior episodes b. Specific non-medication interventions used-entered code as indicated on BFR. c. Outcome of interventions-use code key listed on BFR i. Behavior interventions-individualized non-pharmacological approaches (including direct care and activities) that are provided as part of a supportive physical and psychological environment, and are directed toward preventing, relieving, and/or accommodating a resident's distressed behavior. d. Any side effects (observed) -use code key listed on BFR D. The resident's Plan of Care (POC) will be reviewed and updated with any changes in behavior and/or treatment. No further information was provided prior to the exit conference on 5/31/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** [NAME] F tag 760 E Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure 2 of 22 residents were free of a significant drug error (Resident #40 and Resident #22). The findings included: 1. The facility staff failed to administer physician ordered insulin to Resident #40. The clinical record of Resident #40 was reviewed 5/29/19 through 5/31/19. Resident #40 was admitted to the facility 2/28/19 and readmitted [DATE] with diagnoses that included but not limited to symbolic dysfunction, insomnia, muscle weakness, hypertension, atherosclerotic heart disease, unspecified dementia with behavioral disturbances, cerebrovascular disease, anxiety disorder, major depressive disorder, hyperlipidemia, type 2 diabetes mellitus, and unspecified psychosis. Resident #40's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/15/19 assessed the resident with a BIMS (brief interview for mental status) as 3/15. Resident #40 was not interviewable. There was not a comprehensive care plan that addressed diabetes. The surveyor reviewed the April 2019 physician's orders and the May 2019 physician's orders. Resident #40 had insulin orders that read Humalog Inject 5 units subcutaneously one time a day for DM (diabetes mellitus)-start date 3/3/19 and Lantus (Insulin Glargine) Inject 25 units one time a day for DM II (diabetes mellitus type 2) start date-3/1/19. A review of the April 2019 electronic medication administration record (eMAR) revealed the following: In the entry for Lantus on 4/4/19 at 0600-There was an X in the box for the blood sugar at 0600 and the number 19 and initials ls. In the entry for Lantus on 4/6/19, there was an X in the box for blood sugar at 0600 and the number 12 and initials ls. In the entry for Lantus on 4/8/19, there was an X in the box for blood sugar at 0600 and the number 12 and initials ls. In the entry for Humalog on 4/6/19 at 0630, there was a 12 and the initials ls. In the entry for Humalog on 4/8/19 at 0630, there was a 12 and the initials lc. In the entry for Humalog on 4/9/19 at 0630, there was a 19 and the initials vhc. In the entry for Humalog on 4/12/19 at 0630, there was a 12 and the initials ls. In the entry for Humalog on 4/15/19 at 0630, there was a 16 and the initials vhc. Based on the chart codes/follow-up codes, 12=drug refused, 16=Hold/See Nurse Notes, 17=hospitalized , and 19=Other/See Nurse Notes. The 4/4/19 06:51 progress note read Lantus SoloStar Solution pen-injector 100 unit/ml (milliliter) Inject 25 unit subcutaneously one time a day for DM II rsd (resident) BS (blood sugar) 133 insulin not given. The surveyor was unable to locate a physician order to hold the insulin, physician notification that the insulin was held, or any physician orders with hold parameters. The 4/6/19 05:14 progress note read Lantus SoloStar Solution pen-injector 100 unit/ml (milliliter) Inject 25 unit subcutaneously one time a day for DM II rsd (resident) BS (blood sugar) 133 insulin not given. The surveyor was unable to locate a physician order to hold the insulin, physician notification that the insulin was held, or any physician orders with hold parameters. The 4/6/19 05:35 progress note read, Humalog KwikPen Solution Pen-injector 100 unit/ml Inject 5 units subcutaneously one time a day for DM rsd refused admin. (administration) of insulin. The surveyor was unable to physician notification that the insulin was refused by the resident. There was not a progress note for 4/8/19 as to the reason Humalog and Lantus were not administered at 0630. The 4/9/19 05:35 progress note read, Humalog KwikPen Solution Pen-injector 100 unit/ml Inject 5 units subcutaneously one time a day for DM held, long acting insulin given. Unable to determine resident appetite at this time. Resting quietly with eyes closed, refused snack at this time. The surveyor was unable to locate a physician order to hold the Humalog insulin and physician notification that the insulin was not administered by the nurse. There was not a progress note for 4/12/19 as to the reason Humalog was not administered at 0630. The chart code for Lantus not administered on 4/12/19 at 0600 was refusal by the resident per the chart codes. However, there was no documentation that the physician had been made aware of the insulin refusal. The 4/15/19 05:59 progress note read, Humalog KwikPen Solution Pen-injector 100 unit/ml Inject 5 units subcutaneously one time a day for DM blood sugar 126, fast acting insulin held. The surveyor was unable to locate a physician order to hold the Humalog insulin and physician notification that the nurse did not administer the insulin. The May 2019 physician's orders read, Lantus Inject 10 unit subcutaneously one time a day for Diabetes-start date 5/6/19. The entry for Lantus on 5/9/19 at 0600 read 3 and initials l1s. The entry for Lantus on 5/10/19 at 0600 read 12 and initials l1s. The chart codes for 3=No insulin required and 12=drug refused. The progress note dated 5/10/19 at 06:53 read Lantus SoloStar Solution Pen-injector 100 unit/ml Inject 10 unit subcutaneously one time a day for DM II rsd refused insulin d/t (due to) BS (blood sugar) 113. However, there