Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to honor the residents preference of eating meals in the dining room for 1 of 22 current residents, Resident #3. The findings include: The facility staff failed to ensure the dining room was available for all three meals 7 days a week. Resident #3's diagnoses included, but were not limited to, mild protein calorie nutrition and diabetes. Section C (cognitive patterns) of Resident #3's significant change in status minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/03/24 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Per the MDS manual a score of 15=cognitively intact. Section GG (functional abilities and goals) was coded to indicate this resident used a wheelchair for mobility and was partial/moderate assist with eating. On 09/04/24 at 11:35 a.m., during an interview with Resident #3, this resident stated they liked to get out of their room and needed to move around. Resident #3 stated they went to the dining room for meals but was unable to go on weekends as the dining room was not open. On 09/04/24 at 11:40 a.m., during an interview with Licensed Practical Nurse (LPN) #1, this staff stated the dining room was not open on weekends due to staffing issues. On 09/04/24 at 12:30 p.m., during an interview with Certified Nursing Assistant (C.N.A.) #1 this staff stated the dining room was not open in the evenings and weekends. It was open if they have a special event. On 09/04/24 at 2:30 p.m., during a meeting with the Administrator, Director of Nursing (DON), and Regional Nurse Consultant (RNC) these staff were asked if the dining room was being utilized on weekends and nights. The Administrator stated they were not aware if it wasn't being utilized and the DON stated they had a big turn out at lunch and for breakfast on Fridays. On 09/05/24 at 8:29 a.m., the surveyor observed the housekeeping staff cleaning the floors in the dining room. No residents were observed to be in the dining area. Housekeeper #1 stated the dining room was not being used this morning and stated COVID was on the rise. This facility did not have any COVID positive cases during the time of the survey. On 09/05/24, the Dietary Manager stated the dining room was always open at mealtimes for the residents and some choose not to come. On 09/05/24 at 10:30 a.m., the Administrator, DON, and RNC, were made aware of Resident #3's concern that the dining room was not opened for all meals and that the dining room was observed by the surveyor not being utilized for breakfast this morning. The Administrator stated they did not know why it was not being used. 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 staff interview, clinical record review and facility document review, the facility staff failed to notify the provider of a critical lab result for 1 of 9 closed records, Resident #129. The findings included: Resident # 129's diagnoses included but were not limited to history of cerebral infarction (stroke), chronic obstructive pulmonary disease, hypertension, moderate protein calorie malnutrition, depression, vitamin deficiency and depression. The minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/21/23 assigned the resident a brief interview for mental status (BIMS) score of 15 out of 15 indicating intact cognition. A review of resident # 129's medication administration record (MAR) revealed they were on aspirin 81 mg daily for CVA (stroke) prophylaxis and Eliquis (an anticoagulant medication used to treat and prevent blood clots and prevent stroke) 5 mg twice daily. Each of these medications are given to thin the blood and put the patient at risk of bleeding. There was an entry on the treatment administration record (TAR) that read, Monitor for signs and symptoms of bleeding while receiving Eliquis. Notify MD if resident has dark/discolored urine, black tarry stools, nosebleed, vomiting and/or coughing up blood. This nursing intervention is signed as done September 1, 2023, through September 10, 2023. A Nurse Practitioner (NP) progress note dated 9/10/23 read in part, She is being seen today for f/u labs. Pt is sitting up in her bed, appears comfortable and in no acute distress. A&O x3, pleasant and responsive. Resident had recent labs drawn for CBC, CMP & TSH, results were significant for H&H of 6.1/19.2 and elevated LFT's ALT 180, AST 189 & Alk Phos 757. She was sent to the ER for blood transfusion. There have been no reported fevers or hypoxia. Denies CP, abd pain, SOB or N/V. H & H is the abbreviation for hemoglobin and hematocrit. The hemoglobin of 6.1 was a critical low result and this was indicated in red lettering on the lab report. The lab results were reviewed by this surveyor and noted to have a resulted date of 9/9/23 at 5:03 PM. According to the progress notes, the critical results were not given to, or addressed by a practitioner until 9/10/23 at 2:54 PM. According to the National Center for Biotechnology, a hemoglobin of less than 6.5 is life threatening and should be considered a medical emergency. The resident was readmitted to the facility on [DATE], less than 2 weeks later. Hospital records indicate they required two units of blood for a diagnosis of a gastrointestinal bleed. A hospital progress note with a date of service of 9/11/23 read in part, .presented at (hospital name omitted) on September 10 with complaints of vomiting and anemia. She also complained of feeling lightheaded for the past month but denies blood in her stool that she was aware of. She was found to be anemic (not enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) and tachycardic (fast heart rate which is a common symptom of blood loss). On 9/5/24 at 4:44 PM this surveyor interviewed the Director of Nursing (DON) and the Regional Nurse Consultant. Surveyor asked about the delay between the lab results being available in the electronic medical record and actually being seen and addressed by the practitioner. The DON stated, They didn't call us, so we didn't know. It was just a routine lab, so we weren't looking for the results, we didn't expect any problem. They are supposed to call us when they get a critical result and then they put on the actual results who they talked to, but they didn't do that. I just don't feel like that is our fault. The Regional Nurse Consultant stated the facility has been having concerns with the lab service for some time. This surveyor reviewed the policy entitled, Resident Change in Condition Policy with an effective date of 1/27/2011. The document read in part, A Significant Change in Condition is a decline or improvement in the resident's status and 6. In the event of an emergency situation, 911 will be called immediately and the physician or provider/family/responsible party will be notified as soon as practicably possible. The survey team met with the Administrator, DON, Regional Nurse Consultant and the Regional VP of Operations on 9/5/24, this concern was discussed. No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide Notice of Medicare Non-Coverage at least two days prior to the end of a Medicare covered Part A stay when benefit days were not exhausted for 1 of 3 sampled residents, Resident #45. The findings included: For Resident #45, the facility staff failed to provide Notice of Medicare Non-Coverage at least two days prior to the end of their Medicare covered Part A stay. Resident #45's diagnosis list indicated diagnoses, which included, but not limited to Sepsis, Generalized Muscle Weakness, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Chronic Kidney Disease, and Type 2 Diabetes Mellitus. The minimum data set (MDS) with an assessment reference date (ARD) of 3/14/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #45's last covered day of Medicare Part A services was 4/03/24. A Notice of Medicare Non-Coverage (NOMNC) was issued and signed by the resident on 4/02/24. An 4/02/24 2:37 PM social services progress note read in part Notice of Medicare Non Coverage [sic] given to resident on this date. Last covered day of skilled care will be 4/03/24. Appeals and denials process explained to resident. [Resident #45] states [he/she] does not want to appeal this denial and will discharge home . On 9/05/24 at 12:57 PM, surveyor spoke with the facility social worker (SW) and inquired reason why Resident #45 was not issued a NOMNC at least two days prior to their last cover day. SW stated the NOMNC should have been signed 48 hours prior and they were not sure why it was not. Surveyor requested and received the facility policy titled Medicare Cut Letter Policy with a last revision date of 8/24/23 which read in part The Facility will assure all residents receive timely and appropriate notification of Medicare non-coverage for services in accordance with State and Federal guidelines .Notice must be issued prior to, but no later than 2 days before the termination of such services .For Residents who have days remaining in their benefit period, and will be discharged the first calendar day following their last Medicare covered day, the Social Worker, or Designee, will notify the Resident/Authorized Representative when the resident is approaching the end of coverage, but no later than 2 days prior to the last covered Medicare Part A day, by issuing the Notice of Medicare Provider Non-Coverage CMS-10123 . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure appropriate information is documented and/or communicated to the receiving healthcare institution for 1 of 31 sampled residents Resident #26. The findings included: For resident # 26 the facility staff failed to provide evidence that the receiving healthcare facility was provided adequate information to care for the resident on 3/31/24. Resident # 26's diagnoses included but were not limited to Type 2 diabetes, chronic obstructive pulmonary disease, protein calorie malnutrition, congestive heart failure, hypertension, depression and chronic kidney disease. The minimum data set (MDS) assessment with an assessment reference date of 8/16/24 assigned the resident a brief interview for mental status score of 15 out of 15 indicating intact cognition. During a review of the clinical record, a progress note dated 3/31/24 at 11:16 PM read, Patient present with confusion and hallucination. Patient daughter called requesting that the patient be sent out. ____ called and stated that another course of action needed to be taken and to not send the patient out. Writer went into patient room again and patient is still hallucinating. Patient states that kids are in her room and that things are crawling on the ceiling and the walls trying to get her. Writer is waiting on call back from ____ as to course of action to take. ____ called back and stated to send patient to the ER. No further information was documented in the notes. Surveyor was unable to locate a transfer form in the record. On 9/5/24 at 11:14 AM this surveyor interviewed corporate staff # 4. Surveyor asked for evidence that the staff communicated all pertinent information to the receiving hospital including contact information of the practitioner responsible for the care of the resident, resident representative contact information, advance directives, special instructions and/or precautions for ongoing care; special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions, the resident's comprehensive care plan goals, and all other information necessary to meet the resident's needs. They stated, They didn't even do the transfer form or anything. On 9/5/24 at 4:44 PM the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultant, and Regional VP of Operations. This concern was discussed with them at that time. No further information was provided to the survey team prior to the exit conference.

2. For Resident #71, the facility staff failed to provide the resident and/or the resident's representative with the facility bed-hold policy upon transfer on 5/8/24 and 7/5/24. Resident #71's diagnosis list indicated diagnoses that included, but were not limited to, Prostate Cancer, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Congestive Heart Failure, Depression and Candidal Cystitis, and Urethritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/15/24, assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating Resident #71 was cognitively intact. A review of the clinical record indicated Resident #71 was transferred to the hospital on 5/8/24 and on 7/5/24. No evidence of the facility's bed-hold policy being provided to the resident and/or the resident's representative could be located. On 9/5/24 at 11:05 AM, corporate staff #4 (CS#4) informed surveyor that no evidence could be located of the bed hold being given to Resident #71 and/or resident's representative for the transfers to the hospital on 5/8/24 and 7/5/24. This concern was discussed at the pre-exit meeting on 9/5/24 at 5:03 PM with the administrator, director of nursing, regional director of clinical services, and regional vice president of operations. Surveyor requested and received a facility document, titled, Resident Discharge/Transfer Letter Policy, that read in part, .G. The resident or responsible party will receive a bed hold notice .3. A copy of the completed bed hold notice will be scanned into the electronic chart . Surveyor also received a facility document titled, BED HOLD NOTICE, that read in part, .This notice is to be provided to the resident and his/her representative at the time of transfer. In the case of an emergency, the paperwork should be provided within 24 (twenty-four) hours . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/5/24. Based on Staff interview, clinical record review and facility document review, the facility staff failed to provide evidence of a bed hold being provided to 2 of 31 residents, Residents #26 and #71. The findings included: 1. Resident # 26's diagnoses included but were not limited to Type 2 diabetes, chronic obstructive pulmonary disease, protein calorie malnutrition, congestive heart failure, hypertension, depression and chronic kidney disease. The minimum data set (MDS) assessment with an assessment reference date of 8/16/24 assigned the resident a brief interview for mental status score of 15 out of 15 indicating intact cognition. During a review of the clinical record, a progress note dated 3/31/24 at 11:16 PM read, Patient present with confusion and hallucination. Patient daughter called requesting that the patient be sent out. ____ called and stated that another course of action needed to be taken and to not send the patient out. Writer went into patient room again and patient is still hallucinating. Patient states that kids are in her room and that things are crawling on the ceiling and the walls trying to get her. Writer is waiting on call back from ____ as to course of action to take. ____ called back and stated to send patient to the ER. No further information was documented in the notes. Surveyor was unable to locate a transfer form in the record. On 9/5/24 at 11:14 AM this surveyor interviewed Corporate staff # 4. Surveyor asked for evidence that the staff provided the resident or resident representative with the bed hold policy. They stated, They didn't even do the transfer form or anything. On 9/5/24 at 4:44 PM the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultant, and Regional VP of Operations. This concern was discussed with them at that time. No further information was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review the facility staff failed to ensure an accurate minimum data set (MDS) assessment for 2 of 9 closed record reviews, Resident #76 and Resident #25. The findings included: 1. For Resident #76 the facility staff incorrectly coded the resident's discharge MDS assessment. Resident #76's face sheet listed diagnoses which included but not limited to cellulitis and diabetes mellitus. Resident #76's discharge MDS with an assessment reference date of 06/14/24 coded the resident as being discharged to short-term general hospital (acute hospital). Resident #76's clinical record contained a nurse's progress note dated 06/14/24 which read in part, Resident discharged home with home health services. His transportation via wheelchair took him to his residence. All medications and paperwork was taken by the resident. Resident signed for his narcotics and other medications. Vital signs are within normal limits. All personal belongings were taken by the resident. Nursing educated resident on fall precautions and resident verbalized understanding. NP (nurse practitioner) approved all orders. Surveyor spoke with registered nurse (RN) # 1 on 09/04/24 at 4:40 pm. Surveyor asked RN #1 where resident discharged to, and RN #1 stated, He discharged home on [DATE]. Surveyor asked RN #1 where resident's MDS read that they were discharged to, and RN #1 looked at MDS and stated, It says he discharged to the hospital, that's not right. RN #1 stated they would do a correction to the MDS. The concern with the incorrectly coded MDS was discussed with the administrator, director of nursing, and regional director of clinical services on 09/05/24 at 10:30 am. No further information was provided prior to exit. 2. For Resident #25, the facility staff failed to complete a discharge minimum data set (MDS) assessment. Resident #25's diagnoses included, but were not limited to, diabetes and dementia. During the Resident Assessment task Resident #25 had flagged for an MDS assessment over 120 days old. During the record review the surveyor was unable to find a discharge MDS assessment when the Resident had been discharged from the facility On 09/04/24 at 4:36 p.m., during an interview with MDS coordinator #1 and #2 both staff were asked about a discharge MDS assessment for Resident #25. After reviewing the clinical record these staff confirmed that a discharge MDS assessment had not completed and stated they had switched software systems in March of 2024. Under the census tab in the clinical record, the facility staff had documented this resident had been discharged in April 2024 return not anticipated. On 09/04/24 at 2:30 p.m., during a meeting with the Administrator, Director of Nursing, and Regional Nurse Consultant the concern with the missing discharge MDS assessment was reviewed. Prior to the exit conference the MDS coordinators provided the surveyor with a copy of a form (no title) indicating they had completed Resident #25's discharge assessment and it had been accepted. No further information regarding this issue was provided to the survey team prior to the exit conference.

