Based on observation, staff interview, and facility document review, the facility staff failed to keep a controlled medication in a separately locked, permanently affixed compartment on 1 of 3 units, Unit 2. The findings included: The facility staff failed to secure the medication, Gabapentin (a schedule V controlled substance under Virginia state law used to treat seizures and nerve pain) in a separately locked, permanently affixed compartment in the medication cart. On 6/24/21 at 11:40 am, the surveyor accompanied by LPN (licensed practical nurse) #2, observed two separate bubble pack cards of Gabapentin in an open area of the medication cart drawer beside the separately locked, permanently affixed, metal compartment containing controlled medications. One bubble pack card was labeled Gabapentin 300 mg and contained 13 capsules and had the Controlled Substance Sheet folded around the card, the sheet indicated there were 13 capsules remaining. The second bubble pack card was labeled Gabapentin 300 mg and contained 21 capsules and also had a Controlled Substance Sheet folded around the card, the sheet indicated there were 21 capsules remaining. LPN #2 stated the resident went home yesterday and the unit manager comes around and picks up the medications. At 11:55 am, LPN #2 stated I just pulled them this morning to prevent an error. The director of nursing was also present and stated they have called the pharmacy to bring a new cart with a single locking door with two compartments for the narcotics drawer. Surveyor requested and received the facility policy entitled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles which states in part: Procedure 3. General Storage Procedures: 3.1 Facility should store Schedule II - V Controlled Substances, in a separate compartment within the locked medication carts and should have a different key or access device, i.e. 3.1.1 Store all drugs and biologicals in locked compartments, including the storage of Schedule II - V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access On 6/24/21 at 4:00 pm during a meeting with the facility administrative team, surveyor discussed the concern of the facility staff not properly storing the medication Gabapentin in the Unit 2 medication cart. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/24/21.

2. For Resident #58, the facility staff failed to perform hand hygiene while performing treatments to multiple pressure areas. Resident #58's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus without Complications, Essential Primary Hypertension, Presence of Left Artificial Knee Joint, Aftercare following Joint Replacement Surgery, and Pain Unspecified. The most recent significant change MDS (minimum data set) with an ARD (assessment reference date) of 6/07/21 assigned the resident a BIMS (brief interview for mental status) score of 13 out of 15 in section C, Cognitive Patterns. In section M, Skin Conditions, Resident #58 was coded for the presence of two (2) unstageable pressure ulcers with slough and/or eschar and five (5) unstageable pressure areas presenting as deep tissue injury. Resident #58's active physician's orders included the following current orders for the treatment of pressure ulcers: 1. Apply sure prep to right heel and right 5th metatarsal and cover with bordered gauze every day shift 2. Apply sure prep to left heel, left lateral malleolus, and left mid foot, cover with bordered gauze every day shift 3. Cleanse wound to left lower extremity lateral aspect with normal saline, apply santyl to wound bed, cover with bordered gauze every day shift 4. Cleanse wound to right buttock with wound cleanser, apply santyl and calcium AG to wound bed and cover with bordered gauze, change every day and as needed On 6/23/21 at 4:58 pm, surveyor entered Resident #58's room to observe wound treatments. LPN (licensed practical nurse) #1 had already prepared the over bed table with dressings, treatment solutions had been poured into clear medication cups and ointment was also placed in a clear medication cup. Surveyor was unable to verify the solutions in each medication cup. LPN #1, with the assistance of RN (registered nurse) #1 turned the resident on their left side and discovered the resident had recently had a bowel movement. With gloved hands, LPN #1 cleaned the bowel movement from the resident's skin and placed a new pad under the resident and immediately proceeded to treatment the pressure area to the right buttock and apply the clean dressing without removing gloves and performing hand hygiene. LPN #1 removed gloves but did not wash hands or use hand sanitizer and obtained two clean gloves and carried them out of the resident's room. LPN #1 returned to the room with two gloves and a wash cloth in their hands. LPN #1 donned the gloves and cleaned the pressure areas to the resident's right lateral foot, left heel, left mid foot, and applied the treatment to the left mid foot and left lateral malleolus without performing hand hygiene or changing gloves. There was a knock at the resident's door and LPN #1 touched the door handle and opened the door with the same gloved hands. With the same gloved hands, LPN #1 returned to the resident and applied a dressing to right heel. LPN #1 then removed gloves and left the room without performing hand hygiene. LPN #1 returned to the room and donned clean gloves and cleaned the area to the resident's left lower extremity and applied the treatment. With the same gloved hands, LPN #1 pulled an ink pen from their hair and dated a clean dressing and applied it to the left lower extremity. With the same gloved hands, LPN #1 applied a dressing to the right lateral foot. On 6/24/21 at 10:12 am, surveyor discussed treatment observations with the infection control nurse who stated the nurse should have done hand hygiene and changed gloves during the treatments. On 6/24/21 at 10:25 am, surveyor spoke with LPN #1 and asked about their hand hygiene during the treatment observation. LPN #1 immediately replied I didn't do it like I was supposed to. LPN #1 further stated that they should have washed their hands and changed gloves after cleaning the resident's bowel movement and between each wound, LPN #1 stated they did use hand sanitizer between one. On 6/24/21 at 4:00 pm during a meeting with the facility management staff, surveyor discussed the concerns of the lack of hand hygiene identified during the observation of treatment administrations performed by LPN #1. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/24/21. Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow established infection control procedures during wound care observations for 2 of 26 residents. Residents #74 and #58. The findings included: 06/24/2021 the (DON) director of nursing provided the survey team with a copy of a policy titled, Hand Hygiene/Handwashing Policy date of revision 01/31/2020. This policy read in part, Hand washing is the most important component for preventing the spread of infection. Use of gloves does not replace the need for hand cleaning by either hand rubbing or hand washing .Perform hand hygiene .Before and after having direct contact with residents .After removing gloves .After contact with body fluids or excretions, mucous membranes, non-intact skin and/or wound dressings .If moving from a contaminated body site to a clean body site during resident care . 1. For Resident #74, the facility staff failed to complete hand hygiene during a wound care observation. Resident #74 had three stage IV pressure ulcers and an excoriated area to their sacrum. Resident #74's facesheet in the (EHR) electronic health record included the diagnoses, adult failure to thrive, (MS) multiple sclerosis, nutritional deficiency, and major depressive disorder. Section C (cognitive patterns) of Resident #74's quarterly (MDS) minimum data set assessment with an (ARD) assessment reference date of 05/23/2021 included a (BIMS) brief interview for mental status summary score of 6 out of a possible 15 points. Section G (functional status) was coded (4/3) for bed mobility, transfers, locomotion of unit, dressing, and toilet use to indicate the resident required total assistance of two people for these tasks. Section M (skin conditions) was coded to indicate the resident was at risk for pressure ulcers and had three stage IV pressure ulcers. Resident #74's (CCP) comprehensive care plan included the focus areas at risk for infection related to history of recurrent infections pneumonia, urinary tract infections, sepsis, and wound. Total assistance for all activities of daily living, quadriplegia. Risk for skin breakdown related to decreased mobility, function and weakness diagnosis MS, skin is fragile, resistive to care such as turning and repositioning, pressure relief positioning and devices actual skin breakdown to right hip right buttocks, left hip, and sacrum. Resident #74's EHR included physician orders for contact isolation, dakins solution to left hip, right hip and right buttock topically every shift for wound care. 06/23/21 2:00 p.m., wound care observation with (LPN) licensed practical nurse #3 and the (IP) infection preventionist. These staff were observed to wear a protective mask, gown, and gloves due to Resident #74's contact isolation status. LPN #3 was observed to remove the old dressings from the excoriated area and two stage IV pressure ulcers. LPN #3 changed their gloves and then cleaned these three areas with (DWC) dermal wound cleanser, applied skin prep to the sacral area X2 and a protective dressing, opened kerlix, changed gloves, poured the dakins solution onto the kerlix, applied the dakins soaked kerlix to two stage IV pressure ulcers, applied a protective dressing to the left hip wound, and then changed their gloves. LPN #3 was unable to cover wound #2 with a protective dressing due to the residents position. LPN #3 and the IP repositioned Resident #74 to their left side, removed the dakins gauze from wound #2, placed new dakins soaked kerlix into the wound bed, and applied a protective dressing. LPN #3 changed their gloves, cleaned wound #3 with DWC, applied dakins soaked kerlix to the wound bed, and then applied a protective dressing. 06/24/21 10:09 a.m., interview with IP. This nurse stated LPN #3 washed their hands before starting the treatments and after completion of the treatments but did not complete any hand hygiene during wound care. The IP stated LPN #3 should have washed her hands during wound care and they had discussed it after the observation. 06/24/21 4:00 p.m., the administrator, DON, nurse consultant, assistant administrator, and regional vice president of operations were made aware that LPN #3 did not complete hand hygiene during a treatment observation of three stage IV wounds. No other information regarding this issue was provided to the survey team prior to the exit conference.