was no documentation that the physician had been made aware of the insulin refusal. The surveyor informed the director of nursing of the above concern on 5/31/19 at 11:24 a.m. and requested the facility policy on diabetes management and physician notification. The surveyor reviewed the facility policy titled Caring for the Diabetic Date Revised October 15, 2015 on 5/31/19. The policy read in part PROCEDURE: g) The physician will authorize pertinent periodic evaluations such as ophthalmology and nephrology, as indicated. The physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. i. The staff will incorporate such parameters into the Medication Administration Record and care plan. The surveyor reviewed the facility policy titled Change in Resident Condition Date Revised: July 2015. The policy read in part 5. The Resident/Physician/Family/Responsible Party will be notified when there has been: e. A need to alter the resident's medical treatment. The surveyor informed the administrator, the director of nursing, and the corporate registered nurse of the above issue on 5/31/19 at 6:20 p.m. No further information was provided prior to the exit conference on 5/31/19. 2. The facility staff failed to follow the physician's orders for insulin administration for Resident #22. The facility staff failed to administer Humalog and Lantus as ordered by the physician and failed to notify the physician of insulin refusals. The clinical record of Resident #22 was reviewed 5/28/19 through 5/31/19. Resident #22 was admitted to the facility 4/26/11 and readmitted [DATE] with diagnoses that included but not limited to type 2 diabetes mellitus, end-stage renal disease, morbid obesity, post-menopausal bleeding, hypertension, hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, contracted elbow, contracted left hand, and chronic pain. Resident #22's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 4/13/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #22's current comprehensive care plan date initiated 8/18/2015 and revised 5/14/19 identified non-compliance with medication/insulin. Interventions: Notify MD (medical doctor) of non-compliance per routine and prn (whenever necessary). The May 2019 physician's orders were reviewed. Resident #22 had orders for Humalog (Insulin Lispro) Inject 12 units subcutaneously three times a day for DM (diabetes mellitus) and Lantus (insulin Glargine) Inject 62 units subcutaneously at bedtime for DM. The surveyor reviewed the May 2019 electronic medication administration records (eMARs). The entry that read Humalog (insulin Lispro) Inject 12 unit subcutaneously three times a day for DM revealed Resident #22 was not administered Humalog on the following days/times: 5/2/19 at 0600 (chart code 12), 1100 (chart code=14), and 1700 (5:00 p.m.)(chart code=3). Chart codes: 3=No insulin required 12=Drug refused 14=Absent from home 15-Away from home with meds A review of the 5/2/19 progress notes did not have documentation as to why the medication was not administered or the physician had been informed of the insulin refusal. 5/3/19 at 0600=12 marked 5/3/19 at 1100=12 marked 5/4/19 at 0600=12 marked 5/4/19 at 1100=13 marked 5/7/19 at 0600=12 marked 5/7/19 at 1100=14 marked 5/8/19 at 0600=12 marked 5/8/19 at 1100=15 marked 5/9/19 at 0600=12 marked 5/9/19 at 1100=13 marked 5/9/19 at 1700=3 marked 5/10/19 at 0600=12 marked 5/10/19 at 1100=12 marked 5/11/19 at 1100=14 marked 5/11/19 at 1700=12 marked 5/12/19 at 0600=12 marked 5/14/19 at 0600=12 marked 5/14/19 at 1100=13 marked 5/14/19 at 1700=12 marked 5/15/19 at 0600 and 1100=12 marked 5/16/19 at 0600=12 marked 5/16/19 at 1100=13 marked 5/16/19 at 1700=12 marked 5/17/19 at 0600=3 marked 5/18/19 at 0600=12 marked 5/19/19 at 0600=12 marked 5/20/19 at 0600=12 marked 5/20/19 at 1100=14 marked 5/21/19 at 0600-12 marked 5/22/19 at 0600=12 marked 5/22/19 at 1700=14 marked 5/23/19 at 0600=12 marked 5/23/19 at 1100=13 marked 5/24/19 at 0600=12 marked 5/25/19 at 0600 and 1700=12 marked 5/25/19 at 1100=14 marked 5/26/19 at 0600=12 marked 5/27/19 at 0600 and 1100=12 marked 5/28/19 at 0600 and 1700=12 marked 5/28/19 at 1100=13 marked 5/29/19 at 0600=12 marked 5/30/19 at 0600=12 marked 5/30/19 at 1100=14 marked 5/31/19 at 1100=12 marked The entry for Lantus Inject 62 unit subcutaneously at bedtime for DM-start date 4/27/19 was reviewed. The entry for 5/22/19 at 2000 (8:00p.m.) was marked with 12 (drug refused). The May 2019 progress notes were reviewed. Only two progress notes (one dated 5/19/19 at 0604 and a second one dated 5/20/19 at 0559) had documentation why the resident refused the insulin. However, there was no documentation the physician was notified of Resident #22's insulin refusals and the physician orders for insulin not followed. The surveyor informed the MDS/RN (registered nurse) of the above concern on 5/31/19 at 4:42 p.m. and requested the facility policy on diabetes management and physician notification. The surveyor reviewed the facility policy titled Caring for the Diabetic Date Revised October 15, 2015 on 5/31/19. The policy read in part PROCEDURE: g) The physician will authorize pertinent periodic evaluations such as ophthalmology and nephrology, as indicated. The physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. i. The staff will incorporate such parameters into the Medication administration Record and care plan. The surveyor reviewed the facility policy titled Change in Resident Condition Date Revised: July 2015. The policy read in part 5. The Resident/Physician/Family/Responsible Party will be notified when there has been: e. A need to alter the resident's medical treatment. The surveyor informed the administrator, the director of nursing, and the corporate registered nurse of the above issue on 5/31/19 at 6:20 p.m. No further information was provided prior to the exit conference on 5/31/19.