2. For Resident #379, the facility staff failed to follow a provider's order for the resident to be NPO (nothing by mouth) for a scheduled medical procedure on 3/29/23. This was a closed record review. Resident #379's diagnosis list indicated diagnoses, which included, but not limited to End Stage Renal Disease, Edema, Depression, Dependence on Renal Dialysis, Type 2 (two) Diabetes Mellitus with Diabetic Neuropathy, Chronic Obstructive Pulmonary Disease, Weakness, and Retention of Urine. The minimum data set (MDS) with an assessment reference date (ARD) of 3/22/23 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of the clinical record revealed a nursing progress note dated, 3/28/2023, that read in part, .Follow up appointment made for 3/29/23 with an arrival time of 1130am [sic], surgery time scheduled for 130pm [sic]. Resident is NPO after midnight for the procedure . A provider's order dated 3/28/24, that read in part, .NPO diet NPO texture for Upcoming surgery for 1 (one) Day . Surveyor requested and received Resident #379's meal intake record that revealed a code of 3 (three) on 3/29/23, which indicated the resident had eaten 76%-100% of breakfast on the day of the scheduled surgical procedure. On 9/5/24 at 10:52 AM, administrative staff #4 agreed that resident received breakfast on 3/29/23, prior to the scheduled medical procedure. The medical procedure was performed, but the resident was not able to have anesthesia for the procedure. This concern was discussed with the administrator and administrative staff #4 on 9/5/24 at 9:45AM and again at the pre-exit meeting on 9/5/24 at 5:03 PM with the administrator, director of nursing, regional director of clinical services, and regional vice president of operations Surveyor requested and received a facility policy title, Physician/Provider Orders, that read in part, .The Charge Nurse shall .review all physician/provider orders . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/5/24. Based on staff interview, clinical record review, and facility document review, the facility staff failed to follow provider orders for 2 of 9 closed record reviews, Residents #229 and #379. The findings include: 1. For Resident #229, the facility staff failed to complete provider ordered treatments to a surgical wound. Resident #229's diagnoses included, muscle weakness, need for assistance with personal care, diabetes, and non-pressure related chronic ulcer of other part of left foot. Section C (cognitive patterns) of Resident #229's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 04/04/23 included a brief interview for mental status (BIMS) score of 15. Per the MDS manual a score of 15=cognitively intact. Resident #229's comprehensive care plan included the focus area resident has risk of skin breakdown and actual impaired skin integrity. Interventions included administer medications/treatments as ordered. The clinical record included the following progress note documented on the residents admission to the facility .Wound type is skin graft .Wound Location left heel .Area is community acquired. Skin impairment was present on admission . On 03/08/23 the nursing staff documented a progress note indicating the surgical incision wound location was the left plantar foot and lateral foot. Treatment updated to pack with normal saline moist gauze. A review of the clinical record revealed that on March 9, 10, and 31 the treatment administration blocks where the nursing staff would have documented that they had completed the treatment were left blank. For the month of April, the nursing staff had failed to document they had completed the treatment on April 1 and 11. For the month of May the facility nursing staff failed to document they had completed the provider ordered treatment on May 8 and 19. On 09/04/24 at 4:10 p.m., during an interview with Licensed Practical Nurse #6 this staff stated they remembered this resident having dressings to their feet but did not recall them saying anything about the treatments not being completed. On 09/05/24 at 2:14 p.m., during an interview with the Regional Nurse Consultant this staff was asked what a blank spot (hole) on the treatment administration record (TAR) where nursing would document they had completed a treatment would mean. The Nurse Consultant stated it could mean it wasn't done or they just forgot to sign for the treatment. On 09/05/24 at 2:45 p.m., the Administrator, Director of Nursing (DON), and Regional Nurse Consultant were made aware that there was no evidence to indicate the facility nursing staff had completed the provider ordered treatments to Resident #229's surgical wound for the dates provided in March, April and May of 2023. No evidence was provided to the survey team to indicate these treatments had been completed by the nursing staff prior to the exit conference on 09/05/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure residents were free of significant medication errors for 1 of 9 closed record reviews. (Resident #279). The findings were: For Resident #279, facility staff failed to administer Insulin Lispro (1 Unit dial) Solution Pen-Injector 100 UNIT/ML according to hospital discharge orders. Resident #279's stay at the facility was approximately two (2) days. The admission record listed diagnoses which included but not limited to sepsis, and osteomyelitis, left ankle and foot. The acute care hospital discharge summary listed the active problem of type 2 diabetes mellitus with complication, with long-term current use of insulin. Resident #279's minimum data set (MDS) [NAME] Report listed the resident's cognition having ok short-term and long-term memory. The resident was able to recall the season, room location, staff names/faces, and that the resident was in a nursing home. The MDS [NAME] read the resident was independent with daily decision making. The provider orders included but were not limited to, two (2) insulin orders. One order dated 01/07/2023 was for Insulin Lispro Kwikpen 100 unit/1 ml insulin pen. Inject as per sliding scale: If 100 - 120 = 10 units; 151 - 200 = 14 units; 201 - 250 = 18 units; 251+ = 22 units, subcutaneously three times a day for DMII (diabetes mellitus type 2). This provider order's sliding scale did not address blood sugar results between 121 and 150. The second insulin order read, Basaglar KwikPen Solution Pen-Injector 100 units/ml (Insulin Glargine). Inject 42 units subcutaneously two times a day for diabetes mellitus type 2. The medication administration record (MAR) for January 2023 was reviewed and noted three (3) times when the Insulin Lispro Kwikpen dose was not administered. Those doses were documented as a 3 which the chart code defined as no insulin required. 1. On 01/07/23 at 6:00 a.m., the blood sugar = 137 with no insulin administered. 2. On 01/07/23 at 2:00 p.m., the blood sugar = 143 with no insulin administered. 3. On 01/08/23 at 6:00 a.m., the blood sugar = 75 with no insulin administered. On 09/05/24 at 4:26 p.m., the staff development coordinator, (licensed practical nurse - LPN #4) was interviewed about the insulin and sliding scale provider order that did not include orders for blood sugars between 121 and 150. LPN #4 reported facility staff use hospital discharge orders to document facility admission orders for residents. The nurse stated the insulin sliding scale orders had been transcribed incorrectly which resulted in an insulin administration error. LPN #4 provided the acute care hospital discharge summary and pointed out the Insulin Lispro (1 Unit Dial) 100 unit/ml pen injector order read to inject subcutaneously three times a day before meals using a sliding scale: 100 - 150 = 10 units; 151 - 200 = 14 units; 201 - 250 = 18 units; greater than 250 = 22 units. LPN #4 acknowledged that if facility staff had transcribed the insulin sliding scale from the hospital discharge orders correctly, Resident #279 should have received insulin for two of the three doses when the resident did not receive any insulin: the blood sugar = 137 and the blood sugar = 143. The MAR noted the Basaglar KwikPen Solution (Insulin Glargine) doses were administered on 01/07/23 for both doses however, the 01/08/23 9:00 a.m. dose was not administered with a chart code listed as 19 which was defined as Other/See Nurses Notes. No nurses note for that date and time was found in the progress notes. The surveyor was unable to determine the exact time Resident #279 left the facility. The MAR did not contained documentation to indicate Resident #279 refused insulin. The concern regarding Resident #279's insulin sliding scale transcription error and subsequent missed insulin doses was discussed with the administrator, director of nursing, regional nurse consultant, and vice president of operations on 09/05/24 at 5:05 p.m. On 09/05/24 at 4:16 p.m., this surveyor unsuccessfully attempted to contact the nurse who admitted Resident #279. The nurse who provided care to the resident during day shift no longer worked at the facility. No further information was provided prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to obtain a provider ordered laboratory test for 1 of 22 residents, Resident #20. The findings included: For resident # 20, the facility staff failed to obtain a Depakote level on 11/22/23 per physician's order. Resident # 20's diagnoses included but were not limited to unspecified dementia, bipolar disorder and depression. Resident # 20's minimum data set (MDS) assessment with an assessment reference date of 6/8/24 indicated that resident is severely cognitively impaired, they are rarely/never understood, rarely never understands others and decision making is severely impaired as well. During a review of resident # 20's Medication Regimen Reviews for the last year, a pharmacist Consultation Report with a date of 12/19/23, read in part, .has orders for labs but at the time of this review they were not available in the medical record. The missing lab values include: Depakote level every Wed related to bipolar disorder .Unless otherwise indicated, please ensure that ordered labs are obtained. Please disregard recommendation if these labs have been recently obtained. The report was signed by the Director of Nursing (DON) on 1/16/24. This surveyor was unable to locate the lab results in the clinical record. The orders were reviewed and an order for the lab work was noted, it was dated 11/21/23. The treatment administration record (TAR) for November 2023 was reviewed. The order for the lab was on the TAR to be obtained on 11/22/23. The order had not been signed off as done on the TAR. On 9/5/24 at 2:19 PM this surveyor spoke with the DON and asked if they could provide the results of the Depakote level done on 11/22/23. At 2:26 PM Licensed Practical Nurse (LPN) # 3 brought in labs dated 1/3/24 and 1/10/24. They stated they were not able to locate any labs from 11/22/23 and that they had even checked with the contracted lab provider. When surveyor asked why the lab wasn't done, they stated, I'm not sure. It was missed. The survey team met with the DON, Administrator, Regional Nurse Consultant and Regional VP of Operations on 9/5/24 at 4:44 PM. This concern was discussed at that time. No further information was provided to the survey team prior to the exit conference.

Based on observation and staff interview, the facility staff failed to store food in accordance with professional standards for food service safety in the facility kitchen. The findings included: The facility staff failed to discard seven (7) containers of unsweetened coconut milk that had exceeded the best by date of 5/13/24. On 9/04/24 at 9:30 AM, in the presence of the Dietary Manager (DM), the surveyor observed seven (7) 32-ounce containers of unsweetened coconut milk each with a best if used by date of 5/13/24 present in the dry storage area of the facility kitchen. The DM removed the containers of unsweetened coconut milk from the dry storage area. On 9/05/24 at 10:40 AM, the survey team met with the Administrator, Director of Nursing, and the Clinical Services Manager and discussed the concern of out-of-date coconut milk present in the facility kitchen. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record reviews, and facility document review, the facility staff failed to ensure a complete and/or accurate clinical record for 3 of 31 sampled residents, Resident #379, Resident #9, and Resident #62. The findings include: 1. For Resident #379, the facility staff failed to document the resident's allergy to the medication Hydrocodone in the clinical record. This was a closed record review. Resident #379's diagnosis list indicated diagnoses, which included, but not limited to End Stage Renal Disease, Edema, Depression, Dependence on Renal Dialysis, Type 2 (two) Diabetes Mellitus with Diabetic Neuropathy, Chronic Obstructive Pulmonary Disease, Weakness, and Retention of Urine. The minimum data set (MDS) with an assessment reference date (ARD) of 3/22/23 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of the clinical record revealed Resident #379 had no known allergies on the face sheet, provider's orders, care plan, and on the March 2023 MAR (medication administration record). Further review of an H & P (history and physical exam) dated 3/5/23 from the transferring hospital, revealed Resident #379 had an allergy to Hydrocodone-Acetaminophen. A facility document titled, Nursing admission Report, indicated resident had an allergy to Hydrocodone. This concern was discussed with the administrator and administrative staff #4 on 9/5/24 at 9:45 AM and again at the pre-exit meeting on 9/5/24 at 5:03 PM with the administrator, director of nursing, regional director of clinical services, and regional vice president of operations. Surveyor requested and received a facility policy titled Physician/Provider Orders, that read in part, .PROCEDURE .All information received from the referring facility or agency shall be reviewed. 1. Transcribe all orders from the transfer form to the facility admission physician order form. Orders should include the following .l. Allergies . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/5/24. 2. For resident # 9, the facility staff failed to ensure a complete and accurate Social Services Annual Evaluation. Resident # 9's diagnoses included but were not limited to chronic obstructive pulmonary disease, history of stroke, moderate protein calorie malnutrition, adult failure to thrive and major depressive disorder. During a review of the clinical record an order for DNR (do not resuscitate) status was observed. There were no advanced directives in the record. An annual Social Services Evaluation with an effective date of 5/23/23 was reviewed. The document stated that resident # 9 had a Living Will. On 9/5/24 at 9:29 AM this surveyor asked the Regional Nurse Consultant for a copy of resident # 9's Living Will. On 9/5/24 at 10:26 AM this surveyor asked Registered Nurse (RN) # 3 if they were aware of resident # 9 having a Living Will. They did not and stated it would be in the electronic record if there was one. When informed of the Social Services Annual Assessment they stated, It was marked incorrectly. On 9/5/24 at 4:44 PM the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultant and Regional VP of Operations. This concern was discussed at that time. No other information was provided to the survey team prior to the exit conference. 3. For Resident #62 the facility staff failed to accurately complete a Virginia Department of Health Durable Do Not Resuscitate (DDNR) form. Resident #62's face sheet listed diagnoses which included but not limited to congestive heart failure, diabetes mellitus, and peripheral vascular disease. Resident #62's most recent minimum data set with an assessment reference date of 08/03/24 assigned the resident a 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 #62's comprehensive care plan was reviewed and contained a care plan for Resident has chosen DNR (do not resuscitate) status. Resident #62's clinical record was reviewed and contained a Virginia Department of Health DDNR for which read in part, I, the undersigned, state that I have a [NAME] fide physician/patient relationship with the patient named above. I have certified in the patient's medical record that he/she or a person authorized to consent on the patient's behalf has directed that life-prolonging procedures be withheld or withdrawn in the event of cardiac or respiratory arrest. I further certify (must check 1 or 2): No boxes were check under this section. The form went on the read, If you checked 2 above, check A, B, or C below: No boxes in this section were checked. Surveyor spoke with the regional director of clinical services (RDCS) on 09/05/24 at 10:20 am regarding Resident #62's DDNR form. RDCS stated that form was incomplete. The concern of the incomplete DDNR form was discussed with the administrator, director or nursing, and RDCS on 09/05/24 at 10:30 am. No further information was provided prior to exit.

Based on observation and staff interview, the facility staff failed to maintain infection prevention and control practices during medication administration for 1 of 2 nursing units, Unit #1. The findings included: For Unit #1, the licensed practical nurse (LPN) placed a resident's inhaler in their uniform pocket to transport into the resident's room prior to administration. On 9/05/24 at 8:43 AM, surveyor observed LPN #5 place a resident's Breo inhaler in the pocket of their uniform top to transport to the resident's room. LPN #5 removed the inhaler from their pocket and handed it to the resident for administration. When asked about placing the Breo inhaler in their pocket, LPN #5 stated they did not know if the resident would have tissues available in their room for use with their eye drops so they took theirs from the medication cart causing them to have extra items in their hands and they did not want to make two trips. On 9/05/24 at 10:40 AM, the survey team met with the Administrator, Director of Nursing, and Clinical Services Manager and discussed the concern of LPN #5 placing a resident's inhaler in their uniform pocket. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer a pneumococcal vaccine in accordance with nationally recognized standards for 3 of 5 sampled residents reviewed for immunizations (Resident #42, #49, and #72). The findings included: 1. For Resident #42, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 15 (PCV15) or a pneumococcal conjugate vaccine 20 (PCV20) following admission to the facility. Resident #42's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Parkinson's Disease, and Generalized Muscle Weakness. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/02/24 assigned the resident a brief interview for mental status (BIMS) summary score of 8 out of 15 indicating the resident was moderately cognitively impaired. Resident #42 was over the age of 65 years when admitted to the facility. Surveyor reviewed Resident #42's clinical record and was unable to locate a pneumococcal vaccination history or evidence the resident was offered a PCV15 or PCV20 following admission to the facility. The Centers for Disease Control and Prevention (CDC) guideline titled, Recommended Adult Immunization Schedule for Ages 19 Years or Older dated 12/28/23 read in part that adults age [AGE] years or older who have not previously received a dose of PCV13 (pneumococcal conjugate vaccine 13), PCV15, or PCV20 or whose previous vaccination history is unknown should receive one dose of PCV15 or PCV20. Surveyor met with the Infection Preventionist (IP) and Administrative Staff Member (ASM) #4 on 9/04/24 at 2:50 PM and discussed Resident #42's pneumococcal vaccination status. The IP and ASM #4 were unable to provide evidence of the facility offering the resident a PCV15 or PCV20 following admission. Surveyor requested and received the facility policy titled, Resident Vaccination Policy with a last revision date of 5/18/22 which read in part, Resident and/or their responsible party will be asked about prior vaccinations at admission. Prior doses of .pneumococcal .and other vaccines will be documented in the immunization portal in the electronic health record .The Infection Preventionist will track resident immunizations and holds the responsibility for ensuring resident's vaccination history is reviewed with/by their providers and that vaccines are administered timely when ordered . On 9/04/24 at 3:14 PM, the survey team met with the Administrator, Director of Nursing, and Regional Clinical Services Manager and discussed the concern of staff failing to offer Resident #42 a pneumococcal vaccine. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24. 2. For Resident #49, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 20 (PCV20) or a pneumococcal polysaccharide vaccine 23 (PPSV23) following admission to the facility. Resident #49's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Aortic Valve Stenosis, and Essential Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/13/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #49 was over the age of 65 years when admitted to the facility. Resident #49's clinical record revealed the resident had previously received a pneumococcal conjugate vaccine 13 (PCV13) in 2016 and a PPSV23 in 2018 prior to admission and before age [AGE]. Surveyor was unable to locate evidence of Resident #49 being offered a PCV20 or PPSV23 following admission to the facility. The Centers for Disease Control and Prevention (CDC) guideline titled, Recommended Adult Immunization Schedule for Ages 19 Years or Older dated 12/28/23 read in part that adults 65 years or older who have previously received both PCV13 and PPSV23 but no PPSV23 was received at age [AGE] years or older should receive 1 dose of PCV20 or 1 dose of PPSV23. Surveyor met with the Infection Preventionist (IP) and Administrative Staff Member (ASM) #4 on 9/04/24 at 2:50 PM and discussed Resident #49's pneumococcal vaccination status. The IP and ASM #4 were unable to provide evidence of the facility offering the resident a PCV20 or PPSV23. Surveyor requested and received the facility policy titled, Resident Vaccination Policy with a last revision date of 5/18/22 which read in part, Resident and/or their responsible party will be asked about prior vaccinations at admission. Prior doses of .pneumococcal .and other vaccines will be documented in the immunization portal in the electronic health record .The Infection Preventionist will track resident immunizations and holds the responsibility for ensuring resident's vaccination history is reviewed with/by their providers and that vaccines are administered timely when ordered . On 9/04/24 at 3:14 PM, the survey team met with the Administrator, Director of Nursing, and Regional Clinical Services Manager and discussed the concern of staff failing to offer Resident #49 a pneumococcal vaccine. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24. 3. For Resident #72, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 15 (PCV15) or a pneumococcal conjugate vaccine 20 (PCV20) following admission to the facility. Resident #72's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease of Native Coronary Artery, Dementia, and Adult Failure to Thrive. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/13/24 assigned the resident a brief interview for mental status (BIMS) summary score of 10 out of 15 indicating the resident was moderately cognitively impaired. The MDS documented Resident #72's pneumococcal vaccination was not up to date with the reason being not offered. Resident #72 was over the age of 65 years when admitted to the facility. Surveyor reviewed Resident #72's clinical record and was unable to locate a pneumococcal vaccination history or evidence the resident was offered a PCV15 or PCV20 following admission to the facility. The Centers for Disease Control and Prevention (CDC) guideline titled, Recommended Adult Immunization Schedule for Ages 19 Years or Older dated 12/28/23 read in part that adults age [AGE] years or older who have not previously received a dose of PCV13 (pneumococcal conjugate vaccine 13), PCV15, or PCV20 or whose previous vaccination history is unknown should receive one dose of PCV15 or PCV20. Surveyor met with the Infection Preventionist (IP) and Administrative Staff Member (ASM) #4 on 9/04/24 at 2:50 PM and discussed Resident #72's pneumococcal vaccination status. The IP and ASM #4 were unable to provide evidence of the facility offering the resident a PCV15 or PCV20 following admission. Surveyor requested and received the facility policy titled, Resident Vaccination Policy with a last revision date of 5/18/22 which read in part, Resident and/or their responsible party will be asked about prior vaccinations at admission. Prior doses of .pneumococcal .and other vaccines will be documented in the immunization portal in the electronic health record .The Infection Preventionist will track resident immunizations and holds the responsibility for ensuring resident's vaccination history is reviewed with/by their providers and that vaccines are administered timely when ordered . On 9/04/24 at 3:14 PM, the survey team met with the Administrator, Director of Nursing, and Regional Clinical Services Manager and discussed the concern of staff failing to offer Resident #72 a pneumococcal vaccine. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer an updated 2023-2024 COVID-19 vaccine for 1 of 5 sampled residents (Resident #49), failed to provide evidence of education regarding the risks, benefits and potential side effects of the COVID-19 vaccine prior to the administration for 2 of 5 sampled residents (Resident #2 and #42), and failed to provide evidence of consent prior to the administration of a COVID-19 vaccine for 1 of 5 sampled residents (Resident #42). The findings included: 1. For Resident #49, the facility staff failed to offer the resident an updated 2023-2024 formula COVID-19 vaccine. Resident #49's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Aortic Valve Stenosis with Insufficiency, and Essential Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/13/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. A review of Resident #49's clinical record revealed their most recent COVID-19 vaccine was received on 2/02/23. Surveyor was unable to locate evidence of the resident being offered an updated 2023-2024 COVID-19 vaccine. Surveyor met with the Infection Preventionist (IP) and Administrative Staff Member (ASM) #4 on 9/04/24 at 2:50 PM and discussed Resident #49's COVID-19 vaccination status. The IP and ASM #4 were unable to provide evidence of the facility offering the resident an updated 2023-2024 COVID-19 vaccine. Surveyor requested and received the facility policy titled Resident Vaccination Policy with a last revision date of 5/18/22 which read in part .COVID vaccination will be offered to all residents and administered per provider orders .The Infection Preventionist will track resident immunizations and holds the responsibility for ensuring resident's vaccination history is reviewed with/by their providers and that vaccines are administered timely when ordered . On 9/04/24 at 3:14 PM, the survey team met with the Administrator, Director of Nursing, and the Regional Clinical Services Manager and discussed the concern of staff failing to offer Resident #49 an updated 2023-2024 formula COVID-19 vaccine. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24. 2. For Resident #42, the facility staff failed to provide evidence of the resident/resident representative (RR) receiving education regarding the risks, benefits, and potential side effects and obtaining consent prior to the administration of a COVID-19 vaccine. Resident #42's diagnosis list indicated diagnoses, which included, but not limited to Parkinson's Disease, Type 2 Diabetes Mellitus, and Generalized Muscle Weakness. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/02/24 assigned the resident a brief interview for mental status (BIMS) summary score of 8 out of 15 indicating the resident was moderately cognitively impaired. A review of Resident #42's clinical record revealed they received a COVID-19 vaccine on 6/27/24. Surveyor was unable to locate documentation indicating the resident and/or resident representative was provided education regarding the risks, benefits and potential side effects of the vaccine or consent was obtained prior to administration. On 9/04/24 at 2:50 PM, surveyor met with the Infection Preventionist (IP) and Administrative Staff Member (ASM) #4 who confirmed they were also unable to locate evidence of Resident #42's receiving education or providing consent prior to the administration of the COVID-19 vaccine. Surveyor requested and received the facility policy titled Resident Vaccination Policy with a last revision date of 5/18/22 which read in part .When a vaccination is ordered, a nurse or other licensed clinician/provider will review the CDC Vaccine Information Statement[s] (VIS) or Emergency Use Authorization (EUA) Statement[s] for any recommended vaccines with the resident/resident representative before obtaining consent. The resident/representative will have an opportunity to ask questions . On 9/04/24 at 3:14 PM, the survey team met with the Administrator, Director of Nursing, and the Regional Clinical Services Manager and discussed the concern of staff failing to provide education and obtain consent prior to the administration of a COVID-19 vaccine for Resident #42. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24. 3. For Resident #2, the facility staff failed to provide evidence of the resident/resident representative (RR) receiving education regarding the risks, benefits, and potential side effects prior to the administration of a COVID-19 vaccine. Resident #2's diagnosis list indicated diagnoses, which included, but not limited to Multiple Sclerosis, Schizophrenia, and Dementia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/08/24 assessed the resident as rarely/never able to make self understood and rarely/never able to understand others. Resident #2 was assessed as being severely impaired in cognitive skills for daily decision making. A review of Resident #2's clinical record revealed they received a Moderna Monovalent booster COVID-19 vaccine on 11/16/23. Surveyor was unable to locate documentation indicating the resident representative (RR) was provided education regarding the risks, benefits and potential side effects of the vaccine prior to administration. On 9/04/24 at 2:50 PM, surveyor met with the Infection Preventionist (IP) and Administrative Staff Member (ASM) #4 who confirmed they were also unable to locate evidence of Resident #2's RR receiving education prior to the administration of the COVID-19 vaccine. Surveyor requested and received the facility policy titled Resident Vaccination Policy with a last revision date of 5/18/22 which read in part .When a vaccination is ordered, a nurse or other licensed clinician/provider will review the CDC Vaccine Information Statement[s] (VIS) or Emergency Use Authorization (EUA) Statement[s] for any recommended vaccines with the resident/resident representative before obtaining consent. The resident/representative will have an opportunity to ask questions . On 9/04/24 at 3:14 PM, the survey team met with the Administrator, Director of Nursing, and the Regional Clinical Services Manager and discussed the concern of staff failing to provide education prior to the administration of a COVID-19 vaccine for Resident #2. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 13. For Resident #75, the facility staff failed to ensure the resident and/or the resident's representative had the opportunity to develop an advanced directive. Resident #75's diagnosis list indicated diagnoses that included, but were not limited to, Unspecified Dementia, Adult Failure to Thrive, Chronic Kidney Disease, and Herpes Simplex Myelitis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of [DATE], indicated the resident was severely impaired in cognitive skills for daily decision making with short and long-term memory deficits. No BIMS (brief interview for mental status) score was indicated in Section C for cognitive patterns of the MDS. Review of Resident #75's clinical record failed to provide evidence of the facility staff addressing whether the resident and/or the resident's representative desired to formulate an advanced directive. On [DATE] at 11:04 AM, Administrative Staff #4 stated there was no evidence for advance directives or advance directive education for Resident #75 and/or the resident's representative. This concern was discussed at the end of day meeting on [DATE] at 2:32 PM with administrator, director of nursing, and regional director of clinical services, and again at the pre-exit meeting on [DATE] at 5:03 PM with the above noted staff and the regional vice president of operations. No further information was provided to the survey team prior to the exit conference on [DATE]. 6. For Resident #4 the facility staff failed to ensure the resident had an opportunity to develop an advance directive. Resident #4's face sheet listed diagnoses which included but not limited to dementia, cerebral infarction, and type 2 diabetes mellitus. Resident #4's most recent minimum data set with an assessment reference date of [DATE] coded the resident has having both long- and short-term memory problems with severely impaired cognitive skills for daily decision making. Resident #4's comprehensive care plan was reviewed and contained a care plan for Resident is DNR (do not resuscitate). Approaches for this care plan included Review advanced directives with resident/family periodically, Involve physician/NP (nurse practitioner) in advanced directives conversations, and document resident's advanced directive. Resident #4's clinical record was reviewed, and surveyor could not locate any information related to an advance directive. Surveyor spoke with the facility administrator on [DATE] at 2 pm regarding Resident #4's advance directive. Administrator stated the facility changed electronic health record software in [DATE], and they haven't completed uploading documents to the new record system. Administrator stated they still have access to the previous electronic health record system. Surveyor could not locate advance directive information in either system. The concern on not offering an opportunity to develop an advance directive was discussed with the administrator, director of nursing, and regional director of clinical services on [DATE] at 10:40 am. The administrator informed the surveyor on [DATE] at 12:05 that they did not have any information related to advance directives for Resident #4. No further information was provided prior to exit. 7. For Resident #16 the facility staff failed to ensure the resident had an opportunity to develop an advance directive. Resident #16's face sheet listed diagnoses which included but not limited to chronic obstructive pulmonary disease, end stage renal disease, and congestive heart failure. Resident #16's most recent minimum data set with an assessment reference date of [DATE] coded the resident as 9 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #16's clinical record was reviewed and contained an Advance Care Planning Tracking Form dated [DATE] which read in part, Resident guardian . (name omitted) stated Resident has a living will. Surveyor reviewed the clinical record and could not locate a living will. Surveyor spoke with the facility administrator on [DATE] at 2 pm regarding Resident #16's living will. Administrator stated the facility changed electronic health record software in [DATE], and they haven't completed uploading documents to the new record system. Administrator stated they still have access to the previous electronic health record system. Surveyor could not locate advance directive information in either system. The concern on not offering an opportunity to develop an advance directive was discussed with the administrator, director of nursing, and regional director of clinical services on [DATE] at 10:40 am. The administrator informed the surveyor on [DATE] at 12:05 that they did not have any information related to advance directives for Resident #16. No further information was provided prior to exit. 8. For Resident #62 the facility staff failed to ensure the resident had an opportunity to develop an advance directive. Resident #62's face sheet listed diagnoses which included but not limited to congestive heart failure, type 2 diabetes mellitus, and peripheral vascular disease. Resident #62's most recent minimum data set with an assessment reference date of [DATE] assigned the resident a 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 #62 comprehensive care plan was reviewed and contained a care plan for Resident has chosen DNR (do not resuscitate) status. Approaches for this care plan included Review code status as needed, and at least annually with resident and/or responsible party. Resident #62's clinical record was reviewed, and surveyor could not locate any information regarding advance directive planning. Surveyor spoke with the facility administrator on [DATE] at 2 pm regarding Resident #62's advance directive planning. Administrator stated the facility changed electronic health record software in [DATE], and they haven't completed uploading documents to the new record system. Administrator stated they still have access to the previous electronic health record system. Surveyor could not locate advance directive information in either system. The concern on not offering an opportunity to develop an advance directive was discussed with the administrator, director of nursing, and regional director of clinical services on [DATE] at 10:40 am. The administrator informed the surveyor on [DATE] at 12:05 that they did not have any information related to advance directives for Resident #16. No further information was provided prior to exit. Based on staff interview, clinical record review, and facility document review the facility staff failed to ensure that residents and/or resident representatives had the opportunity to develop an Advanced Directive for 12 of 22 residents, Residents #3, 5, 29, 47, 4, 16, 62, 2, 38, 42, 50, and 75 and failed to honor an Advance Directive for 1 of 22 Residents, Resident #23. The findings include: On [DATE], the facility administrative staff provided the survey team with a copy of a policy titled, ADVANCE DIRECTIVES PROTOCOL. This policy read in part, .Upon admission during Your Path Meetings, advance directives will be discussed with resident and/or resident representative to determine if any advance directives have be [sic] chosen .Advance directives will be reviewed at minimum annually according to MDS [minimum data set] schedule . 1. For Resident #3, the facility staff failed to provide the resident and/or the resident representative with information concerning the right to accept or refuse medical or surgical treatment and the option to formulate an advance directive. Resident #3's diagnoses included, but were not limited to, mild protein calorie nutrition and diabetes. Section C (cognitive patterns) of Resident #3's significant change in status MDS assessment with an assessment reference date (ARD) of [DATE] included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Per the MDS manual a score of 15=cognitively intact. During the clinical record review, the surveyor was unable to locate any evidence to indicate the facility staff had provided the resident and/or their representative the option to formulate an advance directive. On [DATE] at 2:30 p.m., during a meeting with the Administrator, Director of Nursing, and Regional Nurse Consultant the concern with the missing information regarding advance directives was reviewed. On [DATE] at 12:04 p.m., the Administrator stated they were unable to find any information on advance directives. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #5, the facility staff failed to provide the resident and/or the resident representative with information concerning the right to accept or refuse medical or surgical treatment and the option to formulate an advance directive. Resident #5's diagnoses included acute ischemic heart disease and congestive heart failure. Section C (cognitive patterns) of Resident #5's quarterly MDS assessment with an assessment reference date (ARD) of [DATE] had been coded [DATE] to indicate this resident had problems with long- and short-term memory and was severely impaired in cognitive skills for daily decision making. During the clinical record review, the surveyor was unable to locate any evidence to indicate the facility staff had provided the resident and/or their representative the option to formulate an advance directive. On [DATE] at 2:30 p.m., during a meeting with the Administrator, Director of Nursing, and Regional Nurse Consultant the concern with the missing information regarding advance directives was reviewed. On [DATE] at 12:04 p.m., the Administrator stated they were unable to find any information on advance directives. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #29, the facility staff failed to provide the resident and/or the resident representative with information concerning the right to accept or refuse medical or surgical treatment and the option to formulate an advance directive. Resident #29's diagnoses included, but were not limited to, Schizoaffective disorder. Section C (cognitive patterns) of Resident #29's quarterly MDS assessment with an assessment reference date (ARD) of [DATE] included a brief interview for mental status (BIMS) score of 1 out of a possible 15 points. Per the MDS manual a score of 1=severe impairment. During the clinical record review, the surveyor was unable to locate any evidence to indicate the facility staff had provided the resident and/or their representative the option to formulate an advance directive. On [DATE] at 2:30 p.m., during a meeting with the Administrator, Director of Nursing, and Regional Nurse Consultant the concern with the missing information regarding advance directive was reviewed. On [DATE] at 12:04 p.m., the Administrator stated they were unable to find any information on advance directives. No further information regarding this issue was provided to the survey team prior to the exit conference. 4. For Resident #47, the facility staff failed to provide the resident and/or the resident representative with information concerning the right to accept or refuse medical or surgical treatment and the option to formulate an advance directive. Resident #47's diagnoses included, but were not limited to, cerebral infarction and chronic obstructive pulmonary disease. Section C (cognitive patterns) of Resident #47's quarterly MDS assessment with an assessment reference date (ARD) of [DATE] included a brief interview for mental status (BIMS) score of 14 out of a possible 15 points. Per the MDS manual a score of 14=cognitively intact. During the clinical record review, the surveyor was unable to locate any evidence to indicate the facility staff had provided the resident and/or their representative the option to formulate an advance directive. On [DATE] at 2:30 p.m., during a meeting with the Administrator, Director of Nursing, and Regional Nurse Consultant the concern with the missing information regarding advance directives was reviewed. On [DATE] at 12:04 p.m., the Administrator stated they were unable to find any information on advance directives. No further information regarding this issue was provided to the survey team prior to the exit conference. 5. For Resident #23, the facility staff failed to honor the residents advance directive wishes. Resident #23's diagnoses included, but were not limited to, diabetes and neuropathy. Section C (cognitive patterns) of Resident #23's quarterly MDS assessment with an assessment reference date (ARD) of [DATE] included a brief interview for mental status (BIMS) score of 5 out of a possible 15 points. Per the MDS manual a score of 5=severe impairment. Resident #23's clinical record included a Virginia Advance Directive for Health Care form signed and notarized on [DATE]. Resident #23 had been admitted to this facility on [DATE]. Under the section MY HEALTH CARE INSTRUCTIONS the box that read in part, I do not want any treatments to prolong my life. This includes .cardiopulmonary (CPR) . had been marked with an X. All the other boxes were left blank. Resident #23's clinical record included the following information: Face sheet that indicated this resident was a full code. Provider order dated [DATE] that read full code. Comprehensive Care Plan (CCP) revised on [DATE] indicating this resident was a full code. On [DATE] at 9:35 a.m., the concern with the residents code status not being honored was shared with the Social Worker. This staff person never provided the surveyor with any updated information. On [DATE] at 2:30 p.m., during a meeting with the Administrator, Director of Nursing, and Regional Nurse Consultant the concern regarding Resident #23's code status was reviewed. On [DATE], the administrative staff provided the surveyor with the following, updated face sheet indicating the resident was a do not resuscitate (DNR), provider order dated [DATE] that read Code Status DNR, updated CCP indicating the Resident had chosen to be a DNR, and a progress note that read in part, .spoke with RP [responsible party] .in regards to a code status audit for [Resident #23] .We discussed her prior advanced directive and her RP wishes to respect her wishes of being a DNR. No further information regarding this issue was provided to the survey team prior to the exit conference. 9. For Resident #2, facility staff failed to ensure the resident had an opportunity to develop an advance directive. Resident #2's most recent minimum data set with an assessment reference date of [DATE] coded the resident as having long-term and short-term memory problems with severely impaired cognitive skills for daily decision making. The resident's clinical record contained a Durable Do Not Resuscitate document. The surveyor found no evidence of an advance directive or evidence facility staff provided the resident or representative written information regarding the formulation of an advance directive. The administrator reported the facility transitioned from one clinical record software system to their current software system in [DATE]. The administrator acknowledged facility staff have maintained access to the previous software system. On [DATE] at 2:32 p.m. during a meeting with the administrator, director of nursing, and regional nurse consultant, the concern regarding Resident #2's advance directive was discussed. On [DATE] at 12:05 p.m., the administrator informed the survey team that he was unable to find anything on Advanced Directives for any of the residents the survey team had discussed which included Resident #2. No further information was provided prior to the exit conference. 10. For Resident #38, facility staff failed to ensure the resident had an opportunity to develop an advance directive. Resident #38's most recent minimum data set with an assessment reference date of [DATE] coded the resident's brief interview for mental status score a 5 out of 15 in section C, cognitive patterns. This score indicated a severe cognitive impairment. The resident's clinical record contained a Durable Do Not Resuscitate document. The surveyor found no evidence of an advance directive or evidence facility staff provided the resident or representative written information regarding the formulation of an advance directive. The administrator reported the facility transitioned from one clinical record software system to their current software system in [DATE]. The administrator acknowledged facility staff have maintained access to the previous software system. On [DATE] at 2:32 p.m. during a meeting with the administrator, director of nursing, and regional nurse consultant, the concern regarding Resident #38's advance directive was discussed. On [DATE] at 12:05 p.m., the administrator informed the survey team that he was unable to find anything on Advanced Directives for any of the residents the survey team had discussed with administration which included Resident #38. No further information was provided prior to the exit conference. 