3. For Resident #58, the facility staff failed to follow physician's orders for the administration of Novolog (a rapid-acting insulin) on two separate occasions. Resident #58's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus without Complications, Essential Primary Hypertension, Presence of Left Artificial Knee Joint, Aftercare following Joint Replacement Surgery, and Pain Unspecified. The most recent significant change MDS (minimum data set) with an ARD (assessment reference date) of 6/07/21 assigned the resident a BIMS (brief interview for mental status) score of 13 out of 15 in section C, Cognitive Patterns. In section I, Active Diagnoses, Resident #58 was coded for the diagnosis of Diabetes Mellitus. Resident #58's active physician's orders included an order for Novolog FlexPen Solution Pen-Injector 100 UNIT/ML (Insulin Aspart) Inject 4 unit subcutaneously before meals related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9) **Hold for BG (blood glucose) less than 200**. A review of Resident #58's June 2021 MAR (medication administration record) revealed the resident received Novolog 4 units on 6/15/21 at 5:41 am in the right arm with a documented blood sugar of 104. On 6/16/21 at 5:46 am, the resident received Novolog 4 units in the right lower abdominal quadrant with a documented blood sugar of 117. On 6/24/21 at 4:00 pm during a meeting with the facility administrative team, surveyor discussed the concern of Resident #58 receiving Novolog on 6/15/21 and 6/16/21 with documented blood sugars below 200. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/24/21. 4. For Resident #2 the facility staff administered insulin outside the physician ordered parameters. Resident #2's face sheet listed diagnoses which included, but not limited to type 2 diabetes mellitus, acute respiratory failure, dysphagia, end stage renal disease, and anxiety. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 06/17/21 assigned the resident a BIMS (brief interview for mental status) of 14 of 15 in section C, cognitive patterns. This indicated the resident is cognitively intact. Resident #2's comprehensive care plan was reviewed and contained a care plan for Resident is at risk for hypo/hyperglycemia episodes R/T (related to): dx (diagnosis) IDDM (insulin dependent diabetes mellitus); hypoglycemia with recent ER visit. Interventions for this care plan included medication as ordered; hold as needed per ordered parameters. Resident #2's clinical record was reviewed and contained a physician's order summary for the month of June 2021, which read in part Humalog Solution (Insulin Lispro). Inject 10 unit subcutaneously before meals for DM (diabetes mellitus). Hold if <180 (less than). Resident #2's eMARs (electronic medication administration record) for the month of June was reviewed and contained an entry as above. The entry for 06/01/21 at 11:30 am recorded the resident's blood glucose level as 163 and was initialed as insulin given. The notes section of the eMAR indicated the resident had been administered insulin subcutaneously in the right lower abdomen. The concern of administering insulin outside physician ordered parameters was discussed with the administrative team (administrator, director of nursing, regional nurse consultant, regional vice president of operations, assistant administrator) during a meeting on 06/24/2021 at approximately 4:00 pm No further information was provided prior to exit. Based on staff interview and clinical record review, the facility staff failed to ensure 5 of 26 residents were free of significant medication errors involving insulin. Residents #3, #92, #58, #2, and #20. The findings included: 06/24/2021 the (DON) director of nursing provided the survey team with a copy of a policy titled, Facilities Receiving Pharmacy Products and Services from Pharmacy. This policy read in part, .Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following .Verify each time a medication is administered that it is the correct medication at the correct dose . 1. For Resident #3, the facility staff failed to follow the physician ordered parameters in regards to insulin administration. Resulting in resident #3 not receiving their insulin on 05/07/2021 for a (BS) blood sugar of 180 and receiving insulin on 05/25/2021 for a BS of 159. Resident #3's facesheet in the (EHR) electronic health record included the diagnoses, diabetes, aphasia, hypertension, and major depressive disorder. Section C (cognitive patterns) of Resident #3's annual (MDS) minimum data set assessment with an (ARD) assessment reference date of 06/15/2021 included a (BIMS) brief interview for mental status summary score of 8 out of a possible 15 points. Resident #3's EHR included a physicians order for Novolog insulin inject 12 unit subcutaneously before meals for diabetes. Hold if BS less than 180. The order date was documented as 11/02/2020. A review of Resident #3's (EMARs) electronic medication administration records revealed the following 05/07/2021 the nursing staff documented a 16. Per the preprinted code on the EMAR a 16=Hold/See Nurses Note. This nurse documented Resident #3's BS as 180 and documented in the medication administration note that the insulin was held. Per the physicians order the insulin should have been administered. 05/25/2021 the nursing staff documented a BS of 159 and that the insulin was administered in the right lower quadrant of Resident #3's abdomen. Per the physicians order the insulin should have been held. 06/23/2021 4:05 p.m., the administrator, DON, regional nurse, regional vice president of operations and assistant administrator/ADON (assistant director of nursing) were made aware of the issue regarding Resident #3's insulin. This issue was again reviewed on 06/24/2021 at 4:00 p.m. with these same staff. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #92, the facility staff failed to follow the physician ordered parameters in regards to insulin administration. Resulting in resident #92 not receiving their insulin on 06/13/2021 for a (BS) blood sugar of 210. Resident #92's facesheet in the (EHR) electronic health record included the diagnoses diabetes and cognitive communication deficit. Section C (cognitive patterns) of the residents quarterly (MDS) minimum data set assessment with an (ARD) assessment reference date of 06/03/2021 included a (BIMS) brief interview for mental status summary score of 9 out of a possible 15 points. Resident #92's EHR included a physicians order dated 05/21/2021 for Novolog insulin inject 10 units subcutaneously two times a day for diabetes. Hold for (BG) blood glucose less 180. Give before lunch and supper. A review of Resident #92's (EMARs) electronic medication administration records revealed that the nursing staff documented a 3 on 06/13/2021 at 5:00 p.m. Per the preprinted code on this form a 3=No insulin required. The blood sugar was documented as 210. Indicating the resident should have received insulin per the physician ordered parameters. 06/23/2021 4:05 p.m., the administrator, DON, regional nurse, regional vice president of operations and assistant administrator/ADON (assistant director of nursing) was made aware of the issue regarding Resident #92's insulin. This issue was again reviewed on 06/24/2021 at 4:00 p.m. with these same staff. No further information regarding this issue was provided to the survey team prior to the exit conference. 5. For Resident #20 the facility failed to hold the resident's Novolog (insulin) according to the provider's written order. The resident's electronic clinical record was reviewed and the facesheet listed diagnoses to include but not limited to: Type 2 diabetes mellitus with hyperglycemia, schizoaffective disorder, malignant neoplasm of larynx, and chronic obstructive pulmonary disease. Resident #20's MDS (minimum data set) with an ARD (assessment reference date) of 04/04/2021 noted in Section C (cognitive patterns) the resident had a BIMS (brief interview for mental status) score of 11 out of 15. One of the resident's medication orders, with a 04/03/2021 start date, read NovoLOG FlexPen Solution Pen-Injector 100 UNIT/ML (Insulin Aspart) Inject 6 unit [sic] subcutaneously before meals related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65) Hold for BG [blood glucose] less than 180. Resident #20's MAR (medication administration record) was reviewed and for the month of June 2021, there were three (3) times facility staff documented the medication was administered when the resident's blood glucose was noted less than 180; on 06/01/2021 at 4:30 p.m. the resident's blood glucose was 177, on 06/03/2021 at 4:30 p.m., the resident's blood glucose was 178, and on 06/06/2021 at 6:30 a.m. the resident's blood glucose was 138. On 06/24/21 at 11:30 a.m. the director of nursing (DON) was interviewed about the facility's staff documenting they administered insulin to Resident #20 when the resident's blood glucose was less than the ordered parameter of 180. The DON acknowledged Resident #20's June 2021 MAR contained evidence the resident received insulin with blood glucose levels less than 180. The DON reported becoming aware of this concern while recently completing an insulin audit and reported discussing the concern with the medical director. The DON, administrator, assistant administrator, regional director of clinical services, and regional vice president of operations were informed of the medication findings described above on 06/24/2021 at 4:00 p.m. No further information was provided prior to the exit conference.