11. For Resident #42, facility staff failed to ensure the resident had an opportunity to develop an advance directive. Resident #42's most recent minimum data set with an assessment reference date of [DATE] coded the resident's brief interview for mental status score an 8 out of 15 in section C, cognitive patterns. This score indicated a moderate cognitive impairment. The resident's clinical record contained a Durable Do Not Resuscitate document. The surveyor found no evidence of an advance directive or evidence facility staff provided the resident or representative written information regarding the formulation of an advance directive. The administrator reported the facility transitioned from one clinical record software system to their current software system in [DATE]. The administrator acknowledged facility staff have maintained access to the previous software system. On [DATE] at 2:32 p.m. during a meeting with the administrator, director of nursing, and regional nurse consultant, the concern regarding Resident #42's advance directive was discussed. On [DATE] at 12:05 p.m., the administrator informed the survey team that he was unable to find anything on Advanced Directives for any of the residents the survey team had discussed which included Resident #42. No further information was provided prior to the exit conference. 12. For Resident #50, facility staff failed to ensure the resident had an opportunity to develop an advance directive. Resident #50's most recent minimum data set with an assessment reference date of [DATE] coded the resident as having long-term and short-term memory problems with severely impaired cognitive skills for daily decision making. The resident's clinical record contained a Durable Do Not Resuscitate document. The surveyor found no evidence of an advance directive or evidence facility staff provided the resident or representative written information regarding the formulation of an advance directive. The administrator reported the facility transitioned from one clinical record software system to their current software system in [DATE]. The administrator acknowledged facility staff have maintained access to the previous software system. On [DATE] at 2:32 p.m. during a meeting with the administrator, director of nursing, and regional nurse consultant, the concern regarding Resident #50's advance directive was discussed. On [DATE] at 12:05 p.m., the administrator informed the survey team that he was unable to find anything on Advanced Directives for any of the residents the survey team had discussed which included Resident #50. No further information was provided prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #71, the facility staff failed to provide the resident and the resident's representative written notice of the reason(s) of transfer/discharge to the hospital on 5/8/24 and 7/5/24 and failed to notify the Office of the State Long-Term Care Ombudsman of the transfer/discharge on [DATE] and 7/5/24. Resident #71's diagnosis list indicated diagnoses that included, but were not limited to, Prostate Cancer, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Congestive Heart Failure, Depression and Candidal Cystitis, and Urethritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/15/24, assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating Resident #71 was cognitively intact. A review of the clinical record indicated Resident #71 was transferred to the hospital on 5/8/24 and on 7/5/24. No evidence of written notice of the transfer being provided to the resident and the resident's representative could be located. On 9/5/24 at 10:15 AM, surveyor interviewed the social worker-other staff #1 (OS#1) and she informed surveyor she notifies the ombudsman once a month of transfers and discharges via fax and that she would look for notification of the transfer for Resident #71 for the 5/8/24 and 7/5/24 discharges to the hospital. On 9/5/24 at 11:05 AM, corporate staff #4 (CS#4) informed surveyor that no evidence of written notification for the reason of transfer could be located for Resident #71 and resident's representative for 5/8/24 or 7/5/24, and there was no evidence of notification of transfer or discharge for the ombudsman for the transfers for 5/8/24 and 7/5/24. This concern was discussed at the pre-exit meeting on 9/5/24 at 5:03 PM with the administrator, director of nursing, regional director of clinical services, and regional vice president of operations. Surveyor requested and received a facility document, titled, Resident Discharge/Transfer Letter Policy, that read in part, .The facility will complete discharge letters .according to all federal, state, and local regulations .C .3. Completed and signed letters will be uploaded back to the electronic chart .D. Discharge notices must have the following components: 1. The reason for discharge/transfer .E. Social Service or designee will assure the original discharge/transfer letter is given to the resident .1. Copies will be sent to .Ombudsman Office .and/or scanned into the electronic chart .F. Social service or designee will document in the chart all discharge/transfer reasons, any notices given .G. The resident .responsible party will receive .discharge/transfer letter . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/5/24. 4. For Resident #72, the facility staff failed to provide the resident and the resident's representative written notice of the reason(s) of transfer to the hospital on 5/17/24 and 7/18/24 and failed to notify the Office of the State Long-Term Care Ombudsman of the transfer/discharge on [DATE] and 7/18/24. Resident #72's diagnosis list indicated diagnoses that included, but were not limited to, Encounter for surgical aftercare following surgery on the digestive system, Diabetes Mellitus Type 2, Difficulty Walking, Transient Ischemic Attack (TIA), Dementia, Atherosclerotic Heart Disease, Hyperlipidemia, Osteoarthritis of Knee, and Depression. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/13/24, assigned the resident a brief interview for mental status (BIMS) summary score of 10 out of 15 for cognitive abilities, indicating Resident #72 was moderately impaired in cognition. A review of the clinical record indicated Resident #72 was transferred to the hospital on 5/17/24 and on 7/18/24. No evidence of written notice of the transfer being provided to the resident and the resident's representative could be located. On 9/5/24 at 9:25 AM, surveyor interviewed licensed practical nurse #4 (LPN#4) and she stated the social worker is not notifying the ombudsman of transfers to the hospital, she is only notifying the ombudsman of discharges home. LPN#4 stated she would look for evidence of written reason for transfer/discharge to the resident and resident representative. LPN#4 returned to surveyor at 9:53 AM and stated there was no evidence that written notice of the reason for transfer was given to Resident #72 or resident's representative. On 9/5/24 at 10:15 AM, surveyor interviewed the social worker-other staff #1 (OS#1) and she informed surveyor she notifies the ombudsman once a month of transfers and discharges via fax and that she would look for notification of the transfer for Resident #72 for the 5/17/24 and 7/18/24 discharges to the hospital. On 9/5/24 at 10:28 AM, regional director of clinical services informed surveyor that OS#1 is not sending transfer notifications to the ombudsman. This concern was discussed at the pre-exit meeting on 9/5/24 at 5:03 PM with the administrator, director of nursing, regional director of clinical services, and regional vice president of operations. Surveyor requested and received a facility document, titled, Resident Discharge/Transfer Letter Policy, that read in part, .The facility will complete discharge letters .according to all federal, state, and local regulations .C .3. Completed and signed letters will be uploaded back to the electronic chart .D. Discharge notices must have the following components: 1. The reason for discharge/transfer .E. Social Service or designee will assure the original discharge/transfer letter is given to the resident .1. Copies will be sent to .Ombudsman Office .and/or scanned into the electronic chart .F. Social service or designee will document in the chart all discharge/transfer reasons, any notices given .G. The resident .responsible party will receive .discharge/transfer letter . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/5/24. Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure that written transfer notices were provided for 4 of 31 Residents, Residents #26, #129, #71, and #72. The findings included: 1. For resident # 26 the facility failed to notify the resident and/or the resident's representative(s) of the transfer and the reasons in writing, and in a language and manner they understand. The facility staff also failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. Resident # 26's diagnoses included but were not limited to, history of cerebral infarction (stroke), chronic obstructive pulmonary disease, hypertension, moderate protein calorie malnutrition, depression, vitamin deficiency and depression. The minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/21/23 assigned the resident a brief interview for mental status (BIMS) score of 15 out of 15 indicating intact cognition. During a review of the clinical record, a progress note dated 3/31/24 at 11:16 PM read, Patient present with confusion and hallucination. Patient daughter called requesting that the patient be sent out. ____ called and stated that another course of action needed to be taken and to not send the patient out. Writer went into patient room again and patient is still hallucinating. Patient states that kids are in her room and that things are crawling on the ceiling and the walls trying to get her. Writer is waiting on call back from ____ as to course of action to take. ____ called back and stated to send patient to the ER. No further information was documented in the notes. Surveyor was unable to locate a transfer form in the record. On 9/5/24 at 9:25 AM a surveyor interviewed Licensed Practical Nurse (LPN) # 4. They stated the Social Worker is not notifying the Ombudsman of transfers to hospitals, only the transfers to homes. On 9/5/24 at 10:28 AM a surveyor interviewed the Regional Director of Clinical Services who stated the social worker is not notifying the Ombudsman of transfers to the hospital. On 9/5/24 at 11:14 AM this surveyor interviewed Corporate staff # 4. Surveyor asked for evidence that the staff notified the resident and/or the resident's representative(s) of the transfer and the reasons for the transfer in writing, and in a language and manner they understand. They stated, They didn't even do the transfer form or anything. On 9/5/24 at 4:44 PM the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultant, and Regional VP of Operations. This concern was discussed with them at that time. No further information was provided to the survey team prior to the exit conference. 2. For resident # 129, the facility failed to notify the resident and/or the resident's representative(s) of the transfer and the reasons in writing, and in a language and manner they understand. The facility staff also failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. Resident # 129's diagnoses included but were not limited to history of cerebral infarction (stroke), chronic obstructive pulmonary disease, hypertension, moderate protein calorie malnutrition, depression, vitamin deficiency and depression. The minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/21/23 assigned the resident a brief interview for mental status (BIMS) score of 15 out of 15 indicating intact cognition. A nurse progress note dated 6/8/23 at 1:15 PM read, at 0830, CNA informed this nurse, that the resident was c/o tightness in her chest and chest pain on the left side. Nurse assessed pt and pt complain of chest pain 4/10. Vitals: 127/74-bp, 97-HR, 16-R, 94%RA. Pt emergency contact was called and informed and she requested that the pt be sent out to ER for further eval. Dr. [NAME] was informed and made aware of the family request to send pt out to ER. Pt was sent out to ER at 0930 and paperwork(care plan, bed hold, med list, face sheet) was given to EMT. On 9/5/24 at 9:25 AM a surveyor interviewed Licensed Practical Nurse (LPN) # 4. They stated the Social Worker is not notifying the Ombudsman of transfers to hospitals, only the transfers to homes. On 9/5/24 at 10:28 AM a surveyor interviewed the Regional Director of Clinical Services who stated the social worker is not notifying the Ombudsman of transfers to the hospital. On 9/5/24 at 11:14 AM this surveyor interviewed Corporate staff # 4. Surveyor asked for evidence that the staff notified the resident and/or the resident's representative(s) of the transfer and the reasons for the transfer in writing, and in a language and manner they understand. They stated, They didn't even do the transfer form or anything. On 9/5/24 at 4:44 PM the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultant, and Regional VP of Operations. This concern was discussed with them at that time. No further information 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 facility document review, the facility staff failed to ensure the safe and secure storage of medications and biologicals for 2 of 4 medication carts (Unit 1/Cart 1 and Unit 2/Cart 1) and 1 of 2 medication storage rooms (Unit 1). The findings included: 1. For Unit 1/Medication Cart 1, the facility staff left a Colestipol tablet (medication used to lower cholesterol) unattended on top of the medication cart. On [DATE] at 8:26 AM during a medication pass observation, surveyor observed Licensed Practical Nurse (LPN) #1 place a Colestipol tablet in a separate medication cup as it appeared damaged and obtained a replacement tablet for administration. LPN #1 left the cup containing the damaged tablet on top of the medication cart unattended and entered a resident's room. While in the resident's room, LPN #1 provided care and administered medications with the door closed leaving the Colestipol tablet unattended in the hall for approximately nine (9) minutes. When asked about the unattended medication, LPN #1 placed the cup containing the medication in the medication cart and stated they wanted to show other staff members the damaged tablet. Surveyor requested and received the facility policy titled General Dose Preparation and Medication Administration with a last revision date of [DATE] which read in part, .2.8 Facility staff should not leave medications or chemicals unattended . On [DATE] at 10:40 AM, the survey team met with the Administrator, Director of Nursing, and Clinical Services Manager and discussed the concern of the unattended medication. No further information regarding this concern was presented to the survey team prior to the exit conference on [DATE]. 2. For Unit 2/Medication Cart 1, the facility staff failed to label a multi-dose insulin pen with the date of opening and/or discard date. On [DATE] at 1:40 PM, surveyor observed an open, partially used Aspart 70/30 Insulin pen in the Unit 2/Medication Cart 1. The insulin pen was not labeled with an opened or discard date. Registered Nurse (RN) #4 stated there were two doses remaining and they were ordering a new insulin pen for the resident. Surveyor requested and received the facility policy titled General Dose Preparation and Medication Administration with a last revision date of [DATE] which read in part .2.10 Facility staff should enter the date opened on the label of medications with shortened expiration dates (e.g., insulins, irrigation solutions, etc.). 2.10.1 Facility staff may enter the expiration date based on date opened on the label of medications with shortened expiration dates . On [DATE] at 5:00 PM, the survey team met with the Administrator, Director of Nursing, Clinical Services Manager, and the [NAME] President of Operations and discussed the concern of the undated insulin pen. No further information regarding this concern was presented to the survey team prior to the exit conference on [DATE]. 3. For the Unit 1 Medication Storage Room, the facility staff failed to discard expired COVID-19 testing cards. On [DATE] at 1:16 PM, surveyor observed an opened box containing 30 [NAME] BinaxNOW COVID-19 Ag tests (Lot #220976) with a printed expiration date of [DATE]. According to the [NAME] product website (https://www.globalpointofcare.[NAME]/us/en/product-details/binaxnow-covid-19.html), [NAME] BinaxNOW COVID-19 Ag testing cards Lot #220976 with an original expiry date of [DATE] had been extended to a 22 month expiry date of [DATE]. Surveyor spoke with Registered Nurse (RN) #3 on [DATE] at 2:34 PM and discussed the extended expiry date of [DATE]. RN #3 stated they were discarding the tests. Surveyor requested and received the facility policy titled Storage and Expiration Dating of Medications and Biologicals with a last revision date of [DATE] which read in part, .10. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines .are stored separate from other medications until destroyed or returned to the pharmacy or supplier . On [DATE] at 5:00 PM, the survey team met with the Administrator, Director of Nursing, Clinical Services Manager, and the [NAME] President of Operations and discussed the concern of the expired COVID-19 tests. No further information regarding this concern was presented to the survey team prior to the exit conference on [DATE].

Based on staff interviews, clinical record review and facility's documentation, the facility staff failed to ensure 1 out of 2 residents (Resident #2) in the survey was free from abuse. Resident #2 was physically restrained to his wheelchair by tying the strings of his hospital gown to the rear bars on his wheelchair. This deficiency is cited as past non-compliance (PNC.) The finding included: Resident #2 was originally admitted the nursing facility on 04/20/22. Diagnosis for Resident #2 included but not limited to Dementia with behavioral disturbance, history of falling and muscle weakness. The most recent Minimum Data Set (MDS - an assessment protocol) a significant change assessment with an Assessment Reference Date (ARD) of 04/27/23 coded Resident #2 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. The MDS coded Resident #2 total dependence of one with bathing, extensive assistance of one with toilet use and personal hygiene, limited assistance of two with transfer, limited assistance of one with bed mobility and supervision with one assist with eating for Activities of Daily Living (ADL) care. A review of Resident #2's nurses note entered on 03/11/23 by License Practical Nurse (LPN) #2 indicated the resident was observed sitting in his wheelchair at the nurses' station. The resident had on a hospital gown with the strings of the hospital gown tied to the back of the wheelchair bar. Once the observation was made, the strings were released and the resident assessed. On 06/07/23 at 12:46 p.m., an interview was conducted with Certified Nursing Assistant (CNA) #1. The CNA stated he was not assigned to Resident #2 on 03/11/23 (7a-3p) shift. He stated Resident #2 had fallen earlier that morning but without injury. The resident kept getting out of bed without assistance, so he bathed the resident. After he had finished bathing the resident, he placed a hospital gown over top the resident's clothes and tied the strings of hospital gown to back of his wheelchair bar. He said by tying the hospital gown to the wheelchair, that would stop the resident from getting up and falling again. He stated a CNA noticed Resident #2's hospital gown was tied to the resident's wheelchair and reported it to the nurse. He stated he was told by the nurse to clock out, leave the unit and wait for the Administrator in the front lobby which he did. He stated did not realize tying the strings of a hospital gown to the resident's wheelchair was a form of abuse until he was interviewed by the Administrator that same day. License Practical Nurse (LPN) #2 was interviewed on 06/07/23 at 11:49 a.m. She stated she was assigned to Resident #2 on 03/11/23 (day shift.) She stated Resident #2 was placed at the nurse's station and was observed without any behaviors/agitation. She said Certified Nursing Assistant (CNA) #4 informed her that Resident #2 was in a hospital gown with the strings of the gown tied to the back of the wheelchair. She said she and CNA #3 and #4 rolled Resident #2 to his room, cut the hospital gown strings from the wheelchair bars, placed the resident in the bed, completed an assessment and contacted Administration of the incident. She stated the CNA #1 was informed to leave the patient care area and wait in the front lobby until Administration arrived. She stated restraining the resident using the strings of his hospital gown in a form of abuse. The Administrator was interviewed on 06/07/23 at approximately 2:25 p.m. He stated he received a phone call from the Director of Nursing (DON) on 03/11/23 around noon. He was informed Resident #2 had been observed by staff to be in a hospital gown with the strings of the gown tied to his wheelchair. He stated the staff member who had restrained Resident #2 to his wheelchair was CNA #1. He said CNA #1 was informed to immediately clock out but to remain in the front lobby, out of the resident's care area until he arrived at the facility. He stated once he arrived at the facility, the CNA was sitting in the front lobby as instructed. The CNA was taken to his office and interviewed. The CNA stated he tied the strings on Resident #2's hospital gown to the bars on the back of his wheelchair because he kept falling. The CNA stated he thought he was keeping the resident safe. On the same day, the Administrator presented a Quality Assurance and Performance Improvement (QAPI) plan dated 03/11/23. The QAPI documented the Root Cause Analysis (RCA) results for the improper use of restraints and improper/improper keep safe interventions for post fall interventions. On 06/08/23 at 12:15 p.m., a final interview was conducted with the Administrator. It was determined that the facility implemented its Corrective Action Plan, and there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of the current survey for the regulatory requirement, F-600. Corrective Action Plan, 3/11/23: Step 1a. What was done to the resident that was affected? Resident was observed by staff with the strings of a hospital gown tied to the rear bars of his wheelchair. Step 1b. What immediate interventions were for affected resident? Once the staff observed Resident #2's hospital gown strings were tied to the rear bars on his wheelchair, he was immediately taken to his room, ties were cut, assessed for injury and change in condition started on 03/11/23. The CNA who tied the strings of the resident's hospital gown was immediately taken out of the resident's care area and was interviewed and suspended by the Administrator. Step 2a. What immediate actions were taken to identify all potential affected? All interviewable residents were interviewed for the use of any type of restraints were ever used. For non-interviewable residents, skin assessments were completed for skin impairment started on 03/11/23. Step 2b. What continued and immediate interventions were implemented for identified resident or systems? All staff were educated on the facility's Abuse policy and procedures for reporting in a timely manner. All newly hired staff and agency will be educated before working in patient care areas started on 03/11/23. Step 2c. Results of all monitoring will be presented to the monthly QA Committee for analysis and recommendations for further monitoring, education, or recommendations. The facility's policy titled Abuse, Neglect and Exploitation revised 05/26/23. It is the facility policy not to tolerate abuse, neglect, mistreatment, exploitations of resident, and misappropriation of the resident's property by anyone. Definition -Abuse includes actions such as he willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It includes physical and chemical restraints.

Based on staff interviews, clinical record review and facility's documentation, the facility staff failed to ensure 1 out of 2 residents (Resident #2) in the survey sample was free from physical restraint. The Certified Nursing Assistant (CNA) used the strings from the resident's hospital gown, tied them to the rear bars of his wheelchair restricting freedom of movement. This deficiency is cited as past non-compliance (PNC.) The finding included: Resident #2 was originally admitted the nursing facility on 04/20/22. Diagnosis for Resident #2 included but not limited to Dementia with behavioral disturbance, history of falling and muscle weakness. The most recent Minimum Data Set (MDS - an assessment protocol) a significant change assessment with an Assessment Reference Date (ARD) of 04/27/23 coded Resident #2 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. The MDS coded Resident #2 total dependence of one with bathing, extensive assistance of one with toilet use and personal hygiene, limited assistance of two with transfer, limited assistance of one with bed mobility and supervision with one assist with eating for Activities of Daily Living (ADL) care. A review of Resident #2's nurses note entered on 03/11/23 by License Practical Nurse (LPN) #2 indicated the resident was observed sitting in his wheelchair at the nurses' station. The resident had on a hospital gown with the strings of the hospital gown tied to the back of the wheelchair bar. Once the observation was made, the strings were released and the resident assessed. On 06/07/23 at 12:46 p.m., an interview was conducted with CNA #1. The CNA stated he was not assigned to Resident #2 on 03/11/23 (7a-3p) shift. He stated Resident #2 had fallen earlier that morning but without injury. The resident kept getting out of bed without assistance, so he bathed the resident. After he had finished bathing the resident, he placed a hospital gown over top the resident's clothes and tied the strings of hospital gown to back of his wheelchair bar. He said by tying the hospital gown to the wheelchair, that would stop the resident from getting up and falling again. He stated a CNA noticed Resident #2's hospital gown was tied to the resident's wheelchair and reported it to the nurse. He stated he was told by the nurse to clock out, leave the unit and wait for the Administrator in the front lobby which he did. On 06/07/23 at 11:46 a.m., CNA #4 was interviewed who stated on 03/11/23, she was passing out trays when saw Resident #2 trying to raise up from his wheelchair but was unable. She stated she walked over towards the resident and observed he had on a hospital gown with the strings of the gown tied to the bar to the back of his wheelchair. She stated she immediately informed his nurse LPN #2. She stated Resident #2 was immediately taken to his room, the hospital gown strings were cut from the bars on the wheelchair. License Practical Nurse (LPN) #2 was interviewed on 06/07/23 at 11:52 a.m. She stated she was assigned to Resident #2 on 03/11/23 (day shift.) She stated Resident #2 was placed at the nurse's station and was observed without any behaviors/agitation. She said Certified Nursing Assistant (CNA) #4 informed her that Resident #2 was in a hospital gown with the strings of the gown tied to the back of the wheelchair. She said she and CNA #3 and #4 rolled Resident #2 to his room, cut the hospital gown strings from the wheelchair bars, placed the resident in the bed, completed an assessment and contacted Administration of the incident. She stated the CNA #1 was informed to leave the patient care area and wait in the front lobby until Administration arrived. An interview was conducted with CNA #3 on 06/07/23 at 12:15 p.m. CNA was assigned to Resident #2 on 03/11/23 (7a-3p) shift who stated Resident #2 was left in bed because he was combative during his morning care. She stated Resident #2 stays up late so if he is agitated, he will get up right before lunch. She stated she was shocked to see Resident #2 in a hospital gown restrained in his wheelchair. She stated she another CNA along with the resident's nurse took him to his room and cut him out of the restraints (hospital gown strings that were tied to his wheelchair.) The Administrator was interviewed on 06/07/23 at approximately 2:25 p.m. He stated he received a phone call from the Director of Nursing (DON) on 03/11/23 around noon. He was informed Resident #2 had been observed by staff to be in a hospital gown with the strings of the gown tied to his wheelchair. He stated the staff member who had restrained Resident #2 to his wheelchair was CNA #1. He said CNA #1 was informed to immediately clock out but to remain in the front lobby, out of the resident's care area until he arrived at the facility. He stated once he arrived at the facility, the CNA was sitting in the front lobby as instructed. The CNA was taken to his office and interviewed. The CNA stated he tied the strings on Resident #2's hospital gown to the bars on the back of his wheelchair because he kept falling. The CNA stated he thought he was keeping the resident safe. On the same day, the Administrator presented a Quality Assurance and Performance Improvement (QAPI) plan dated 03/11/23. The QAPI documented the Root Cause Analysis (RCA) results for the improper use of restraints and improper/improper keep safe interventions for post fall interventions. On 06/08/23 at 12:15 p.m., a final interview was conducted with the Administrator. It was determined that the facility implemented its Corrective Action Plan, and there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of the current survey for the regulatory requirement, F-604. Corrective Action Plan, 3/11/23. Step 1a. What was done to the resident that was affected? Resident was observed by staff with the strings of a hospital gown tied to the rear bars of his wheelchair. Step 1b. What immediate interventions were for affected resident? Once the staff observed Resident #2's hospital gown ties were used as a restraint, he was immediately taken to his room, ties were cut and assessed for injury or change in condition started on 03/11/23. Step 2a. What immediate actions were taken to identify all potential affected? All interviewable residents were interviewed for the use of any type of restraints were ever used. For non-interviewable residents, skin assessments were completed assessing for skin impairment started on 03/11/23. Step 2b. What continued and immediate interventions were implemented for identified resident or systems? Interviews to be completed on five (5) random residents weekly with BIMS score 12 and above concerning abuse for 12 weeks to ensure no signs/symptoms of mistreatment has occurred and 5 random skin assessment will be completed weekly on residents whose BIMS are below 12 for 12 weeks. Random staff members will be audited weekly for 6 weeks to ensure reporting and restraint policy is understood and followed started on 03/13/23. Step 2c. Results of all monitoring will be presented to the monthly QA Committee for analysis and recommendations for further monitoring, education, or recommendations. The facility policy titled Restraint revised on 03/03/23. Policy: Physical and/or chemical restraints will be initiated only after a comprehensive review determines that they are necessary to treat the resident's medical symptoms that warrant their use. Definitions -Freedom of Movement is the ability of the resident to move around within the context of the resident's functional capacity as assessed by the facility (e.g., Does the item prevent the resident from performing an action that they are otherwise capable of performing?). -Physical Restraint is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interviews the facility's staff failed to afford the opportunity to get out of bed daily as desired for 1 of 36 residents (Resident #50), in the survey sample. The findings included: Resident #50 was originally admitted to the facility 12/3/14 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Multiple sclerosis, diabetes and depression. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/27/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #50's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of two people with transfers, total care of one person with bed mobility, personal hygiene, bathing, transfers, dressing, and toileting, and supervision after set-up with eating. An interview was conducted with Resident #50 on 3/16/21 at approximately 12:40 p.m. Resident #50 stated the walls were closing in on him because he had been under observation for 14 days after discharge from the hospital and since his transfer to the general population unit there continued to be days in which staff wouldn't get him up. Resident #50 stated he required two people to get him out of bed using a mechanical lift and the staff states they don't have enough staff to get him up but his roommate requires the exact same assistance yet he is out of bed daily and early. On 3/17/21 at approximately 11: 00 a.m., and again at approximately 1:00 p.m., the resident was in bed due to a scheduled appointment which required him to be in bed until it was completed. After staff learned the appointment was canceled at approximately 1:30 p.m., the resident wasn't transferred to get out of bed until late afternoon. An interview was conducted with Certified Nursing Assistant (CNA) #1 on 3/18/21 at approximately 12:55 p.m. CNA #1 stated the facility had eliminated itself of problematic CNAs and hired others but; they continued to struggle with CNA staffing because of frequent call outs, especially Thursday through Sunday. CNA #1 further stated Resident #50 was left in bed on days in which staffing was a problem. On 3/18/21 the Resident #50 was again left in bed though, he constantly rung his call bell for someone to get him out bed. At approximately 2:20 p.m., Certified Nursing Assistant (CNA) #3 informed Resident #50, they were very busy and if there was time after rounds were completed for a specific assignment they would get him out of bed into his wheel chair but the plan was contingent on the length of time necessary to complete the other assignment. On 3/18/21 at approximately 3:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The Director of Nursing stated the resident should be out of bed as desired based on his preference and every effort would be made to accommodate the resident going forward.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a medical record review, facility document review and staff interviews the facility The facility staff failed to ensure a Notice of Medicare Non-Coverage was given timely prior to the last covered skilled day of 12/17/20 for 1 of 36 residents in the survey sample, Resident #59. The findings included: Resident #59 is a [AGE] year old admitted to the facility on [DATE] with diagnoses to include but not limited to Diabetes Mellitus, End Stage Renal Disease and Hypertension. Resident #59's medical record indicated the resident was discharged home on [DATE] at 11:00 A.M. The most recent MDS (Minimum Data Set) for Resident #59 was a Discharge Assessment with a ARD (Assessment Reference Date) of 12/18/20. Resident #59's BIMS (Brief Interview for Mental Status) score was a 15 out of a possible 15 indicating the resident was cognitively intact and capable of daily decision making. Resident #59's Notice of Medicare Non-Coverage (NOMNC) document with Skilled Nursing Services ending on 12/17/20 was reviewed and is documented in part, as follows: Page 1: The Effective Date Coverage if Your Current PT(Physical Therapy), OT(Occupational Therapy), ST(Speech Therapy) Services Will End: 12/17/20. Page 2: Please sign below to indicate you received and understood this notice. I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting QIO (Quality Improvement Organization). Signature of Resident #59 Date: 12/17/2020. Signature of Director of Social Services Date: 12/17/2020. A phone interview was conducted on 3/18/21 at 9:07 A.M. with the facility Social Worker regarding how far in advance should residents be provided a Notice of Medicare Non-Coverage. The Social Worker stated, If a resident is discharging you need to give the medicare notice three to five days before the discharge date . This gives the resident or family time to appeal, because they need to do their appeal before the services end. A phone interview was conducted on 3/18/21 at approximately 10:15 A.M. with the Administrator, who was asked what were the expectations for issuing a Notice of Medicare Non-Coverage to residents. The Administrator stated, The notice should be given at least 48 hours prior to discharge so they have a chance to appeal. The facility policy titled Medicare Cut Letter Policy last revised on 1/29/2021 was reviewed and is documented in part, as follows: Policy: The Facility will assure all residents receive timely and appropriate notification of Medicare non-coverage for services in accordance with State and Federal guidelines. III. Delivery of Notice: All Notices are to be issued to the Resident/beneficiary or an authorized representative when the Resident is not capable of comprehending the Notice contents. Notice must be issues in accordance with the Triggering events and prior to the delivery of medical care which is presumed to be non-covered, a change or termination of services, but no later than 2 days prior to the change or termination. A pre-exit phone debriefing was conducted at 10:45 A.M. with the Administrator the the above information was reviewed. Prior to exit no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews the facility's staff failed to maintain 1 of 36 residents (Resident #50), wheel chair in a clean and sanitary manner. The findings included: Resident #50 was originally admitted to the facility 12/3/14 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Multiple sclerosis, diabetes and depression. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/27/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #50's cognitive abilities for daily decision making were intact. On 3/17/21 at approximately 1:00 p.m., observation was made of Resident #50's wheel chair. A large amount of crumbs and other debris was observed on the side and beneath the seat cushion. An interview was conducted with Resident #50 on 3/17/21 at approximately 1:00 p.m. Resident #50 stated he wasn't aware of his wheel chair getting clean. He further stated no one comes to clean it. On 3/18/21 at approximately 11:00 a.m., again the debris was observed to the wheel chair therefore; an interview was conducted with Patient Care Assistant (PCA) #1. PCA #1 stated she would clean the debris from the resident's wheel chair. PCA #1 stated she was unaware of wheel chair cleaning schedules but she would find out. PCA #1 didn't return with the information. On 3/18/21 at approximately 7:00 p.m., the above findings were shared with the Administrator. The Administrator stated she would look further into the concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide evidence that care plan goals were sent with one of 36 residents (Resident #15) upon transfer to the hospital on 1/7/21. The findings included: Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to stroke, high blood pressure, unspecified protein calorie malnutrition, and atrial fibrillation. Resident #15's most recent MDS (Minimum data set) assessment was a quarterly assessment with an ARD (Assessment Reference Date) of 1/23/21. Resident #15 was coded as being moderately impaired in cognitive function scoring 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #15's clinical record revealed that he was sent out to the hospital on 1/7/21 for a possible stroke. The following was documented in a nursing note dated 1/7/21: Resident at approximately 3pm resident noted with change in condition. He had difficulty speaking any words. Rt (right) side flaccid, unable to grasp with Rt hand. Unable to pull foot back and no response when rubbed bottom of right foot. He has a very strong grip with left hand and moving his left leg without difficulty. Call was placed to (Name of Nurse Practitioner), NP (Nurse Practitioner) and new orders to send him out 911. Attempted to call his 2 daughters, message left to return call to facility. Call placed to ED (Emergency Department) to give report, no answer at ED. Resident is his own responsible party. EMT's (Emergency Medical Technician) were made aware and that he is a full code. Review of Resident #15's Acute Care Transfer Document Checklist, also failed to show that Resident #15's care plan or care plan goals were sent with Resident #15 upon transfer to the hospital. Review of Resident #15's SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form dated 1/7/21 also failed to show that care plan goals were sent with Resident #15 at the time of transfer. Further review of Resident #15's clinical record revealed that he arrived back to the facility on 1/11/21 with a new diagnosis of stroke. On 3/18/21 at 10:05 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #2, Resident #15's nurse. When asked what documents were sent with a resident upon transfer to a hospital, LPN #2 stated that nurses with send the facesheet, medication list, the transfer summary, and the bed hold policy. When asked if the care plan or care plan goals were sent with each resident upon transfer, LPN #2 stated, Care Plan goals, no, unless its part of the transfer summary. On 3/18/21 at 3:40 p.m. during a pre-exit conference; ASM (Administrative Staff Member) #1, the Administrator, ASM #2, the DON (Director of Nursing), ASM #3, the Regional [NAME] President of Operations, and ASM #4, the Regional Director of Clinical Services were made aware of the above concerns. A policy could not be provided regarding the above concerns. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to stroke, high blood pressure, unspecified protein calorie malnutrition, and atrial fibrillation. Resident #15's most recent MDS (Minimum data set) assessment was a quarterly assessment with an ARD (Assessment Reference Date) of 1/23/21. Resident #15 was coded as being moderately impaired in cognitive function scoring 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #15's clinical record revealed that he was sent out to the hospital on 1/7/21 for a possible stroke. The following was documented in a nursing note dated 1/7/21: Resident at approximately 3pm resident noted with change in condition. He had difficulty speaking any words. Rt (right) side flaccid, unable to grasp with Rt hand. Unable to pull foot back and no response when rubbed bottom of right foot. He has a very strong grip with left hand and moving his left leg without difficulty. Call was placed to (Name of Nurse Practitioner), NP (Nurse Practitioner) and new orders to send him out 911. Attempted to call his 2 daughters, message left to return call to facility. Call placed to ED (Emergency Department) to give report, no answer at ED. Resident is his own responsible party. EMT's (Emergency Medical Technician) were made aware and that he is a full code. On 3/18/21 at 12:50 p.m., an interview was conducted with OSM (Other Staff Member) #3, social services. When asked the process for notifying the long term ombudsman regarding an acute care transfer, OSM #3 stated that she was only notifying the long term ombudsman for emergency transfers at the end of each month. When asked if she could present information that she notified the long term care ombudsman regarding Resident #15's transfer, OSM #2 stated that she just notified the long term care ombudsman regarding all January and February 2021 transfers on 3/17/21. OSM #3 stated that she was not aware that that was her responsibility; that the Director of Social Services was doing that; and that the facility no longer had a director. Review of an email dated 3/17/21 at 6:58 p.m., from the social worker to the ombudsman, revealed that the long term care ombudsman was not notified of Resident #15's transfer to the hospital until 3/17/21. On 3/18/21 at 3:40 p.m. during a pre-exit conference; ASM (Administrative Staff Member) #1, the Administrator, ASM #2, the DON (Director of Nursing), ASM #3, the Regional [NAME] President of Operations, and ASM #4, the Regional Director of Clinical Services were made aware of the above concerns. Facility policy titled, Discharge/Transfer Letter Policy, documents in part, the following: Social Service or designee will assure the original discharge/transfer letter is given to resident or guardian/sponsor, if applicable. 