Based on observation and staff interview, the facility staff failed to provide a dignified existance by ensuring that privacy was maintained for residents during a group meeting. The findings included: During the group meeting, a facility staff entered the meeting, disturbing the group meeting, and proceeded to heat their food in the microwave. On 08/07/19 at 11:00 a.m., a group meeting wasas held with nine alert and orientated Residents of the facility. This meeting was held in the resident dining area. Prior to leaving the room, the activity staff shut the door. The staff had previously posted a notice on the entrance door that would alert anyone who wished to enter that a group meeting was being conducted. At 11:09 a.m., CNA (certified nursing assistant) #1 entered the group meeting, placed her food into the microwave, and proceeded to heat her food. After heating her food, CNA #1 left the dining area. At the conclusion of this meeting, the surveyor checked the outside door of the meeting room to ensure the sign was still posted. This sign was still in place. On 08/07/19 at approximately 4:08 p.m., the administrator, director of nursing, regional vice president of operations, and regional director of clinical services were notified of the issue regarding CNA #1 disturbing the group meeting. On 08/08/19 at 7:44 a.m., CNA #1 stated she saw the sign on the outside of the door for group but did not realize it meant she should not enter. No further information regarding this issue was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #123 the facility staff failed to ensure the DDNR (durable do not resuscitate) form was complete. Resident #123 was admitted to the facility on [DATE]. Diagnoses included but not limited to cancer, hypertension, pneumonia, diabetes mellitus, hyperlipidemia, hypothyroidism, anxiety, depression, and respiratory failure. The admission MDS (minimum data set) with an ARD (assessment reference date) of [DATE] assigned the Resident a BIMS (brief interview for mental status) score of 13 out of 15 in section C, cognitive patterns. The advance directives section of the Resident's clinical record was reviewed on [DATE]. It contained a Virginia Department of Health DDNR form, which read as follows: I further certify (must check 1 or 2): [] 1. The Patient is CAPABLE of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment. (Signature of patient is required) [] 2. The Patient is INCAPABLE of making an informed decision about provided, withholding, or withdrawing a specific medical treatment because he/she is unable to understand the nature, extent or probable consequences of the proposed medical decision , or to make a rational evaluation of the risks and benefits of alternatives to that decision. If you checked 2 above, check A, B, or C below: [] A. While capable of making an informed decision, the Patient has executed a written advanced directive which directs that life-prolonging procedures be withheld or withdrawn. [] B. While capable of making an informed decision, the patient has executed a written advanced directive which appoints a Person Authorized to Consent on the Patient's Behalf with authority to direct that life-prolonging procedures be withheld or withdrawn. (Signature of Person Authorized to Consent on the Patient's Behalf is required.) [] C. The Patient has not executed a written advanced directive (living will or durable power of attorney for health care). (Signature of Person Authorized to Consent on the Patient's Behalf is required) Sections I and II of the DDNR form had not been checked as directed. Surveyor spoke with the ADON (assistant director of nursing) on [DATE] at approximately 2:45 PM regarding the incomplete DDNR form. ADON stated that the form should have been completed. The concern of the incomplete DDNR form was discussed with the administrative team (administrator, director of nourishing, regional nurse consultant, and regional vice-president of operations) on [DATE] at approximately 4:20 PM. No further information was provided prior to exit. 3. For Resident #34, the facility staff failed to complete a DDNR (durable do not resuscitate). All the boxes on this form had been left blank (unchecked). The clinical record review revealed that Resident #34 had been admitted to the facility [DATE]. Diagnoses included, but were not limited to, hypertension, asphyxia, chronic kidney disease, and other diseases of larynx. Section C (cognitive patterns) of the Residents admission MDS (minimum data set) assessment with an ARD (assessment reference date) of [DATE] included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. Section O (special treatments/procedures/programs) had been coded to indicate the Resident was receiving hospice services. The EHR (electronic health record) was reviewed on [DATE]. The EHR included a DDNR order form dated [DATE]. The physician and Resident #34 had signed this DDNR This DDNR read in part. Under section 1 I further certify [must check 1 or 2]: 1. The patient is CAPABLE of making an informed decision . 2. The patient is INCAPABLE of making an informed decision . Neither box had been checked. Section 2 read, If you checked 2 above, check A, B, or C below . All three boxes had been left blank. On [DATE] at 3:45 p.m., this DDNR was shared with the DON (director of nursing). The DON acknowledged the DDNR was incomplete. On [DATE] at approximately 4:04 p.m., the administrator, DON, regional vice president of operations, and regional director of clinical services were notified of the issue regarding Resident #34's DDNR being incomplete. Prior to the exit conference on [DATE], the facility provided the surveyor with an updated copy of the Residents DDNR dated [DATE]. No further information regarding this issue was provided to the survey team prior to the exit conference. Based on interviews, clinical record review, and facility document review, it was determined the facility staff failed to correctly address residents' advance directives for three (3) of 25 sampled residents (Resident #57, Resident #34, and Resident #123). The findings included: 1. The facility staff failed to correctly address Resident #57's advance directive decisions. Resident #57 was admitted on [DATE]. Resident #57's diagnoses included, but were not limited to: high blood pressure, urinary tract infection, and sepsis. Resident #57's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] assessed the resident with a BIMS (brief interview for mental status) score of 15 out of 15; this assessment also documented the resident as being able to express ideas and wants and as being able to make himself/herself understood. During the review of Resident #57's clinical record on [DATE] at approximately 4:00 p.m., a document titled POLICY ON CPR (CARDIOPULMONARY RESUSCITATION) was noted. This document was completed on [DATE]; it was signed by Resident #57's responsible party. This document had the following statement selected: I do not wish CPR be performed. On [DATE] at 04:13 p.m., Licensed Practical Nurse (LPN) #16 was interviewed about Resident #57's code status; LPN #16 reported the resident was a full code. LPN #16 showed the surveyor a 'unit report form' which had a heart-shaped symbol beside Resident #57's name. LPN #16 stated the heart-shaped symbol indicated the patient was a full code. On the afternoon of [DATE], it was also noted that Resident #57's clinical record included a care plan which included the Focus of Resident/Responsible party has chosen Full Code. On [DATE] at 9:25 a.m., LPN #14 provided the surveyor with the following documents: - a revised care plan for Resident #57, dated [DATE], indicating the patient was now DNR (do not resuscitate), - a provider order for Resident #57, dated [DATE] and timed 4:45 p.m., indicating the patient was DNR, and - a Durable Do Not Resuscitate (DDNR) Order form completed for Resident #57 on [DATE]. The issue of Resident #57 being a full code when documentation in the resident's clinical record indicated the resident was not to receive CPR was discussed during a survey team meeting with the facility's administrative team on [DATE] at 4:25 p.m.; the facility's administrative team at this meeting included the Administrator, the Director of Nursing (DON), the Regional Director of Clinical Services, and the Regional Vice-President of Operations. On [DATE] at 1:30 p.m., LPN #12 provided the survey team with a policy titled Code Status Audit Policy (this policy had an effective date of [DATE] and a reviewed date of [DATE]). This policy included the following statement: The Facility will ensure resident's [sic] code status is accurate and current throughout the residents stay and the clinical record represent the accurate code status.

Based on staff interview, employee record review, facility document review, the facility staff failed to implement their policy/procedure in regards to new hires and criminal background checks for 3 of 25 new hires (New hire #6, #13, and #17). The findings included: The facility staff failed to obtain criminal background checks upon hire per their facility policy/procedure. Facility policy titled Employee Background Screening read in part, .Each facility shall conduct a criminal background check of all employees, as required by law, upon hire . The surveyor reviewed 25 new hire employee record on 08/07 and 08/08/19. Employee #6 was an LPN (licensed practical nurse). Documented DOH (date of hire) 10/08/18 criminal background check completed 12/20/18. Employee #13 was a cook. Documented DOH (08/30/18) criminal background check completed 10/09/18. Employee #17 was an activity staff. Documented DOH (10/26/18) criminal background check completed 12/19/18. On 08/08/19 at 10:00 a.m. human resource employee #1 was asked if they had any further information regarding background checks for these three employees. On 08/08/19 at 1:21 p.m., the surveyor reviewed the hire dates and criminal background dates with human resource employee #1. After this review, this employee verbalized to the surveyor that she had not completed the paperwork for employees #6 and #17. For employee #13 human resource employee #1 stated they must have missed it. On 08/08/19 at approximately 4:04 p.m., the administrator, DON, regional vice president of operations, and regional director of clinical services were notified of the issue regarding employee records. On 08/09/18 at 8:32 a.m., during the QA (quality assurance) task with the administrator, the administrator verbalized to the surveyor that by the end of May they had realized they had placed too much on one person and made some internal changes in regards to job duties. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to accurately complete MDS (minimum data set) assessments for 2 of 27 residents, Residents #34 and #92. The findings included: 1. For Resident #34, the facility staff failed to completed sections C (cognitive patterns) and D (mood) of the resident's quarterly MDS assessment with an ARD (assessment reference date) of 05/24/19. The clinical record review revealed that Resident #34 had been admitted to the facility 02/14/19. Diagnoses included, but were not limited to, hypertension, asphyxia, chronic kidney disease, and other diseases of larynx. Section C (cognitive patterns) of the resident's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/21/19 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. The EHR (electronic health record) was reviewed on 08/06/19. During a review of the resident's MDS assessment with an ARD of 05/24/19, it was noted that sections C and D had been marked with dashes (-). On 08/06/19 at 4:05 p.m., the surveyor reviewed the MDS with the DON (director of nursing). On 08/07/19 at 9:07 a.m., the surveyor interviewed the SW (social worker), the SW verbalized to the surveyor that she really did not know the reason why it had dashes.typically we get them all done timely . This SW stated she was responsible for sections C, D, E, and Q. The MDS coordinator that had signed this MDS as being complete was no longer employed at the facility. On 08/08/19 at approximately 4:04 p.m., the administrator, DON, regional vice president of operations, and regional director of clinical services were notified of the issue regarding Resident #34's MDS assessment being inaccurate. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #92, the facility staff failed to complete sections C (cognitive patterns) and D (mood) of 2 MDS (minimum data set) assessments. The clinical record review revealed that Resident #92 had been admitted to the facility 08/21/17. Diagnoses included, but were not limited to, difficulty in walking, type 2 diabetes, dysphagia, essential hypertension, and dysphagia. Section C of the resident's quarterly MDS assessment with an ARD (assessment reference date) of 01/03/19 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. The resident's EHR (electronic health record) was reviewed on 08/07/19 after a concern brought up in the group meeting. This review revealed that the facility staff had marked sections C and D of the resident's quarterly MDS assessment with an ARD (assessment reference date) of 04/05/19 and the resident's annual MDS assessment with an ARD of 07/06/19 with dashes (-). For the MDS with an ARD of 04/05/19 LPN #2 had signed the MDS as being responsible for sections C and D. The RN (registered nurse) that had signed the assessment as complete was no longer employed at the facility. On 08/07/19 at 3:10 p.m., LPN (licensed practical nurse) #2 verbalized to the surveyor that she had dashed the sections, as she had no information from social services. LPN #2 then added we have asked and emailed. For the MDS with an ARD of 07/06/19 the RN that had signed for sections C and D to be completed and for the assessment to be complete was no longer employed at the facility. On 08/08/19 at approximately 4:04 p.m., the administrator, DON, regional vice president of operations, and regional director of clinical services were notified of the issue regarding Resident #92's MDS assessments being incomplete. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and clinical record review, the facility staff failed to implement the resident's comprehensive care plan in regards to a foley catheter for 1 of 27 residents, Resident #66. The findings included: The facility staff failed to implement the resident's comprehensive care plan in regards to anchoring the resident's foley catheter. The clinical record review revealed that Resident #66 had been admitted to the facility 02/28/17. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, chronic kidney disease, type 2 diabetes, schizoaffective disorder, Alzheimer's disease, obstructive and reflux uropathy, benign prostatic hyperplasia, and bipolar disorder. Section C (cognitive patterns) of the resident's significant change in status MDS (minimum data set) assessment included a BIMS (brief interview for mental status) summary score of 13 out of a possible 15 points. Section H (bladder and bowel) was coded to indicate the resident had a catheter. The resident's EHR (electronic health record) included the following physician's orders- Anchor catheter tubing and check placement every shift. Foley catheter for obstructive uropathy. The resident's comprehensive care plan included the focus area risk for complication in urinary system related to foley catheter use. Interventions included, but were not limited to, anchor catheter tubing and check placement every shift. On 08/08/19 at 7:40 a.m., the surveyor and CNA (certified nursing assistant) #5 checked the resident's foley catheter. This foley catheter was not anchored. On 08/08/19 at 2:26 p.m., the surveyor and LPN (licensed practical nurse) #2 again checked this foley catheter. The foley catheter was now anchored. LPN #2 verbalized to the surveyor that one of the CNA's had put the strap in place. On 08/08/19 at 3:35 p.m., CNA #4 stated she thought CNA #5 had put the strap in place. Attempts to interview this resident were unsuccessful. On 08/08/19 at approximately 4:04 p.m., the administrator, DON, regional vice president of operations, and regional director of clinical services were notified of the issue regarding Resident #66's foley catheter not being anchored. No further information regarding this issue was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review the facility staff failed to review and revise a comprehensive care plan for 1 of 27 residents, Resident #40. The findings included: For Resident # 40 the facility staff failed to revise a care plan for skin breakdown. Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to hypertension and Alzheimer's disease. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/31/19 assigned the resident a BIMS (brief interview for mental status) score of 12 out of 15 in section C, cognitive status. Surveyor observed Resident #40 on 08/07/19 at approximately 8:45. The resident did not have skin-sleeves on either arms or legs at this time. Resident #40's clinical record was reviewed on 08/08/19. The physician's orders section of the clinical record contained a signed physician's order summary for the month of August 2019, which read in part Keep vaseline over both legs and cover with skin sleeves on lower legs at all times. The physician's order summary also contained an entry which read in part, Geri-sleeves to bilateral arms to maintain skin integrity every day shift to maintain skin integrity-start date 02/18/19, end date-03/29/19. Resident #40's comprehensive care plan was reviewed and contained a care plan for at risk for skin breakdown related to: decreased mobility, weakness, med use, wears geri-legs (skin sleeves) per Resident request. Interventions for this care plan included geri-legs and geri-sleeves to all extremities for protection of skin from bumping into objects. Surveyor observed Resident #40 again on 08/08/19 at approximately 1:40. The resident did not have skin-sleeves on either arms or legs at this time. Surveyor observed a bandage to left elbow and two bandages to left lower leg.the Surveyor spoke with LPN #2 on 08/08/19 at approximately 3:35 PM regarding Resident #40's comprehensive care plan. Surveyor asked LPN #2 if the intervention for geri-sleeves should be on the care plan, and LPN #2 stated that it should have been removed when the care plan was updated. The concern of not reviewing/revising the resident's care plan was discussed with the administrative team (administrator, director of nursing, regional nurse consultant, and regional vice-president of operations) during a meeting on 08/08/19 at approximately 4:00 PM. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review the facility staff failed to ensure that residents receive treatment and care by following physician's orders for 3 of 27 residents, Residents #25, #40 and #110. The findings included: 1. For Resident #25 the facility staff failed to follow physician's orders for the administration of insulin. Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to hypertension, obstructive uropathy, diabetes mellitus, dementia, Parkinson's disease, depression, acute kidney failure and gastroesophageal reflux disease. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/24/19 assigned the resident a BIMS (brief interview for mental status) score of 6 out 15 in section C, cognitive status. Resident #25's comprehensive care plan was reviewed and contained a care plan for Resident is at risk for hypo/hyperglycemia episodes R/T (related to): IDDM (insulin dependent diabetes mellitus). Interventions for this care plan include medication as ordered. Resident #25's clinical record was reviewed on 08/07/19. It contained a signed physician's order summary for the month of August 2019, which read in part Humalog Kwickpen 3 ml 100.units/ml. Inject 10 units subcutaneously two times a day for DM (diabetes mellitus). Hold if BS (blood sugar) < (less than) 140. Resident #25's eMAR (electronic medication administration record) for the months of July and August 2019 were reviewed. The eMAR's contained an entry, which read in part, Humalog Kwickpen 3 ml 100 units/1 ml Unit. Inject 10 unit subcutaneously two times a day for DM. Hold if BS <140. The blood sugar for 07/04/19 at 9:00 AM was recorded as 122, and the entry was signed as administered. The blood sugar for 07/09/19 at 9:00 AM was recorded as 126 and the entry was signed as administered. The blood sugar for 08/05/19 was recorded as 126 and the entry was signed as administered. The blood sugar for 08/07/19 was recorded as 128, and the entry was signed as administered. The surveyor spoke with RN #1 on 08/08/19 at approximately 3:35 PM regarding Resident #25's insulin. Surveyor asked RN #1 what a check and initials indicated on the eMAR, and she stated that it meant the medication was administered as ordered. Surveyor then asked RN #1 to look at Resident #25's eMAR for the dates indicated above. RN #1 stated that the resident's insulin should not have been administered on these dates. The concern of not following the physician's orders for Resident #25 was discussed with the administrative staff (administrator, director of nursing, regional nurse consultant, and regional vice-president of operations) during a meeting on 08/08/19 at approximately 4:00 PM. No further information was provided prior to exit. 2. For Resident #40 the facility staff failed to follow physician's orders for the use of geri-legs skin sleeves. Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to hypertension and Alzheimer's disease. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/31/19 assigned the resident a BIMS (brief interview for mental status) score of 12 out of 15 in section C, cognitive status. Surveyor observed Resident #40 on 08/07/19 at approximately 8:45. The resident did not have skin-sleeves on either arms or legs at this time. Resident #40's clinical record was reviewed on 08/08/19. The physician's orders section of the clinical record contained a signed physician's order summary for the month of August 2019, which read in part Keep vaseline over both legs and cover with skin sleeves on lower legs at all times. The physician's order summary also contained an entry which read in part, Geri-sleeves to bilateral arms to maintain skin integrity every day shift to maintain skin integrity-start date 02/18/19, end date-03/29/19. Resident #40's comprehensive care plan was reviewed and contained a care plan for at risk for skin breakdown related to: decreased mobility, weakness, med use, wears geri-legs (skin sleeves) per Resident request. Interventions for this care plan included geri-legs and geri-sleeves to all extremities for protection of skin from bumping into objects. Surveyor observed Resident #40 again on 08/08/19 at approximately 1:40. The resident did not have skin-sleeves on either arms or legs at this time. Surveyor observed a bandage to left elbow and two bandages to left lower leg. Surveyor spoke with LPN #1 on 08/08/19 at approximately 1:50 PM. Surveyor asked LPN #1 if Resident #40 was supposed to be wearing skin sleeves on his legs and LPN #1 stated, He has them for his arms but not his legs, he doesn't have an order for his legs yet. He is wearing them on his arms. Surveyor asked LPN #1 to pull Resident #40's physician's order summary. LPN #1 read the order summary, and stated I guess he is supposed to be wearing them on his legs. The concern of not following the physician's orders for geri-sleeves was discussed with the administrative staff (administrator, director of nursing, regional nurse consultant, and regional vice-president of operations) during a meeting on 08/08/19 at approximately 4:00 PM. No further information was provided prior to exit. 3. For Resident #92, the facility staff failed to administer the residents 9:00 a.m. medication until the resident verbalized a concern to the surveyor during a group meeting and had awoken the resident at 1:00 a.m. to administer aspirin. The clinical record review revealed that Resident #92 had been admitted to the facility 08/21/17. Diagnoses included, but were not limited to, difficulty in walking, type 2 diabetes, dysphagia, essential hypertension, and dysphagia. Section C of the resident's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 01/03/19 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. The resident's EHR (electronic health record) was reviewed on 08/07/19 after a concern brought up in the group meeting regarding not receiving her morning insulin and being awoken at 1:00 a.m. to be administered an aspirin. On 08/07/19 at 11:21 a.m., Resident #92 verbalized to the surveyor that she had not received her morning insulin. Resident #92 stated the nursing staff had checked her BS (blood sugar) but she did not get her insulin. When asked if she felt okay, Resident #92 stated she did. Resident #92 also stated the facility nursing staff had awoken her at 1:00 a.m. to administer an aspirin. The surveyor immediately spoke with the administrator and LPN (licensed practical nurse) #1. LPN #1 verbalized to the surveyor that the resident had not received her insulin as she had not been in her room and she was unable to find her. LPN #1 stated the resident's insulin was due to be administered at 10:00 a.m. On 08/07/19 at 11:32 a.m., LPN #1 verbalized to the surveyor that she had not administered any of the resident's morning medications that the computer system was new to her, and she was just trying to figure it out. During this interview, LPN #6 verbalized to the surveyor that she had just administered the resident's medications. A review of the resident's eMARs (electronic medication administration records) revealed that the resident was due to receive lasix 20 mg for edema, lisinopril 20 mg for hypertension, norvasc 10 mg for hypertension, therems tablet (multivitamin), 18 units of lantus insulin for diabetes, and metformin 500 mg for diabetes. LPN #1 had signed for all of these medications as if they had been administered. In regards to the resident's aspirin the resident's physicians orders revealed that the resident had a new order for aspirin 81 mg to be given in the morning for prophylaxis the order date was documented as 08/05/19 and the start date was documented as 08/06/19. A review of the resident's eMAR revealed that the facility nursing staff had placed a check mark beside the time of 12:00 a.m. on 08/07/19 indicating the aspirin had been administered. The facility nursing staff had also placed a check mark beside the timeframe of 8:00 a.m. on 08/06/19 indicating the aspirin had been administered. There was no medication scheduled for 10:00 a.m. as LPN #1 stated. 08/07/19 at 2:52 p.m., LPN #1, who was an agency nurse, verbalized to the surveyor that it was her third day in the building and her first day on that unit. When asked if she had received any orientation LPN #1 stated A little. On the first day, they kind of showed me around the facility, ins and outs of the computer. If I have an issue, I just grab whom I see and they direct me to whomever. LPN #1 stated she had been a nurse 12 years and that the resident's BS was obtained on 3rd shift and when she was completing the medication pass the Resident was there and after she had set up the Residents medications, she was gone. LPN #1 stated the Resident was in therapy and therapy stated she would be up there for 45 minutes. LPN #1 stated she called back to therapy and therapy said she was down here. I could not find her. LPN #1 stated she was still familiarizing herself with the system. When asked why she had signed as if the medication had been administered LPN #1 stated you can check yes, you can hit lock, or save and apparently I hit the save button instead of the lock button. LPN #1 stated she had relieved an agency nurse when she took report and there was not a whole lot the previous nurse could tell me about the unit. On 08/07/19 at approximately 4:08 p.m., the administrator, DON (director of nursing), regional vice president of operations, and regional director of clinical services were notified of the issue regarding Resident #92's medications. The facility policy/procedure titled, General Dose Preparation and Medication Administration read in part, .Verify each time a medication is administered that it is the correct medication, at the correct time .Confirm that the MAR reflects the most recent medication order .Administer medication within timeframes specified by facility policy . On 08/08/19 at approximately 4:04 p.m., during a meeting with the administrator, DON, regional vice president of operations, and regional director of clinical services the DON verbalized to the surveyor that the medication guidelines were that a medication could been administered one hour before or one hour after their scheduled time. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure that this resident who is continent of bladder received services and assistance to maintain continence by following physician's orders in regards to a foley catheter care for 1 of 27 residents, Resident #66. The findings included: The facility staff failed to anchor Resident #66's foley catheter per the physicians order. The clinical record review revealed that Resident #66 had been admitted to the facility 02/28/17. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, chronic kidney disease, type 2 diabetes, schizoaffective disorder, Alzheimer's disease, obstructive and reflux uropathy, benign prostatic hyperplasia, and bipolar disorder. Section C (cognitive patterns) of the resident's significant change in status MDS (minimum data set) assessment included a BIMS (brief interview for mental status) summary score of 13 out of a possible 15 points. Section H (bladder and bowel) was coded to indicate the resident has a catheter. Attempts to interview the resident were unsuccessful. The resident's EHR (electronic health record) included a physicians order to anchor catheter tubing and check placement every shift. The resident's comprehensive care plan included the focus area risk for complication in urinary system related to foley catheter use. Interventions included, but were not limited to, anchor catheter tubing and check placement every shift. On 08/08/19 at 7:40 a.m., the surveyor and CNA (certified nursing assistant) #5 checked the resident's foley catheter. This foley catheter was not anchored. On 08/08/19 at 2:26 p.m., the surveyor and LPN (licensed practical nurse) #2 again checked this foley catheter. The foley catheter was now anchored. LPN #2 verbalized to the surveyor that one of the CNA's had put the strap in place. On 08/08/19 at 3:35 p.m., CNA #4 stated she thought CNA #5 had put the strap in place. On 08/08/19 at approximately 4:04 p.m., the administrator, DON, regional vice president of operations, and regional director of clinical services were notified of the issue regarding Resident #66's foley catheter not being anchored. No further information regarding this issue was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility staff failed to ensure that a resident who needs respiratory care is provided such care storing oxygen equipment appropriately for 2 of 27 residents in the sample survey (Resident #32 and # 82). The findings included: 1. The facility staff failed to store a nebulizer mask appropriately when not in use for Resident #32. Resident #32 was admitted to the facility on [DATE] with the following diagnosis of, but not limited to anemia, high blood pressure, renal disease, dementia, anxiety disorder, depression and respiratory failure. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/24/19, the resident was coded as requiring extensive assistance of 2 staff members for dressing, personal hygiene and bathing. On 8/7/19 at 8:21 am, the surveyor accompanied LPN (licensed practical nurse) #2 into Resident #32's room to observe the medication pass. Upon entering the room, the surveyor observed the nebulizer mask laying on the bedside table and was not stored in a plastic bag. The surveyor asked LPN #2 how the nebulizer mask was to be stored when not in use by the resident. LPN #2 stated, The mask of the nebulizer is to be stored in a plastic bag. At 9:30 am, the surveyor notified the DON (director of nursing) and the regional nurse consultant of the above documented findings. On 8/8/19 at 4:22 pm, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 8/9/19. 2. The facility staff failed to ensure Resident #82's respiratory treatment mask and oral suction catheters were appropriately stored. Resident #82 was admitted on [DATE]. Resident #82's diagnoses included, but were not limited to: anemia, high blood pressure, Alzheimer's Disease, and respiratory failure. Resident #82's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 7/16/19 assessed the resident being unable to obtain a BIMS (brief interview for mental status) score due to the resident is rarely/never understood; this assessment also documented the resident as being dependent on facility staff for bed mobility, dressing, eating, toileting, and personal hygiene. On 8/6/19 at 2:52 p.m., the following was observed: - the suction canister at Patient #82's bed side had been used but was not dated, - a yankauer suction catheter was lying uncovered on a towel on Patient #82's beside table, - a flexible suction catheter was lying uncovered on a towel on Patient #82's bedside table, - a mask for providing breathing treatments was lying uncovered on a towel on Patient #82's beside table, and - a plastic bag was in floor beside Patient #82's bed side table. The failure of facility staff to ensure Resident #82's respiratory treatment/suction equipment was correctly stored was discussed on 8/8/19 at 4:05 p.m. during a survey team meeting with the facility's Administrator, Director of Nursing (DON), Regional Director of Clinical Services (RDCS), and Regional Vice-President of Operations. The RDCS reported there was not a written policy and procedure to guide the storage of the aforementioned respiratory equipment. The DON reported the respiratory treatment mask should be changed weekly and kept stored in a bag, the yankauer suction catheter should be changed daily, and the flexible suction catheter should be discarded after use. During a survey team meeting with the facility's Administrator, Director of Nursing (DON), Regional Director of Clinical Services (RDCS), and Regional Vice-President of Operations on 8/9/19 at 9:45 a.m., the DON reported Resident #82's daughter suctions the patient and had been previously been provided education about the use/storage of the respiratory equipment. The surveyor asked for documentation of education provided to the resident's daughter. The following information, found in Patient #82's care plan, was provided to the surveyor: Daughter observed suctioning resident . Daughter education to ask nursing for suctioning PRN (as needed). No further information was provided to the surveyor prior to the exit conference on 8/8/19.

Based on staff interview and clinical record review, the facility staff failed to report any irregularities to ensure that drug regiment review recommendations were reported to the attending physician, facility medical director, and/or the director of nursing for 1 of 27 residents, Resident #3. The findings included: The facility staff failed to ensure the attending physician, facility medical director, and DON (director of nursing) reviewed and/or acted on a pharmacy recommendation for April 2019. The clinical record review revealed that Resident #3 had been admitted to the facility 06/23/15. Diagnoses included, but were not limited to, dysphagia, peripheral vascular disease, chronic kidney disease, hypertension, and diabetes. Section C (cognitive patterns) of the resident's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 07/30/19 included a BIMS (brief interview for mental status) summary score of 9 out of a possible 15 points. The resident's EHR (electronic health record) was reviewed on 08/06-08/08/19. The EHR included a Pharmacy Review Note dated 04/16/19. The pharmacist had documented See report for any noted irregularities and/or recommendations. On 08/08/19 at 12:13 p.m., the DON (director of nursing) was made aware that the surveyor needed to review the pharmacy recommendations for 04/16/19. On 08/08/19 at 1:46 p.m., the DON verbalized to the surveyor that she had reviewed her reports and she did not have anything for the date of 04/16/19. On 08/08/19 at approximately 4:04 p.m., the administrator, DON, regional vice president of operations, and regional director of clinical services were notified of the missing pharmacy recommendation. No further information regarding this issue was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility staff failed to ensure 1 of 27 resident was free of unnecessary medications. The findings included: 1. For Resident #25 the facility staff failed to ensure the resident was free of an unnecessary administration of insulin. Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to hypertension, obstructive uropathy, diabetes mellitus, dementia, Parkinson's disease, depression, acute kidney failure and gastroesophageal reflux disease. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/24/19 assigned the resident a BIMS (brief interview for mental status) score of 6 out 15 in section C, cognitive status. Resident #25's comprehensive care plan was reviewed and contained a care plan for Resident is at risk for hypo/hyperglycemia episodes R/T (related to): IDDM (insulin dependent diabetes mellitus). Interventions for this care plan include medication as ordered. Resident #25's clinical record was reviewed on 08/07/19. It contained a signed physician's order summary for the month of August 2019, which read in part Humalog Kwickpen 3 ml 100.units/ml. Inject 10 units subcutaneously two times a day for DM (diabetes mellitus). Hold if BS (blood sugar) < (less than) 140. Resident #25's eMAR (electronic medication administration record) for the months of July and August 2019 were reviewed. The eMAR's contained an entry, which read in part, Humalog Kwickpen 3 ml 100 units/1 ml Unit. Inject 10 unit subcutaneously two times a day for DM. Hold if BS <140. The blood sugar for 07/04/19 at 9:00 AM was recorded as 122, and the entry was signed as insulin administered. The blood sugar for 07/09/19 at 9:00 AM was recorded as 126 and the entry was signed as insulin administered. The blood sugar for 08/05/19 was recorded as 126 and the entry was signed as insulin administered. The blood sugar for 08/07/19 was recorded as 128, and the entry was signed as insulin administered. The surveyor spoke with RN #1 on 08/08/19 at approximately 3:35 PM regarding Resident #25's insulin. Surveyor asked RN #1 what a check and initials indicated on the eMAR, and she stated that it meant the medication was administered as ordered. Surveyor then asked RN #1 to look at Resident #25's eMAR for the dates indicated above. RN #1 stated that the resident's insulin should not have been administered on these dates. The concern of unnecessarily administering the resident's insulin was discussed with the administrative staff (administrator, director of nursing, regional nurse consultant, and regional vice-president of operations) during a meeting on 08/08/19 at approximately 4:00 PM. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility staff failed to ensure a medication error rate was less than 5% for 3 of 27 residents in the survey sample. There were 29 opportunities for error with 3 medication errors noted by the surveyors that made the medication error rate of 10.34% (Resident #32, #9 and #50). The findings included: 1. The surveyor observed LPN (licensed practical nurse) #2 crush a Mucinex DM and administer this to Resident #32. Resident #32 was admitted to the facility on [DATE] with the following diagnosis of, but not limited to anemia, high blood pressure, renal disease, dementia, anxiety disorder, depression and respiratory failure. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/24/19, the resident was coded as requiring extensive assistance of 2 staff members for dressing, personal hygiene and bathing. On 8/7/19 at 8:21 am, the surveyor was observing LPN #2 administrating medication to Resident #32. During this observation, LPN #2 crushed the medication Mucinex DM and administrated it to the resident. At 9:35 am, the surveyor spoke to the pharmacist on the phone. The pharmacist stated that the Mucincex DM was not to be crushed because it is an extended release tablet that cannot be crushed. At 10:30 am, the surveyor notified the DON (director of nursing) and the regional nurse of the above documented observations. The DON stated, I don't believe that you can crush that. The surveyor requested the Do Not Crush list that the facility staff is to use. The surveyor reviewed the clinical record for Resident #32 at 1 pm. The resident did have a physician order, which stated, .Mucinex DM 1 tablet every BID (twice a day) po (by mouth) . The surveyor received a copy of the Do Not Crush medication list at 1:30 pm from the DON. On this list, the surveyor noted that Mucinex DM was included as one of the medications that is not to be crushed. The surveyor notified the administrative team of the above documented findings on 8/8/19 at 4:22 pm. No further information was provided to the surveyor prior to the exit conference on 8/9/19. 