1. Copies will be sent to the Department of Health, Ombudsman Office .For emergency transfers, one list can be sent to Ombudsman at the end of month. Based on record review, staff interviews and complaint investigation, the facility staff failed to notify the Long Term Care Ombudsman of two residents (Resident #258 and #15) of transferring to the hospital in the survey sample of 36 residents. The findings included: 1. Resident #258 was admitted to the facility on [DATE]. This resident was diagnosed as having Tardue Dyskinesia, hypertension, anxiety, depression, Bipolar, Schizoaffective disorder, hyperlipidemia, and anemia. the ombudsman was not notified of Resident #258 transfer to the hospital. This resident was assessed being stand to pivot x 1 assist, alert and oriented times 1 to self. Resident noted to wander in other patient rooms and exit seeking. A wander guard placed on left ankle. A Nursing note dated 06/03/20 at 5:38 P.M. indicated: Resident noted cursing loudly, screaming, and speaking to self. Resident noted pulling pants down, while walking in hallway. A Nursing note dated 06/04/20 at 6:48 P.M. indicated: 'Police arrived, in contact with local Community Service Board (CSB). Resident continue to be confused, yelling, and having hallucinations (talking to people who are not there). Resident does not follow directions, sitting on the floor, and then laid on the floor. Staff has made her environment secure. Resident's representative advised of status. A Nursing note dated 06/04/20 at 07:04 P.M. indicated: Resident laying on the floor, Emergency Transport arrived to transport to hospital. Physician advised of resident's status to transfer to hospital emergency department. During an interview on 03/17/21 at 4:50 P.M. with the social worker, she was asked if the Ombudsman was notified? The social worker responded, I did not notify the ombudsman. The facility staff failed to notify the ombudsman of Resident #258 transfer to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to stroke, high blood pressure, unspecified protein calorie malnutrition, and atrial fibrillation. Resident #15's most recent MDS (Minimum data set) assessment was a quarterly assessment with an ARD (Assessment Reference Date) of 1/23/21. Resident #15 was coded as being moderately impaired in cognitive function scoring 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #15's clinical record revealed that he was sent out to the hospital on 1/7/21 for a possible stroke. The following was documented in a nursing note dated 1/7/21: Resident at approximately 3pm resident noted with change in condition. He had difficulty speaking any words. Rt (right) side flaccid, unable to grasp with Rt hand. Unable to pull foot back and no response when rubbed bottom of right foot. He has a very strong grip with left hand and moving his left leg without difficulty. Call was placed to (Name of Nurse Practitioner), NP (Nurse Practitioner) and new orders to send him out 911. Attempted to call his 2 daughters, message left to return call to facility. Call placed to ED (Emergency Department) to give report, no answer at ED. Resident is his own responsible party. EMT's (Emergency Medical Technician) were made aware and that he is a full code. There was no evidence in the nursing notes that the bed hold policy was sent with Resident #15 at the time of transfer. Review of Resident #15's Acute Care Transfer Document Checklist, also failed to show that the bed hold policy was sent with Resident #15 upon transfer to the hospital. Review of Resident #15's SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form dated 1/7/21 also failed to show that the bed hold policy was sent with Resident #15 at the time of transfer. On 3/18/21 at 10:05 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #2, Resident #15's nurse. When asked what documentation was sent with a resident upon transfer to the hospital, LPN #2 stated that the bed hold policy was sent with each resident at the time of an acute care transfer. When asked if it should be documented what specific documents were sent with each resident at the time of a transfer, LPN #2 stated that nursing usually documents all of it. When asked how we would determine if a bed hold policy was sent with Resident #15 at the time of his transfer, if it is not documented in his clinical record, LPN #2 stated that she was not sure, that she would have to find out. On 3/18/21 at approximately 11:30 a.m., an interview was conducted with Resident #15. Resident #15 stated that because he was post having a stroke, he was not with it enough to remember if facility staff had gone over a bed hold policy with him at the time of transfer. On 3/18/21 at 1:17 p.m., an interview was conducted with OSM (Other Staff Member) #4, Admissions. When asked if the bed hold policy was discussed with each resident upon admission into the facility, OSM #4 stated that she will go over the admission packet, but does not go over the bed hold policy. OSM #4 stated that nurses were responsible for going over the bed hold policy upon transfer to the hospital. OSM #4 also stated that a hospital liaison will also go over that information with the resident or family while in the hospital; and the liaison will contact her with that information. When asked if she keeps documentation for each resident between her and the hospital liaison, OSM #4 stated that she did not; that these conversations were usually verbal over the telephone. On 3/18/21 at 3:40 p.m. during a pre-exit conference; ASM (Administrative Staff Member) #1, the Administrator, ASM #2, the DON (Director of Nursing), ASM #3, the Regional [NAME] President of Operations, and ASM #4, the Regional Director of Clinical Services were made aware of the above concerns. Facility policy titled, Discharge/Transfer Letter Policy, documents in part, the following: The resident or responsible party will receive a bed hold notice along with the discharge/transfer letter, when applicable. Based on record review, staff interviews and complaint investigation, the facility staff failed to provide two residents (Resident #258 and #15) with bed hold policy notice upon transfer to the hospital in the survey sample of 36 residents. The findings included: 1. Resident #258 was admitted to the facility on [DATE]. This resident was diagnosed as having Tardue Dyskinesia, hypertension, anxiety, depression, Bipolar, Schizoaffective disorder, hyperlipidemia, and anemia. Resident #258 was not provided with a bed hold policy notice upon transfer to the hospital. This resident was assessed being stand to pivot x 1 assist, alert and oriented times 1 to self. Resident noted to wander in other patient rooms and exit seeking. A wander guard placed on left ankle. A Nursing note dated 06/03/20 at 5:38 P.M. indicated: Resident noted cursing loudly, screaming, and speaking to self. Resident noted pulling pants down, while walking in hallway. A Nursing note dated 06/04/20 at 6:48 P.M. indicated: 'Police arrived, in contact with local Community Service Board (CSB). Resident continue to be confused, yelling, and having hallucinations (talking to people who are not there). Resident does not follow directions, sitting on the floor, and then laid on the floor. Staff has made her environment secure. Resident's representative advised of status. A Nursing note dated 06/04/20 at 07:04 P.M. indicated: Resident laying on the floor, Emergency Transport arrived to transport to hospital. Physician advised of resident's status to transfer to hospital emergency department. During an interview on 03/17/21 at 4:45 P.M. with the social worker, she was asked if Resident #258 was provided with a bed hold policy notice? The social worker responded, I did not provide Resident #258 with a bed hold notice policy. The facility staff failed to provide Resident #258 with a bed hold policy notice upon transfer to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interviews and clinical record review the facility staff failed to implement interventions, heel boots, in the comprehensive care plan for 1 of 36 Resident's in the survey sample, (Resident #6). The findings included: Resident #6 was originally admitted to the facility on [DATE]. The resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. The resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to, Peripheral Vascular Disease and Moderate Protein-Calorie Malnutrition. Resident #6's admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 12/16/2020 was coded with a BIMS (Brief Interview for Mental Status) score of 03 indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #6 as requiring total dependence of 2 for bed mobility, dressing, toilet use, personal hygiene and bathing and supervision with set up help only for eating. On 03/17/2021 review of Resident #6's Clinical Record revealed the following: Review of [NAME] Braden Scale Pressure Ulcer Risk Assessment revealed the following: Effective Date: 12/17/2020 Braden Score: 13 Braden Category: Moderate Risk. Review of the Comprehensive Care Plan revealed the following: Focus; Heel Boots: Resident at Risk for impaired skin integrity impaired mobility. Goal: Skin will be free of breakdown. Interventions: Elevate heels off mattress per routine and/or as needed. Review of the Treatment Administration Record for the period of 03/01/2021 - 03/31/2021 revealed that Resident #6 has an order which reads as follows: Right heel - clean with Normal saline, apply betadine, bordered dry dressing and wrap with kerlix every night shift. Start Date - 03/17/2021. On 03/18/2021 at approximately 12:05 p.m., requested that Certified Nursing Assistant (CNA) #4 pull back the covers from Resident #6 feet. After CNA #4 pulled the covers back and a pillow was observed under Resident #6's calves and the residents feet were crossed and her left heel was lying on the mattress. Observed right heel was wrapped with kerlix. CNA #4 stated, I had the pillow under her heels to float her heels. When asked how did the pillow get under Resident #6's calves, CNA #4 stated, She can move it. CNA #4 repositioned the pillow under Resident #6 lower legs to float the residents heels. Observed left heel to still be touching the mattress. When asked if Resident #6 wore heel boots, CNA #4 stated, I don't usually work over here. I worked with her yesterday and today. When asked if Resident #6 wore heel boots yesterday, CNA #4 stated, No. CNA #4 stated, I can get some heel boots and put them on her if you want. When asked how do you know what type care a resident needs, requires, CNA #4 stated, I get report and will ask what care to provide. The Administrator, Director of Nursing and Regional [NAME] President of Operations was informed of the finding on 03/18/2021 at approximately 3:45 p.m. at the pre-exit meeting. When asked what are your expectations of the staff, Director of Nursing stated, Should have on the heel poseys if its in the care plan. The facility did not present any further information about the finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interviews and clinical record review the facility staff failed to failed to revise the care plan with a change in code status for one of 36 residents; (Resident #14) AND failed to ensure that the intervention, compression glove, was included in the comprehensive care plan for one of 36 residents, (Resident #27). The findings included: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses that included but were not limited to atrial fibrillation, muscle wasting and atrophy, diverticulosis of the intestine, and vascular dementia without behavioral disturbance. Resident #14's most recent MDS (Minimum Data Assessment) was a quarterly assessment with an ARD (assessment reference date) of 1/7/21. Resident #14 was coded as being severely impaired in the ability to make daily decision on the Staff Assessment for Mental Status exam. Review of Resident #14's March 2020 POS (Physician Order Summary) revealed the following current order: Full Code. This order was initiated on 12/7/20. Review of Resident #14's facesheet documented Full Code as her code status. Review of Resident #14's care plan dated 2/18/21 documented the following: Resident has chosen DNR (Do Not Resuscitate). On 3/18/21 at 9:20 a.m., an interview was conducted with RN (Registered Nurse) #1, the MDS nurse. When asked who was responsible for revising the care plan, RN #1 stated that the floor nurses were responsible for revising the care plan for changes in the resident's status; but that MDS would review and revise the care plan quarterly. This writer showed RN #1 Resident #14's care plan. RN #1 stated that Resident #14's care plan should reflect Full Code and not DNR. RN #1 stated that Resident #14's care plan was inaccurate. RN #1 stated that Resident #14 used to be a DNR prior to 12/7/2020 and that it was not reflected on the care plan. On 3/18/21 at 3:40 p.m. during a pre-exit conference; ASM (Administrative Staff Member) #1, the Administrator, ASM #2, the DON (Director of Nursing), ASM #3, the Regional [NAME] President of Operations, and ASM #4, the Regional Director of Clinical Services were made aware of the above concerns. Facility Policy titled, Comprehensive Care Planning, documents in part, the following: The MDS Coordinator is to review the 24 hour Report daily for significant changes or changes in resident's ADL (Activities of daily living) status. The Care Planning coordinator will add minor changes in resident's status to the existing Care Plans on daily basis. 2. Resident #27 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side and Type 2 Diabetes Mellitus. Resident #27's admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 02/13/2021 was coded with a BIMS (Brief Interview for Mental Status) score of 13 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #27 as requiring total dependence of one person with bed mobility, transfer, dressing, toilet use, personal hygiene and bathing and supervision with setup help only for eating. On 03/16/2021 at approximately 1:25 p.m. review of Resident #27's Physician Orders revealed an order that reads as follows: Pt to wear compression glove on R hand, remove PRN (As Needed) for hygiene. Revision Date: 03/04/2021. On 03/16/2021 at 2:00 p.m., conducted an interview with Resident #27. When asked if she could move her left arm, Resident #27 lifted her left arm and stated, Yes. When asked if she could move her right arm, Resident #27 stated, I can't move it as well I had a stroke. Resident #27's right hand observed to be edematous. Resident does not have on a compression glove. When asked if she wore the compression glove on her right hand, Resident #27 stated, I think I use to but not lately. On 03/17/2021 review of Resident #27's Clinical Record revealed the following: On 03/17/2021 Nurse Practitioner Progress Note was reviewed and revealed the following: Skin: sacral pressure ulcer, turgor normal, cap (capillary) refill < (less than) 3 sec (seconds), no cyanosis, warm dry, edema present to R arm and hand. On 03/17/2021 admission Nurse Progress Note was reviewed and revealed the following: Effective Date: 2/10/2021 Type: admission Edema is present right arm and hand. On 03/17/2021 [NAME] admission readmission Evaluation was reviewed and revealed the following: Effective Date 02/10/2021 10. Cardiovascular A. Edema Present A1. Edema Describe: right arm and hand. On 03/18/2021 at approximately 1:30 p.m., received copy of Occupational Therapy Treatment Encounter Notes from Unit Manager. Review of Note signed on 3/8/2021 05:07: 55 PM revealed the following and is documented in part, as follows: Date of Service: 3/8/2021 Summary of Daily Skilled Services: RUE (Right Upper Extremity) positioned elevated on pillows to decrease worsening edema in RUE. Unable to locate compression glove. Review of Note signed on 3/8/2021 05:07:56 PM revealed the following and is documented in part, as follows: Date of Service: 3/8/2021 Summary of Daily Skilled Services: 97530: Pt (Patient) re-issued R compression glove. donned with max (Maximum) A (Assist) to decrease edema in R (Right) hand. Retrograde massage completed to further reduce edema to increase R hand functional use in order to increase I with ADLs (Activities Daily Living). An interview was conducted with Registered Nurse (RN) #1, MDS Coordinator, when asked is the order for compression glove addressed in Resident #27's comprehensive care plan, RN #1 stated, I was not made aware of the order, I will care plan it. When asked should it be care planned, RN #1 stated, Yes, should be monitored and checked so it doesn't cut off circulation. The Administrator and Director of Nursing and Regional [NAME] President of Operations was informed of the finding on 03/18/2021 at approximately 3:45 p.m. at the pre-exit meeting. When asked should the compression glove be addressed in the comprehensive care plan, Director of Nursing stated, Yes. When asked what is the purpose of the comprehensive care plan, Director of Nursing stated, Help guide the care to be provided to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on representative interview, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to follow professional standards of practice by signing off medications were administered to two of 15 residents; Residents #212 and #211 that were not available. The findings included: 1. Resident #212 was admitted to the facility on [DATE] with diagnoses that included but were not limited to chronic heart failure, closed fracture of the right tibia with healing, pain in right knee, and high blood pressure. Resident #212's most recent comprehensive MDS (Minimum data set) assessment was an admission assessment with an ARD (assessment reference date) of 7/4/21. Resident #212 was coded as being cognitively intact in the ability to make daily decisions; scoring 13 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #212 was coded in Section J0100. (Pain Management) as not receiving scheduled pain medications in the last 5 days from the ARD date (7/4/21). Resident #212 was coded as receiving prn (as needed) pain medications in the last 5 days AND recieved non medication interventions for pain in the last 5 days. Resident #212 was coded as not having pain. Review of a therapy note dated 7/13/21 revealed that Resident #212 was having a pain of 8/10 during her therapy session. The following was documented in part, .Pt (patient) declined participation in therapy 2/2 (two attempts) to increased pain and fatigue. PTA (Physicial Therapy Assistant) encouraged pt (patient) to engage in seated therex (therpapy exercies), however, pt continued to decline at this time .Pt reported 8/10p (pain) in R (right knee) and requested pain meds (medications), NRSG (Nursing) made aware. Review of a note from the NP (Nurse Practitioner) dated 7/13/21 documented in part, the following: She is being seen today for c/o(complaints) right knee pain. Pt is sitting up in her w/c, appears comfortable and in no acute distress. A&O x3 (Alert and Oriented x3), pleasant and responsive. She has a history of repeated falls where she has a displaced fracture of her right tibia. She is c/o right knee pain that is unrelieved by Tylenol. Right knee is currently stable in a right knee brace. She currently c/o (complaints) 3-4/10 right knee pain, but tolerable . 1. Right knee pain: will give Tramadol (1) 50 mg 1 tab po (by mouth) Q (every) 12 (hours) x (for) 10 days. Review of Resident #212's July 2021 POS (Physician Order Summary) revealed the following order: Tramadol HCl Tablet 50 MG Give 1 tablet by mouth two times a day for Pain for 10 Days. Start Date: 7/13/21 2100 (9 p.m.). Further review of Resident #212's July 2021 MAR (Medication Administration Record) revealed that her Tramadol was to be scheduled for 9 AM and 2100 (9:00 PM). Resident #212 did not receive her 9 p.m. dose of Tramadol on 7/13/21. Review of Resident #212's July 2021 MAR revealed that nurses were signing off that they had administered the scheduled Tramadol on 7/14/21 at 9:00 a.m. and 9:00 p.m. Evidence (Narcotic sheets) could not be provided to show that the ordered Tramadol had made it to the facility from pharmacy. Evidence could not be shown that the nurses obtained the ordered Tramadol from the Omnicell (STAT box). Review of Resident #212's MAR also revealed that she missed her 9 a.m. dose of Tramadol on 7/15/21 (hours before her discharge home on 7/15/21). Further review of Resident #212's clincial record revealed that she was discharged home on 7/15/21 at 1:40 p.m. Review of the Omnicell list of medications revealed that Tramadol 50 mg was a medication available in the Omnicell. On 8/4/21 at 2:23 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #2, the nurse who worked day shift on 7/14/21. When asked the process if she were to go administer a scheduled medication; more specifically a narcotic, and it was not in the medication cart, LPN #2 stated that she would check to see if the medication was available in the STAT Omnicell. LPN #2 stated that she would then pull the medication from the Omnicell. When asked if Tramadol 50 mg was in the Omnicell, LPN #2 stated, Yes, I know that is in the STAT box. When asked if that is where she pulled Resident's #212's Tramadol on 7/14/21, LPN #2 stated, Yes, I pulled from the STAT box. On 8/5/21 at 10:25 a.m., an interview was conducted with the medical records personnel at the facility's pharmacy (OSM (Other Staff Member) #3). OSM #3 stated that the pharmacy had never received an order for the scheduled tramadol or a script (Prescription). OSM #3 stated that a script must also be in place for the nurse to access a STAT dose from the Omnicell. On 8/5/21 at 10:41 a.m., further interview was conducted with LPN (Licensed Practical Nurse) #2, the nurse who worked day shift on 7/14/21. When asked how she signed off that she had administered a 9 a.m. dose of Tramadol on 7/14/21 if the pharmacy had not yet recevied an order or a script for the medication; LPN #2 stated, I don't remember why I signed that off. When asked if it was acceptable to sign off that medications were administered, if they were not in fact given to the resident, LPN #2 stated, No ma'am. When asked what why the Tramadol had not made it to the facility, LPN #2 stated, I don't know exactly the cause. On 8/5/21 during a pre-exit meeting, ASM (Administrative Staff Member) #1, the administrator, and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. The facility could not provide a policy or professional standard for the above concerns. (1) Tramadol- analgesic used to treat moderate to severe pain. This information was obtained from Davis's Drug Guide for Nurses, 11th edition p. 1197. 