2. The surveyor observed LPN #1 administrating Flonase nasal spray to Resident #9. LPN #1 did not have Resident #9 to blow her nose before the administration of this medication. Resident #9 was readmitted to the facility on [DATE] with the following diagnoses of heart failure, depression and asthma. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/8/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 11 out of a possible score of 15. Resident #9 was also coded as requiring supervision of 1 staff member for dressing and personal hygiene and extensive assistance of 1 staff member for bathing. During the medication pass and pour observation on 8/7/19 at 8:43 am, the surveyor observed LPN (licensed practical nurse) #1 administrating Flonase nasal spray to Resident #9. The medication was given as ordered by the physician but LPN did not have the resident blow her nose before administrating this nasal spray to the resident. At 8:55 am, the surveyor asked LPN #1 if the resident was to blow her nose before she was given the nasal spray, Flonase. LPN #1 stated, I thought I did that. The surveyor stated, No I didn't observe you asking or instructing the resident to do this before you gave the resident the Flonase. At 11 am, the surveyor notified the DON (director of nursing) of the above documented observations. The surveyor requested a copy of the package insert for the medication Flonase. At 11:30 am, the DON gave the surveyor the package insert for Flonase. The surveyor noted the following on the package insert which stated, .Blow your nose to clear your nostrils . The surveyor notified the administrative team of the above documented findings on 8/8/19 at 4:22 pm. No further information was provided to the surveyor prior to the exit conference on 8/9/19.3. Resident #50 was administered a crushed medication that should not have been crushed. Resident #50 was admitted to the facility on [DATE]. Resident #50's diagnoses included, but were not limited to: anemia, hyponatremia, seizure disorder or epilepsy, and respiratory failure. Resident #50's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 6/15/19 assessed the resident with a BIMS (brief interview for mental status) score of 7 out of 15; this assessment also documented the resident's urinary continence as always incontinent. On 8/8/19 at 7:45 a.m., LPN (licensed practical nurse) #11 was observed administering Resident #50's medication. One of the medications that was crushed before it was administered to Resident #50 was Oxybutynin 5mg. Resident #50's clinical record included the following medication order: Oxybutynin Chloride ER Tablet Extended Release 24 hours 5 MG Give 5 mg by mouth one time a day for Bladder Spasms DO NOT CRUSH. On 8/8/19 at 8:25 a.m., LPN #11 was interviewed about which of Resident #50's medication he/she had crushed. LPN #11 reported he/she had crushed all the observed medications except the potassium. On 8/8/19 at 8:35 a.m., the facility's Director of Nursing (DON) was interviewed about Resident #50 having his/her Oxybutynin crushed prior to administration. The DON reviewed Resident #50's orders then confirmed the Oxybutynin should not have been crushed. The observation of Resident #50 being administered a crushed medication that should not have been crushed was discussed during a survey team meeting with the facility's administrative team on 8/8/19 at 4:05 p.m.; the facility's administrative team at this meeting included the Administrator, the DON, the Regional Director of Clinical Services, and the Regional Vice-President of Operations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #25 the facility staff failed to ensure the resident was free of a significant medication error. Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to hypertension, obstructive uropathy, diabetes mellitus, dementia, Parkinson's disease, depression, acute kidney failure and gastroesophageal reflux disease. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/24/19 assigned the resident a BIMS (brief interview for mental status) score of 6 out 15 in section C, cognitive status. Resident #25's comprehensive care plan was reviewed and contained a care plan for Resident is at risk for hypo/hyperglycemia episodes R/T (related to): IDDM (insulin dependent diabetes mellitus). Interventions for this care plan include medication as ordered. Resident #25's clinical record was reviewed on 08/07/19. It contained a signed physician's order summary for the month of August 2019, which read in part Humalog Kwickpen 3 ml 100.units/ml. Inject 10 units subcutaneously two times a day for DM (diabetes mellitus). Hold if BS (blood sugar) < (less than) 140. Resident #25's eMAR (electronic medication administration record) for the months of July and August 2019 were reviewed. The eMAR's contained an entry, which read in part, Humalog Kwickpen 3 ml 100 units/1 ml Unit. Inject 10 unit subcutaneously two times a day for DM. Hold if BS <140. The blood sugar for 07/04/19 at 9:00 AM was recorded as 122, and the entry was signed as administered. The blood sugar for 07/09/19 at 9:00 AM was recorded as 126 and the entry was signed as administered. The blood sugar for 08/05/19 was recorded as 126 and the entry was signed as administered. The blood sugar for 08/07/19 was recorded as 128, and the entry was signed as administered. The surveyor spoke with RN #1 on 08/08/19 at approximately 3:35 PM regarding Resident #25's insulin. Surveyor asked RN #1 what a check and initials indicated on the eMAR, and she stated that it meant the medication was administered as ordered. Surveyor then asked RN #1 to look at Resident #25's eMAR for the dates indicated above. RN #1 stated that the resident's insulin should not have been administered on these dates. The concern of not ensuring Resident #25 was free of a significant medication error was discussed with the administrative staff (administrator, director of nursing, regional nurse consultant, and regional vice-president of operations) during a meeting on 08/08/19 at approximately 4:00 PM. No further information was provided prior to exit. Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure 2 of 27 residents were free of significant medication errors involving insulin. Residents #92 and #25. The findings included: 1. For Resident #92, the facility staff failed to administer the resident's insulin until the resident verbalized a concern to the surveyor during a group interview. The clinical record review revealed that Resident #92 had been admitted to the facility 08/21/17. Diagnoses included, but were not limited to, difficulty in walking, type 2 diabetes, dysphagia, essential hypertension, and dysphagia. Section C of the resident's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 01/03/19 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. The resident's EHR (electronic health record) was reviewed on 08/07/19 after a concern brought up in the group meeting regarding not receiving her morning insulin. On 08/07/19 at 11:21 a.m., Resident #92 verbalized to the surveyor that she had not received her morning insulin. Resident #92 stated the nursing staff had checked her BS (blood sugar) but she did not get her insulin. When asked if she felt okay, Resident #92 stated she did and stated her BS was 227. The surveyor immediately spoke with the administrator and LPN (licensed practical nurse) #1. LPN #1 verbalized to the surveyor that the resident had not received her insulin as she had not been in her room and she was unable to find her. LPN #1 stated the resident's insulin was due to be administered at 10:00 a.m. On 08/07/19 at 11:32 a.m., LPN #6 verbalized to the surveyor that she had just administered the resident's medications to included insulin. A review of the resident's eMARs (electronic medication administration records) revealed that the resident was due to receive18 units of lantus insulin for diabetes at 9:00 a.m.; the resident's BS had been obtained at 6:30 a.m. and had been documented as being 226. LPN #1 had signed for the insulin at 9:00 a.m. as if it had been administered. There was no medication scheduled for 10:00 a.m. as LPN #1 stated. 08/07/19 at 2:52 p.m., when asked why she had signed for the resident's medications as if they had been administered LPN #1 stated you can check yes, you can hit lock, or save and apparently I hit the save button instead of the lock button. LPN #1 stated she had relieved an agency nurse when she took report and there was not a whole lot the previous nurse could tell me about the unit. On 08/07/19 at approximately 4:08 p.m., the administrator, DON (director of nursing), regional vice president of operations, and regional director of clinical services were notified of the issue regarding Resident #92's medications. The facility policy/procedure titled, General Dose Preparation and Medication Administration read in part, .Verify each time a medication is administered that it is the correct medication, at the correct time .Confirm that the MAR reflects the most recent medication order .Administer medication within timeframes specified by facility policy . On 08/08/19 at approximately 4:04 p.m., during a meeting with the administrator, DON, regional vice president of operations, and regional director of clinical services the DON verbalized to the surveyor that the medication guidelines were that a medication could been administered one hour before or one hour after their scheduled time. The facility nursing staff had documented the resident's BS at 4:30 p.m. as being 221. No further information regarding this issue was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility staff failed to appropriately store medications in 2 of 5 medication carts in the nursing facility (Unit 1 and 2 Elevator Day Medication Carts) and failed to store madications by keeping medication cart locked during the medication administration observation when the nurse was not in view of this cart (Medication Cart Elevator Day #1). The findings included: 1. To appropriately store medications in 2 of 5 medication carts in the nursing facility. (Unit 1 and 2 Elevator Day Medication Carts) On 8/7/19 at 11:10 am, the surveyor and DON (director of nursing) observed the following pills loose in the medication cart drawer on Unit 1, Elevator Day Medication Cart on 1st floor (these were noted in the 2nd drawer): (1) small round beige in color pill (1) beige tablet oblong pill (1) medium size beige pill (1) tan colored round pill At 11:30 am, the surveyor and DON observed the following loose pill in the medication cart drawer on Unit 2, Elevator Day Medication Cart on 2nd floor: 2nd drawer 1/2 small greenish pill The DON stated to the surveyor, When a nurse sees a pill loose in the med cart, they are to discard the medication. At 4:22 pm, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 8/9/19. 2. To keep medication cart locked during the medication administration observation when the nurse was not in view of this cart. (Medication Cart Elevator Day #1) On 8/7/19 at 08/07/19 at 08:18 am LPN (licensed practical nurse #2) was observed by the surveyor administer medications to a resident in their wheelchair that was located between room [ROOM NUMBER] and 205. While LPN #2 was administrating the medications, she left her medication cart (Medication Cart Elevator #1) unattended and unlocked and she turned her back away from the cart. The surveyor observed that the nurse could not visual see the medication cart. At 10 am, the surveyor notified LPN #2 of the above documented findings. LPN #2 stated, I didn't realize that I did that. I usually always lock my cart. At approximately 2 pm, the surveyor notified the DON (director of nursing) of the above documented findings The DON stated, You never leave your medication cart unlocked when you are not right with it. At 4:22 pm, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 8/9/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for 2 of 27 residents in the survey sample (Resident #122, and #110). The findings included: 1. The facility staff failed to ensure a complete and accurate clinical record in regards to behavioral monitoring for Resident #122. Resident #122 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to atrial fibrillation, neurogenic bladder, pneumonia, dementia, Multiple Sclerosis, seizure disorder and anxiety disorder. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/24/19; the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 9 out of a possible score of 15. Resident #122 was also coded as being dependent on 1 or 2 staff members for dressing, personal hygiene and bathing. The surveyor conducted a review of Resident #122's clinical record on 8/7 and 8/8/19. During this review, the surveyor noted the resident was receiving Ativan 1 milligram at bedtime for anxiety disorder. The surveyor reviewed the Behavior/Intervention Flow Record for the month of August 2019. The information documented did not match the facility form's key on Resident #122. The surveyor notified the DON (director of nursing) on 8/8/19 at 1:27 pm. The DON stated, We have educated and educated these nurses on what and how to document using the key on the behavior form. I just have a bunch of new nurses and that's why we are seeing this. The surveyor notified the administrative team of the above documented findings on 8/8/19 at 4:22 pm. No further information was provided to the surveyor prior to the exit conference on 8/9/19. 2. The facility staff failed to ensure Resident #110's clinical record correctly captured the individual(s)/provider(s) who gave orders for MiraLax Powder, a Dulcolax tablet, and to discontinue (d/c) a colonoscopy. Resident #110 was admitted on [DATE]. Resident #110's diagnoses included, but were not limited to: high blood pressure, arthritis, dementia, and renal disease. Resident #110's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 7/18/19 assessed the resident with a BIMS (brief interview for mental status) score of 0 out of 15; this assessment also documented the resident as usually able to express ideas and wants and sometimes able to understand others. Resident #110's clinical record included provider orders for MiraLax powder, a Dulcolax tablet, and to discontinue (d/c) a colonoscopy. The orders read as if Physician #4 had given the three (3) aforementioned orders. On 08/08/19 at 12:35 p.m., Physician #4 was interviewed via telephone. When asked about the three (3) aforementioned orders, Physician #4 reported he/she did not give the orders. Physician #4 stated he/she was out of country on 7/25/19 when the order to discontinue (d/c) the colonoscopy was given. Physician #4 reported the orders for the Miralax and Dolcolax would have been given by individuals from the facility performing the colonoscopy. During an interview on 8/8/19 at 12:40 p.m., Licensed Practical Nurse (LPN) #12 and LPN #14 reported when taking a verbal order from someone who is covering for a facility provider, the order is entered as being given by the PCP (primary care provider). The surveyor requested a copy of the facility's policy and procedure to guide obtaining this type of verbal order. On 8/8/19 at 1:25 p.m., the facility's administrator reported the facility's electronic order system will not allow an order to be entered by some consulting providers, therefore the facility staff enters the order under the PCP's name. On 8/8/19 at 2:40 p.m., LPN #12 provided the surveyor with a copy of the preparation instructions sent by the providers who were scheduled to complete Resident #110's colonoscopy. LPN #12 reported the facility's staff was unable to enter the colonoscopy prep orders into the facility's electronic order system under the name of a provider who does not have access to sign the orders in the electronic system. LPN #12 reported it was not an expectation that staff would call a facility provider to confirm the order due to the provider reviewing orders when he/she comes to the facility. On 8/8/19 at 2:52 p.m., the Regional Director of Clinical Services (RDCS) reported orders received from a provider, other than the ones allowed to give orders at the facility, have to be reviewed with a provider who is able to give orders prior to the orders being entered into the electronic system. The RDCS reported the facility had no written policy/procedure to guide the process of obtaining orders from a provider not allowed to give orders at the facility. The facility's Medical Director (MD) was interviewed on 8/9/19 at 8:53 a.m. The MD reported, when taking orders from a consulting/specialist provider, the facility staff should verbally contact the provider whose name the order will be entered under prior to entering the order into the facility's electronic order system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to coordinate care with Hospice services for 2 of 25 residents in the survey sample (Resident #122 and #71). The findings included: 1. The facility did not have the hospice clinical notes and care plan available for review by the surveyor for Resident #122. Resident #122 readmitted to the facility on [DATE] with the following diagnoses of, but not limited to atrial fibrillation, blood clot, neurogenic bladder, pneumonia, septicemia and dementia. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/24/19; the resident was coded having a BIMS (Brief Interview for Mental Status) score of 9 out of a possible score of 15. Resident #122 was also coded as being dependent on 1-2 staff members for dressing, personal hygiene and bathing. During the clinical record review on 8/7/19, the surveyor could not locate the Hospice care plan, aide or nursing notes for the visits that the hospice staff has provided to this resident. At 3:51 pm, the surveyor notified the regional nurse of the above documented findings. The regional nurse looked into the hospice notebook located on the nursing unit and she could not find these notes either. She stated that she would notify the DON (director of nursing) about this and get back with the surveyor. On 8/8/19 at 2 pm, the surveyor received copies of the nurses and aides' notes along with the Hospice plan of care. The DON stated that the hospice company brought these notes to the facility on the evening of 8/7/19. No further information was provided to the surveyor prior to the exit conference on 8/9/19. 2. The facility did not have the hospice clinical notes and care plan available for review by the surveyor for Resident #71. Resident #71 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, high blood pressure, dementia and respiratory failure. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/29/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 11 out of a possible score of 15. Resident #71 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and being totally dependent on 2 staff members for bathing. During the clinical record review on 8/8/19, the surveyor noted there were no hospice clinical notes available for review after 7/22/19. This was the last visit that had been made by the hospice company. At 3:06 pm, the surveyor notified the DON (director of nursing) of the above documented findings. On 08/09/19 09:45 am the surveyor was given a copy of a hospice nursing note dated for 7/30/19 by the DON. The DON stated to the surveyor that the hospice company brought this to the facility last night (8/8/19) after they were called. The surveyor notified the administrative team of the above documented findings on 8/9/19 at 10 am. No further information was provided to the surveyor prior to the exit conference on 8/9/19.

Based on observation, staff interview and facility document review, the facility staff failed to maintain an infection control program designed to provide a sanitary practices by ensuring that infection control practices were followed during the medication pass and pour observation on 1 of 3 units in the nursing facility (Unit #1 on 1st floor). The findings included: On 8/7/19 at 8:43 am, the surveyor observed LPN (licensed practical nurse) #1 prepare and administer medications to Resident #57 during the medication pass and pour observation. The surveyor did not observe LPN #1 wash her hands before or after administrating the medications to this resident. At 8:55 am, the surveyor again observed LPN #1 preparing and administrating medications to Resident #9 during the medication pass and pour observation. The surveyor did not observe LPN #1 washing her hands before or after administrating medications to this resident. The surveyor asked LPN #1 when she should wash her hands. LPN #1 stated, You are to wash your hands between residents. The surveyor notified LPN #1 that she was not observed in washing her hands before or after administrating medications to Resident #57 and Resident #9. At 9:29 am, the surveyor notified the DON (director of nursing) and the regional nurse consultant of the above documented findings. The surveyor requested a copy of the facility's policy on hand washing during medication administration. The surveyor received a copy of the facility's policy titled, Hand Washing which read in part, .Wash hands with either plain or antimicrobial soap and water or rub hands with an alcohol-based formulation before handling medication . The surveyor notified the administrative team of the above documented findings on 8/7/19 at 4:22 pm. No further information was provided to the surveyor prior to the exit conference on 8/9/19.