2. Resident #211 was admitted to the facility on [DATE] with diagnoses that included but were not limited to cerebral infarction (stroke), right sided hemiplegia (paralysis) following stroke, type two diabetes mellitus, and end stage renal disease requiring dialysis. Resident #211's most recent comprehensive MDS (minimum data set) assessment was an admission assessment dated [DATE]. Resident #211 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #211 was coded in Section J0100. (Pain Management) as receiving scheduled pain medications in the last 5 days from the ARD date (7/5/21). Resident #211 was coded not receiving prn (as needed) pain medications in the last 5 days AND receiving non medication interventions for pain in the last 5 days. Resident #211 was coded as not having pain. Resident #211 was discharged from the facility on 8/3/21. On 8/4/21 at 9:58 a.m., a telephone interview was conducted with Resident #211's emergency contact as a number was not listed for Resident #211. Resident #211's emergency contact was her son, and did not feel comfortable giving out his mother's telephone number. The son did have a concern regarding his mother's gabapentin (1) for her nerve pain. The son stated that there was quite some time where his mother was out and that nursing staff were not following up with obtaining the medication. The son stated that he eventually had to go to the facility to speak with the DON (Director of Nursing) who then took care of the issue. The son stated that his mother was not yet experiencing pain but was overall sick to her stomach and feeling itchy all over which was usually a withdrawal side effect for her. The son was upset that it took his involvement to finally get his mother's prescribed gabapentin. Resident #211's care plan dated 6/24/21 documented the following for pain: Resident is at risk for pain related to CVA (Stroke) with right hemiparesis .Administer analgesics/medications per physician's orders . Review of Resident #211's June, July and August 2021 POS (Physician Order Summary) revealed the following order: Gabapentin 100 mg (milligrams) 100 mg capsule by mouth Three Times Daily. This order was initiated on 6/24/21. Review of the June, July, and August 2021 MARS (Medication Administration Record) revealed that gabapentin was scheduled for 6:00 a.m., 2:00 p.m., and 9:00 p.m. Review of the narcotic logs revealed on 6/24/21 the pharmacy had delivered 28 capsules of gabapentin. The first dose of gabapentin was given at 2100 (9:00 p.m.) on 6/24/21. Further review of the narcotic sheets revealed that Resident #211 had completed her gabapentin on 7/4/21 at 9:00 p.m.; where it was documented she had (zero) capsules left. Review of the second narcotic sheet for gabapentin revealed that pharmacy had delivered 30 capsules of gabapentin on 7/9/21. Resident #211's first dose of gabapentin was on 7/9/21 at 2100 (9:00 p.m.). There was no narcotic sheets/logs to account for days 7/5/21 through 7/9/21 at (2:00 p.m.) (13 administrations). Review of the facility STAT Omnicell list revealed that Gabapentin 100 mg was in the Omnicell STAT box. Further review of Resident #211's July 2021 MAR revealed that staff had not administered the gabapentin on the following dates: 7/5/21 at 2 p.m. and 9 p.m. 7/7/21 at 6:00 a.m., 2:00 p.m., and 9:00 p.m. 7/8/21 at 6:00 a.m. and 9:00 p.m. and 7/9/21 at 6:00 a.m. The following administration note was documented on 7/5/21 at 7:51 p.m.: On hold until received per NP (Nurse Practitioner). The following note was documented on 7/6/21 by the Nurse Practitioner: .Denies pain and has no complaints, SOB (Shortness of breath), and (abdominal pain) or N/V (nausea/vomiting) .Neuropathy: Continue Neurontin (Gabapentin) 100 mg TID, script renewed. On 7/7/21 the following administration note was documented: Gabapentin Capsule 100 mg- Give 1 mg by mouth three times a day for pain .pharmacy to send. On 7/8/21 the following administration note was documented: Gabapentin Capsule 100 mg .needs hard script. MD (medical doctor) aware. On 7/9/21 at 10:29 a.m., the following administration note was documented: Gabapentin 100 mg three times a day for pain .per MD, administrator, DON (Director of Nursing) ok to give now. Further review of Resident #211's MAR revealed that gabapentin was documented as administered on the following dates; however there was no evidence that facility staff had pulled gabapentin from the facility STAT box: 7/5/21 at 6:00 a.m., 7/6/21 at 6:00 a.m., 2:00 p.m., and 9:00 p.m., 7/8/21 at 2:00 p.m. On 8/4/21 at 3:45 p.m., during an interview with the pharmacist (OSM) Other Staff Member #2; it was determined that the pharmacy did not receive a script for the gabapentin until 7/9/21. OSM #2 stated that the only time nursing accessed the Omnicell to retrieve gabapentin for Resident #211 was on 7/9/21 at 10:24 a.m. OSM #2 stated that staff cannot pull gabapentin from the Omnicell unless a script is renewed so he could not explain why staff were documenting that they had administered the gabapentin on the above dates. OSM #2 stated that the pharmacy initially sent out 28 capsules of gabapentin on 6/24/21 which had run out on 7/4/21. OSM #2 stated that the second time they sent out gabapentin was on 7/9/21 and it was for 30 capsules. OSM #2 confirmed again that the only time Resident #211 received gabapentin in between dates 7/5/21 through 7/9/21 was on 7/9/21 at 10:24 a.m. OSM #2 stated that the request to retrieve the gabapentin was made from the DON (Director of Nursing). On 8/4/21 at 5:00 p.m., an interview was conducted with the DON (Director of Nursing) (ASM (Administrative Staff Member) #2. When asked if there was has been issues obtaining scripts for narcotics or getting those scripts to the pharmacy; ASM #2 stated, Yes. When asked what had happened with Resident #211's gabapentin as the NP had documented that she wrote a script on 7/6/21; ASM #2 stated that she was unaware that Resident #211's gabapentin prescription had run out until the son had come into the building on 7/9/21. ASM #2 stated that he was upset that his mom had missed her gabapentin for several days and wanted to know what was going on with it. ASM #2 stated that she had called the medical doctor to obtain a script that day. ASM #2 stated that she pulled the medication out of the Omnicell and the nurse administered the medication, but could not remember the time. ASM #2 stated that she realized the resident had been out sometime before she initiated getting the resident her gabapentin. When asked if the son really had initiated obtaining his mom's medication, ASM #2 stated, Yes, it was in response to the son coming in. ASM #2 stated that she expected her nurses to follow up with gabapentin and not wait days later before obtaining the medication. ASM #2 stated that she was not sure what they did do, didn't do for the gabapentin. When asked if Resident #211 had an increase amount of pain related to missing 12 doses of gabapentin, ASM #2 stated that she didn't think so, that this information was never reported to her. When asked if nursing staff should be documenting that medications are being administered when they are not in fact given, ASM #2 stated, Absolutely not. When asked if nursing staff should have pulled gabapentin from the Omnicell and administered the medication, ASM #2 stated that nursing staff could do that if there was a script for the medication. ASM #2 stated that she expected her staff to inquiring on why the gapabentin was not available and if it needed a script to call the physician, obtain a script and fax that to the pharmacy. ASM #2 stated that once the pharmacy has a script, the medication can be pulled from the Omnicell. ASM #2 confirmed that not all nurses had access to the Omnicell but that there was always someone in the building with access. ASM #2 stated that she was not aware that not all nurses had access and didn't realize this was the responsibility of the DON to ensure their access. ASM #2 confirmed that all nurses should have access to the Omnicell if they are responsible for passing out medications, and that she was going to work on getting all nurses access. The nurses who had documented that they had administered the gabapentin, when it was in fact, not administered could not be reached for an interview. On 8/5/21 during a pre-exit meeting at 12:30 p.m., ASM (Administrative Staff Member) #1, the administrator, and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. (1) Gabapentin is commonly used to treat neuropathic pain (pain due to nerve damage). This information was obtained from the National Institutes of Health. https://pubmed.ncbi.nlm.nih.gov/28597471/. COMPLAINT DEFICIENCY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to ensure heel boots were implemented per the person centered care plan.: Resident #6 was originally admitted to the facility on [DATE]. The resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. The resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to, Peripheral Vascular Disease and Moderate Protein-Calorie Malnutrition. Resident #6's admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 12/16/2020 was coded with a BIMS (Brief Interview for Mental Status) score of 03 indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #6 as requiring total dependence of 2 for bed mobility, dressing, toilet use, personal hygiene and bathing and supervision with set up help only for eating. On 03/17/2021 review of Resident #6's Clinical Record revealed the following: Review of [NAME] Braden Scale Pressure Ulcer Risk Assessment revealed the following: Effective Date: 12/17/2020 Braden Score: 13 Braden Category: Moderate Risk. Review of the Comprehensive Care Plan revealed the following: Focus; Heel Boots: Resident at Risk for impaired skin integrity impaired mobility. Goal: Skin will be free of breakdown. Interventions: Elevate heels off mattress per routine and/or as needed. Review of the Treatment Administration Record for the period of 03/01/2021 - 03/31/2021 revealed that Resident #6 has an order which reads as follows: Right heel - clean with Normal saline, apply betadine, bordered dry dressing and wrap with kerlix every night shift. Start Date - 03/17/2021. On 03/18/2021 at approximately 12:05 p.m., requested that Certified Nursing Assistant (CNA) #4 pull back the covers from Resident #6 feet. After CNA #4 pulled the covers back and a pillow was observed under Resident #6's calves and the residents feet were crossed and her left heel was lying on the mattress. Observed right heel was wrapped with kerlix. CNA #4 stated, I had the pillow under her heels to float her heels. When asked how did the pillow get under Resident #6's calves, CNA #4 stated, She can move it. CNA #4 repositioned the pillow under Resident #6 lower legs to float the residents heels. Observed left heel to still be touching the mattress. When asked if Resident #6 wore heel boots, CNA #4 stated, I don't usually work over here. I worked with her yesterday and today. When asked if Resident #6 wore heel boots yesterday, CNA #4 stated, No. CNA #4 stated, I can get some heel boots and put them on her if you want. When asked how do you know what type care a resident needs, requires, CNA #4 stated, I get report and will ask what care to provide. The Administrator, Director of Nursing and Regional [NAME] President of Operations was informed of the finding on 03/18/2021 at approximately 3:45 p.m. at the pre-exit meeting. When asked what are your expectations of the staff, Director of Nursing stated, Should have on the heel poseys if its in the care plan. The facility did not present any further information about the finding. 3. The facility staff failed to ensure that Resident #27 was wearing a compression glove to the right hand per physician's order. Resident #27 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side and Type 2 Diabetes Mellitus. Resident #27's admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 02/13/2021 was coded with a BIMS (Brief Interview for Mental Status) score of 13 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #27 as requiring total dependence of one person with bed mobility, transfer, dressing, toilet use, personal hygiene and bathing and supervision with setup help only for eating. On 03/16/2021 at approximately 1:25 p.m. review of Resident #27's Physician Orders revealed an order that reads as follows: Pt to wear compression glove on R hand, remove PRN (As Needed) for hygiene. Revision Date: 03/04/2021. On 03/16/2021 at 2:00 p.m., conducted an interview with Resident #27. When asked if she could move her left arm, Resident #27 lifted her left arm and stated, Yes. When asked if she could move her right arm, Resident #27 stated, I can't move it as well I had a stroke. Resident #27's right hand observed to be edematous. Resident does not have on a compression glove. When asked if she wore the compression glove on her right hand, Resident #27 stated, I think I use to but not lately. On 03/17/2021 review of Resident #27's Clinical Record revealed the following: On 03/17/2021 Nurse Practitioner Progress Note was reviewed and revealed the following: Skin: sacral pressure ulcer, turgor nml, cap (capillary) refill < (less than) 3 sec (seconds), no cyanosis, warm dry, edema present to R arm and hand. On 03/17/2021 admission Nurse Progress Note was reviewed and revealed the following: Effective Date: 2/10/2021 Type: admission Edema is present right arm and hand. On 03/17/2021 [NAME] admission readmission Evaluation was reviewed and revealed the following: Effective Date 02/10/2021 10. Cardiovascular A. Edema Present A1. Edema Describe: right arm and hand. In at Resident #27 bedside on 03/17/2021 at approximately 1:45 p.m., did not observe compression glove on right hand. On 03/18/2021 at approximately 9:40 a.m., in at Resident #27's bedside and did not observe compression glove on right hand. On 03/18/2021 at approximately 10:00 a.m., requested that the Unit Manager, accompany surveyor to Resident #27's bedside. Resident lying in bed with eyes open. Requested that Resident #27 show us her right hand. Observed edematous right hand. When Unit Manager was asked if Resident #27 should be wearing a compression glove on the right hand, Unit Manager stated, I will have to check. After departing Resident #27's room the physician order for the compression glove was reviewed with the Unit Manager. The Unit Manager stated, I can't remember, she may have refused to wear the glove. I will have to check. The Unit Manager was made aware that during the period of 03/16/2021 through 03/18/2021 the resident had not been observed wearing the glove. On 03/18/2021 at approximately 1:30 p.m., received copy of Occupational Therapy Treatment Encounter Notes from Unit Manager. Review of Note signed on 3/8/2021 05:07: 55 PM revealed the following and is documented in part, as follows: Date of Service: 3/8/2021 Summary of Daily Skilled Services: RUE (Right Upper Extremity) positioned elevated on pillows to decrease worsening edema in RUE. Unable to locate compression glove. Review of Note signed on 3/8/2021 05:07:56 PM revealed the following and is documented in part, as follows: Date of Service: 3/8/2021 Summary of Daily Skilled Services: 97530: Pt (Patient) re-issued R compression glove. donned with max (Maximum) A (Assist) to decrease edema in R (Right) hand. Retrograde massage completed to further reduce edema to increase R hand functional use in order to increase I with ADLs (Activities Daily Living). On 03/18/2021 at approximately 1:40 p.m., an interview was conducted with the Unit Manager, when asked if Resident #27 should be wearing a compression glove on the right hand, Unit Manager stated, Yes. The Administrator, Director of Nursing and Regional [NAME] President of Operations was informed of the finding on 03/18/2021 at approximately 3:45 p.m. at the pre-exit meeting. When asked what are your expectations of the staff, Director of Nursing stated, They should make sure to have the glove on as ordered. The facility did not present any further information about the finding. Based on staff interview, facility document review and clinical record review, it was determined that facility staff failed to accurately obtain, assess and monitor weights per physician's order and plan of care for one resident, Resident #40 AND failed to ensure that 2 of 36 residents in the survey sample, (Resident #6, and #27) treatments were implemented. The findings included: 1. Resident #40 was admitted to the facility on [DATE] with diagnoses that included but were not limited to heart failure, peripheral vascular disease, and psychotic disorder. Resident #40's most recent MDS (Minimum Data Set) assessment was a quarterly assessment with an ARD (Assessment Reference Date) of 2/18/21. Resident #40 was coded as being severely impaired in cognitive function on the Staff Assessment for Mental Status Exam. Review of Resident #40's March 2020 POS (Physician Order Summary) revealed the following order: Weigh Resident Daily Notify MD (Medical Doctor) of 3 lb (pound) weight gain in one day/5 lb in one week. Resident #40's care plan dated 12/30/2020 documented in part the following: Increased risk for nutrition problems r/t (related to) CHF (Congestive Heart Failure) .daily weights. Review of Resident #40's weights in his clinical record revealed that on 3/4/21 Resident #40 weighed 165.5 pounds. The next day (3/5/21) Resident #40 was documented as weighing 266.6 pounds (101.1 pound weight gain). Resident #40 was also documented as weighing 266 pounds on 3/6/21, 266.6 on 3/7/21, 266.1 on 3/8/21, 266 on 3/9/21, 201.7 on 3/12/21 and back down to 166.4 on 3/14/21. No weights were recorded for 3/10/21, 3/11/21, and 3/13/21. Review of Resident #40's clinical record revealed no indication that a re-weigh had been conducted due to the higher recorded weights from 3/5/21 through 3/12/21. There was no evidence that staff were monitoring Resident #40's weights. Review of the March 2021 MARS (Medication Administration Record) and TARS (Treatment Administration record) failed to evidence any additional weights obtained. On 3/17/21 at 3:25 p.m., an interview was conducted with CNA #2, a CNA on Resident #40's unit. When asked who was responsible for obtaining daily weights on residents, CNA #2 stated that the nursing aides were responsible. When asked how she obtains weights on residents who are totally dependent on staff for ADLS (Activities of daily living), CNA #2 stated that she would use the mechanical lift scale. When asked what she would do if she noticed a major discrepancy in a resident's weight; CNA #2 stated that she would alert the nurse or DON (Director of Nursing). When asked if she and the other nursing aides had been educated lately on how to accurately obtain weights, CNA #2 stated that she hadn't. On 3/18/21 at 9:30 a.m., an observation was conducted of CNA (Certified Nursing Assistant) #1 obtaining a daily weight on Resident #40 using a mechanical lift scale. There were no concerns related to obtaining his weight. Resident #40 weight was recorded as 164.6 (pounds). On 3/18/21 at 10:21 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #2, Resident #40's nurse. When asked why Resident #40 was on daily weights; LPN #2 stated that Resident #40 was on daily weights for his diagnosis of CHF (Congestive Heart Failure). When asked if there were parameters to notify the physician, LPN #2 stated that usually if a resident had a weight gain of 5 pounds in one week, she would notify the physician. When asked what would happen if a resident had a 100 pound weight gain in one day, LPN #2 stated that she would ask the CNAs (Certified Nursing Assistants) to do a reweigh. When asked if CNAs were responsible for obtaining daily weights, LPN #2 stated that the nursing aides obtain the weight and nurse enters in the weight into the system. When asked if the nurses were responsible for monitoring daily weights, LPN #2 stated that they were. When asked what had happened with Resident #40's weights from 3/5/21 through 3/12/21 documenting a 100 pound weight gain; LPN #2 stated the discrepancy must have been a error in documentation. When asked how an error was made six times on the clinical record, LPN #2 was not sure. LPN #2 stated that a re-weigh was probably done in response to the inaccurate weights. When asked if re-weighs should be documented on the clinical record, LPN #2 stated that re-weighs should be documented in a nursing note but that she didn't think Resident #40's re-weights were recorded. When asked how a resident can be assessed and monitored for daily weight gain if inaccurate weights are recorded in the clinical record and three days (3/10/21, 3/11/21, and 3/13/21) of the daily weights were missing; LPN #2 stated that she would have to find out that information. On 3/18/21 at 3:40 p.m. during a pre-exit conference; ASM (Administrative Staff Member) #1, the Administrator, ASM #2, the DON (Director of Nursing), ASM #3, the Regional [NAME] President of Operations, and ASM #4, the Regional Director of Clinical Services were made aware of the above concerns. Facility policy titled, Weights Policy, documented in part, the following: D) Reweights: 1. For Residents who weigh > (greater) than 100#, all weight changes showing a gain or loss of 5 pounds or more from the previous weight require a reweigh within 24 hours. E) All significant weight changes must be communicated to the resident if appropriate, the attending physician and responsible party. F) Weight Documentation: 1. All weights for each Resident (Including, new admission, readmission, monthly, and weekly) are to be recorded in one central weight record. Appropriate methods for recording weights are: Electronic Health Record. Vital signs and Weight Record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation, it was determined that facility staff failed to ensure pain relief measures were provided to one of 15 residents in the survey sample, Resident #212 who requested pain medication on 7/13/21 and 7/14/21. The findings included: Resident #212 was admitted to the facility on [DATE] with diagnoses that included but were not limited to chronic heart failure, closed fracture of the right tibia with healing, pain in right knee, and high blood pressure. Resident #212's most recent comprehensive MDS (Minimum data set) assessment was an admission assessment with an ARD (assessment reference date) of 7/4/21. Resident #212 was coded as being cognitively intact in the ability to make daily decisions; scoring 13 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #212 was coded in Section J0100. (Pain Management) as not receiving scheduled pain medications in the last 5 days from the ARD date (7/4/21). Resident #212 was coded as receiving prn (as needed) pain medications in the last 5 days AND recieved non medication interventions for pain in the last 5 days. Resident #212 was coded as not having pain. Review of Resident #212's medical record revealed that Resident #212 had an order for the following prn pain medication: Tylenol Tablet 325 mg (milligram) Give 3 tablets by mouth every 6 hours as needed for pain. Review of Resident #212's July TAR (Treatment Administration Record) revealed that Resident #212 received Tylenol 325 mg 3 tablets on 7/1/21 through 7/11/21. Review of the Emar Administration notes revealed that the Tylenol was effective on these dates for pain relief. Review of a therapy note dated 7/13/21 revealed that Resident #212 was having a pain of 8/10 during her therapy session. The following was documented in part, .Pt (patient) declined participation in therapy 2/2 (two attempts) to increased pain and fatigue. PTA (Physicial Therapy Assistant) encouraged pt (patient) to engage in seated therex (therpapy exercies), however, pt continued to decline at this time .Pt reported 8/10p (pain) in R (right knee) and requested pain meds (medications), NRSG (Nursing) made aware. There was no evidence on Resident #212's MAR (Medication Administration Record) that nursing administered prn (as needed) Tylenol to Resident #212 on 7/13/21. There was no evidence of any non-pharmacological pain relief measures provided to Resident #212 on 7/13/21. Review of a note from the NP (Nurse Practitioner) dated 7/13/21 documented in part, the following: She is being seen today for c/o (complaints) right knee pain. Pt is sitting up in her w/c, appears comfortable and in no acute distress. A&O x3 (Alert and Oriented x3), pleasant and responsive. She has a history of repeated falls where she has a displaced fracture of her right tibia. She is c/o right knee pain that is unrelieved by Tylenol. Right knee is currently stable in a right knee brace. She currently c/o (complaints) 3-4/10 right knee pain, but tolerable . 1. Right knee pain: will give Tramadol (1) 50 mg 1 tab po (by mouth) Q (every) 12 (hours) x (for) 10 days. Further review of Resident #212's MAR revealed that her Tramadol was to be scheduled for 9 AM and 2100 (9:00 PM). Resident #212 did not receive her 9 p.m. dose of Tramadol on 7/13/21. Review of a therapy note dated 7/14/21 documented in part, the following: .reported increased R knee pain .Pt left sitting up in wc (wheelchair) and NRSG (nursing) arriving to administer pain meds .Pt reported 7/10 p in R knee, NRSG made aware that pt requested pain meds. Review of Resident #212's MAR revealed that there was no evidence that nursing administered administered prn (as needed) Tylenol to Resident #212 on 7/14/21. There was no evidence of any non-pharmacological pain relief measures provided to Resident #212 on 7/14/21. Further review of the July MAR revealed that a nurse had signed off that she had administered the scheduled Tramadol at 9:00 a.m. Evidence (Narcotic sheets) could not be provided to show that the ordered Tramadol had made it to the facility from pharmacy. Evidence could not be shown that the nurse obtained the ordered Tramadol from the Omnicell (STAT box). Review of Resident #212's pain care plan dated 7/2/21 documented the following: The resident has pain r/t (related to) Right knee pain AEB closed fracture of right tibial plateau, Osteroarthritis .Administer analgesics per orders, Anticipate the patient's need for pain relief and respond to any complaint of pain as needed. Assess/document for probable cause of each pain episode. Remove/limit causes where possible . On 8/4/21 at 12:02 p.m., and 4 p.m., a telephone interview was attempted with Resident #212's representative. She could not be reached for an interview. On 8/5/21 at 10:25 a.m., an interview was conducted with the medical records personnel at the facility's pharmacy (OSM (Other Staff Member) #3). OSM #3 stated that the pharmacy had never received an order for the scheduled tramadol or a script (Prescription). OSM #3 stated that a script must also be in place for the nurse to access a STAT dose from the Omnicell. On 8/5/21 at 10:41 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #2, the nurse who worked day shift on both 7/13/21 and 7/14/21. When asked if she recalled therapy speaking to her about Resident #212's increased pain on both 7/13/21 and 7/14/21; LPN #2 stated that she didn't recall specific days but that they usually let her know. When asked if she provided any pain relief measures to Resident #212 on 7/13/21 and 7/14/21 after therapy had alerted her of Resident #212's pain; LPN #2 stated, I don't remember. When asked if medications are usually signed off on the MAR after they are administered, LPN #2 stated that medications are to be signed off after they have been administered. This writer showed LPN #2 Resident #212's MAR and the lack of evidence that PRN medication was administered. LPN #2 stated, I must not have given it then. When asked how she signed off that she had administered a 9 a.m. dose of Tramadol on 7/14/21 if the pharmacy had not yet recevied an order or a script for the medication; LPN #2 stated, I don't remember why I signed that off. When asked if it was acceptable to sign off that medications were administered, if they were not in fact given to the resident, LPN #2 stated, No ma'am. When asked if non-pharmacological interventions rendered for pain should be documented, LPN #2 stated that it should. LPN #2 stated again that she wasn't sure what happened, that sometimes therapy makes the pain sound bigger than it is and maybe she asked the resident and the resident was fine. LPN #2 could not provide evidence of a pain assessment conducted for Resident #212 on 7/13/21 and 7/14/21. On 8/5/21 at 11:19 a.m., an interview was conducted with OSM #4, the PTA (Physical Therapy Assistant) who worked with Resident #212 on both 7/13/21 and 7/14/21. OSM #4 stated that the first day she had worked with the resident, the resident had declined her therapy due to pain. OSM #4 stated that the second day, Resident #212 was still having pain to that right knee but was able to participate some in therapy. OSM #4 stated that she had alerted the nurse on duty both times regarding her pain. OSM #4 stated that she could not specify who she had told. When asked if she had actually seen the nurse administer pain medication or provide non-pharmacolgical relief interventions; to Resident #212, OSM #4 stated that she did not witness that. On 8/5/21 during a pre-exit meeting at 12:30 p.m., ASM (Administrative Staff Member) #1, the administrator, and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. The facility could not provide a policy or professional standard for the above concerns. (1) Tramadol- analgesic used to treat moderate to severe pain. This information was obtained from Davis's Drug Guide for Nurses, 11th edition p. 1197. COMPLAINT DEFICIENCY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review the facility staff failed to ensure that 1 of 36 residents (Resident #10) in the survey sample had an order for Dialysis. The findings included: Resident #10 was admitted to the facility on [DATE]. Resident #10 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to, HTN (Hypertension) and End Stage Renal Disease. Resident #10's admission Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 12/18/2020 was coded with a BIMS (Brief Interview for Mental Status) score of 13 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #10 as requiring supervision with setup help only with eating, limited assistance of 1 with bed mobility, dressing, toilet use and personal hygiene, extensive assistance of 1 with transfer and physical help in part of bathing activity with assistance of 1. On 03/17/2021 review of Resident #10's Clinical Record revealed the following: Review of Resident #10's Comprehensive Care Plan revealed the following: Resident receives dialysis treatments 3 times weekly. ESRD (End Stage Renal Disease). Date Initiated: 12/15/2020 Created on: 12/15/2020 Revision on: 12/15/2020. Review of Resident #10's Order Summary Report on 03/17/2021 at approximately 2:10 p.m., revealed the following date: Active Orders As Of: 03/01/2021. Review of Order Summary Report did not evidence an order for Dialysis. On 03/18/2021 review of Resident #10's Medication Administration Record for the period of 03/01/2021 - 03/31/2021 did not evidence an order for dialysis. On 03/18/2021 review of Resident #10's Treatment Administration Record for the period of 03/01/2021 - 03/31/2021 did not evidence an order for dialysis. On 03/18/2021 at approximately 3:45 p.m., at pre-exit meeting the Administrator, Director of Nursing and Regional [NAME] President of Operations was informed of the finding. When asked should the resident have an order for dialysis, Director of Nursing stated, Yes should have the order. When asked who obtains the order, The nurse. When asked what are your expectations of the nurses, Director of Nursing stated, Expect them to follow up to get the order. The facility did not present any further information about the finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interviews and review of facility documents, the facility's staff failed to consistently procure an ordered significant medication for 1 of 36 residents (Resident #50), in the survey sample. The findings included Resident #50 was originally admitted to the facility 12/3/14 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Multiple sclerosis (MS). The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/27/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #50's cognitive abilities for daily decision making were intact. An interview was conducted with Resident #50 on 3/16/21 at approximately 12:40 p.m. Resident #50 stated frequently his Multiple Sclerosis medication Glatiramer 20 milligram/1 milliliter subcutaneously is not available for administration. The resident further stated he wasn't sure why the staff allowed it to run out prior to obtaining more. The physicians order dated 12/15/20 read; Glatiramer 40 milligram/1 milliliter subcutaneously one time per day on Monday, Wednesday and Friday, for MS. On 2/24/21, the order was resumed after the resident returned from the hospital. Review of the pharmacy invoices provided revealed the pharmacy delivered a one week supply (3 one dose syringes) of the medication to the facility 12/23/20 and doses were administered 12/25/20, 12/28/20 and 12/30/20, Three more doses were delivered 12/28/20 to be administered 1/1/21, 1/4/21 and 1/6/21, Three more doses were delivered 1/7/21 and administered 1/8/21, 1/11/21 and 1/13/2, Three more doses were delivered 1/15/21 and were administered 1/15/21, 1/18/21 and 1/20/21, Three more doses were delivered 1/20/21 and were administered 1/22/21, 1/25/21 and 1/27/21, there was no medication available to administer 1/27/21 and 1/29/21 for the next three more doses were not delivered until 2/3/21, they were administered 2/3/21, 2/5/21 and 2/8/21, there was no medication available to administer 2/10/21, Three more doses were delivered 2/12/21, they were administered 2/12/21, 2/15/21 and one left for 2/17/21 but the resident was admitted to the hospital on [DATE]. An interview was conducted with Licensed Practical Nurse (LPN) #2 on 3/18/21 at approximately 1:45 p.m. LPN #2 stated there has been occurrences in which the resident's medication Glatiramer had been delivered late to the facility or not available to administer at all but less frequently than previously. On 3/18/21 at approximately 3:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The Director of Nursing stated she would look further into the allegation and provide documentation after it was obtained. Pharmacy invoices for the medication Glatiramer 40 milligram/1 milliliter were requested from 11/1/21 through the last delivery 3/16/21. Invoices for three doses were provided for 11/18/20, 11/30/20, 12/6/20 . Based on clinical record review and staff interview the facility staff failed to acquire medications upon admissions for one resident (Resident #258) in the survey sample of 36 residents. The findings included: Resident #258 was admitted to the facility on [DATE]. This resident was diagnosed as having Tardue Dyskinesia, hypertension, anxiety, depression, Bipolar, Schizoaffective disorder, hyperlipidemia, and anemia. The facility staff failed to acquire medications upon admissions for Resident #258. This resident was assessed being stand to pivot x 1 assist, alert and oriented times 1 to self. Resident noted to wander in other patient rooms and exit seeking. A wander guard placed on left ankle. Resident #258 had a physician's order dated 06/03/20 for the following medications: Alendronate 35 milligrams (mg) tablet (1 tablet) oral one time weekly starting 06/03/20: Latanoprost 0.005% eye drops (1 drop) drops both eyes one time daily starting 06/03/20: Clonazepam 2 mg tablet (1 tablet) tablet oral two times daily starting 06/03/20: Ferrous sulfate 325 mg (65 mg iron) tablet (1 tablet) tablet oral two times daily starting 06/03/20: Risperdal 0.5 mg tablet (1 tablet) tablet oral two times daily starting 06/03/20: Risperdal 1 mg tablet (1 tablet) tablet oral two times daily starting 06/03/20: Amlodipine 10 mg tablet (1 tablet) tablet oral one time daily starting 06/04/20: Escitalopram 10 mg tablet (1 tablet) tablet oral one time daily starting 06/04/20: A review of the Medication Administration Record June 2020 Non-PRN Medication Notes indicated: Clonazepam 2 mg tablet (1 tablet) tablet oral two times daily - Date 06/03/20 - Time 2100 (9:00 P.M.) Notes- Not administered (Med not available). A 06/04/20 note indicated: Time- 9:00 A.M. -Notes - Not administered (Med not available). During an interview on 03/18/21 at 9:07 A.M. with the Director of Nursing (DON) she stated, Resident #258 did not receive her prescribed Clonazepam 2 mg medications on 06/03/20 and 06/04/20 was because the meds were not available. A facility Pharmacy Services policy Medication shortages/Unavailable Medications indicated: Procedures: 1. Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication shortage is discovered at the time of medication administration, facility staff should immediately take the action specified in Sections 2 or 3 of this policy as applicable. 2. If a medication shortage is discovered during normal pharmacy hours: 2.1 Facility nurse should call pharmacy to determine the status of the order. If the medication has not been ordered, the licensed facility nurse should place the order or reorder for the next scheduled delivery. 2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. 2.3 If the medication is not available in the Emergency Medication Supply facility staff should notify pharmacy and arrange for an emergency delivery. 3. If a medication shortage is discovered after normal pharmacy hours: 3.1 A licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply. 3.2 If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: 3.2.1 Emergency delivery: or 3.2.2 Use of an emergency (back-up) third party pharmacy. 4. If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions. During an interview on 03/18/21 at 9:07 A.M. with the DON she stated, The Stat Box information was not available for review because of a lack of access with the prior owner's of the facility. The facility staff failed to acquire medications upon admission to the facility for one resident.

Based on the observation of 2 medication carts, 1 treatment cart and 1 medication room; the facility staff failed to dispose of expired medications and surgical supplies for two units. The facility staff failed to dispose of expired medications on Unit 1 and failed to discard two expired suture trays on unit 2. The findings include: On 3/17/21 at 11:09 AM an Inspection of Treatment Cart on Unit 2 was conducted with LPN (Licensed Practical Nurse) #4. Two suture removal Tray kits with an expiration date of 11/01/2020 was found during the inspection. LPN #4 replied, I should have discarded them. On 03/17/21 at 2:11 PM on unit 1 an inspection of medication cart #1 was conducted with LPN #3. Upon visual inspection a house stock bottle of acetaminophen 500 mg with an expiration date of 1/2021 was seen. It had an opened date of 3/08/21. Located in the same medication cart was 1 bottle of Humalog insulin with an open date of 2/10/21. LPN #3 stated, I meant to take it out this morning. It's over twenty eight days. I should have discarded the insulin and Tylenol. Numerous attempts were made to obtain a policy/policies on expired medications and biologicals from the facility administrator. An exit interview was conducted on 3/18/21 at 2:28 PM with with the Regional [NAME] President of Operations (Corporate Staff #3) No comments were voiced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that facility staff failed to maintain a complete and accurate clinical record for one of 36 residents in the survey sample, Resident #27. The findings included: 1. Resident #27 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side and Type 2 Diabetes Mellitus. Resident #27's admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 02/13/2021 was coded with a BIMS (Brief Interview for Mental Status) score of 13 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #27 as requiring total dependence of one person with bed mobility, transfer, dressing, toilet use, personal hygiene and bathing and supervision with setup help only for eating. On 03/17/2021 Resident #27's Clinical Record was reviewed and revealed the following: Review of Physician Order Summary revealed that Resident #27 has an order for a treatment to the Sacrum clean with NS (Normal Saline), pat dry, apply Dakins soaked gauze packed into wound and bordered dry dressing BID (Twice a Day) and PRN (As Needed) every day and night shift. Order Date: 02/10/2021 Start Date: 02/10/2021. Review of Treatment Administration Record (TAR) for the period of 2/1/2021 - 2/28/2021 revealed the following dates with blank spaces: Day E 2/12, 2/13, 2/14, 2/15, 2/16, 2/20, 2/21, 2/23, 2/24, 2/25, 2/27/2021; Night 2/10, 2/13, 2/26. Review of Treatment Administration Record for the period of 3/1/2021 - 3/31/2021 revealed the following dates with blank spaces: Day E 3/2, 3/5, 3/10, 3/11, 3/13. On 03/18/2021 at approximately 9:30 a.m., an interview was conducted with the Unit Manager. When asked what do blank spaces indicate on the Treatment Administrative Records, Unit Manager stated, Either not signed out or hit Other. If the nurse does not sign out, initial, space will be blank. On 03/18/2021 at approximately 10:45 a.m., an interview was conducted with the Director of Nursing. The blank spaces on the Treatment Administrative Records for February 2021 and March 2021 were reviewed with the Director of Nursing. When asked if something should be documented in the blank spaces on the Treatment Administrative Records, Director of Nursing stated, Yes, if there is a blank and no key it makes me question. Can't answer for them or her. The Administrator, Director of Nursing and Regional [NAME] President of Operations were informed of the finding on 03/18/2021 at approximately 3:45 p.m. at the pre-exit meeting. The facility did not present any further information about the finding.

Based on record review, staff interviews and facility documentation the facility staff failed to have the required minimal committee members attend QAA meetings and failed to meet on a quarterly basis. The findings included: On 3/18/21 at approximately 11:16 AM, a review of the facilities QA/QAPI Plan was conducted and findings were discussed with the Administrator, DON (Director of Nursing), The Regional Director of Operations and The Regional Director of Clinical Services. A review of the QAPI Plan signature page revealed that the Medical Director/designee did not attend the required amount of meetings on the following meeting dates: 2/18/20, 5/21/20 and 5/28/20. The QAPI Plan also revealed that the required quarterly meetings were not conducted. The meetings were conducted on the following dates: 2/18/20, 5/21/20, 5/28/20, 11/30/20 and 2/26/21. No quarterly meetings were conducted in August 2020. (This should have been the 3rd quarterly meeting). The VP (Vice President) of Regional Operations stated, We purchased the nursing home in November 2020. Policy: Quality Assurance and Performance Improvement (QAPI) Program Policy. Effective: 11/28/17. Last Revision Date: 5/28/2020. QAPI efforts are a component of the facility QAA (Quality Assessment and Assurance) committee's responsibilities. The QAA Committee is responsible for both Quality Assessment and Assurance activities (QA) and ongoing, proactive, performance improvement (PI) activities. QAPI represents the merger of these two processes. The purpose of QAPI in the facility is to take a proactive approach to continually improving delivery of care and services and to engage residents, caregivers, and other clinical/operational partners in maximizing quality of life and quality of care. The facility will maintain a QAPI Committee consisting, at a minimum, of: (A) The administrator. (B) The Director of Nursing Services. (C) The Medical Director or his/her designee. (D) The designated Infection Preventionist. (E) Direct Care Staff on a rotating basis. (F)Staff from ancillary departments on a rotating basis. (G) At least two other members of the facility staff. The Committee will meet at least quarterly, and as needed, to coordinate and evaluate activities of the QAPI program/plan. This includes development and implementation of action plans to correct opportunities for improvement and regular review and analysis of data collected under QAPI program/plan. An exit interview was conducted on 3/18/21 at 2:28 PM with the [NAME] President of Regional Operations (Corporate Staff #3). No further comments were made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility's staff failed to maintain Resident #50's dignity by ensuring the bedside drainage bag fluid was concealed from view. Resident #50 was originally admitted to the facility 12/3/14 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Multiple sclerosis and neurogenic bladder. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/27/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #50's cognitive abilities for daily decision making were intact. In section H (Bladder and Bowel) the resident was coded as requiring use of an indwelling catheter. On 3/17/21 at approximately 11:00 a.m., and again at 1:00 p.m., Resident #50 was observed in bed. Viewable from the hallway was a bedside drainage bag with approximately 600 milliliters (ml) of light yellow urine inside. On 3/18/21 at approximately 12:20 p.m., Resident #50 was again observed in bed. Viewable from the hallway was a bedside drainage bag with approximately 900 milliliters (ml) of light yellow urine inside. An interview was conducted with Certified Nursing Assistant (CNA) #1 on 3/18/21 at approximately 12:55 p.m. CNA #1 stated the resident had a dignity cover for his bedside drainage bag because she put it on three days ago when the resident was up in the wheel chair. CNA #1 located the dignity cover in a chair in Resident #50's room, she put the cover on the bedside drainage bag and left the room. On 3/18/21 at approximately 3:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The Director of Nursing stated a bedside drainage bags should have a dignity covers on it. 3. The facility's staff failed to maintain Resident #35's dignity by ensuring the bedside drainage bag fluid was concealed from view. Resident #35 was originally admitted to the facility 2/16/21 and the resident hadn't been discharged since this admission. The current diagnoses included; urinary retention. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/22/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #35's cognitive abilities for daily decision making were intact. In section H (Bladder and Bowel) the resident was coded as requiring use of an indwelling catheter. On 3/16/21 at approximately 1:45 p.m., Resident #35 was observed in bed with a bedside drainage bag viewable upon entering the room. The drainage bag contained yellow urine. On 3/18/21 at approximately 11:05 a.m., Resident #35 was again observed in bed. Viewable from the hallway was a bedside drainage bag holding yellow urine. On 3/18/21 at approximately 12:10 p.m., Resident #35 was observed in bed. Viewable from the hallway was a bedside drainage bag containing yellow urine. An interview was conducted with Certified Nursing Assistant (CNA) #1 on 3/18/21 at approximately 12:55 p.m. CNA #1 stated the resident had a dignity cover for his bedside drainage bag because she put it on. CNA #1 stated she would put the cover on Resident #35's bedside drainage bag. On 3/18/21 at approximately 3:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The Director of Nursing stated a bedside drainage bags should have a dignity covers on it. The facility's policy titled Indwelling Urinary Catheter Care Procedure with a revision date of 11/3/20, read under Procedure #11; Ensure drainage bag is covered with a privacy/dignity cover. Based on observations, clinical record review, staff interview and review of facility documentation, the facility staff failed to ensure dignity was maintained for 3 residents (#409, #50, and #35). The facility staff failed to protect Resident #409 from body exposure to public view and provide his personal clothing. Resident #50 and #35 were not provided dignity covers for bedside drainage bags. The findings included: 1. Resident #409 was originally admitted to the nursing facility on 1/30/21 with diagnoses that included congestive heart failure, encephalopathy, cervical disc degeneration, and readmitted on [DATE] with an added diagnoses of TIAs (mini strokes), acute cystitis and kidney failure. The admission Minimum Data Set (MDS) assessment dated [DATE] coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 3 out of a possible score of 15 which indicated the resident was severely impaired in the necessary cognitive skills for daily decision making. Resident #409 required extensive assistance from one staff for bed mobility, transfers, ambulation in and out of his room, personal hygiene and bathing. The resident was totally dependent on one staff for dressing and toilet use. The resident was assessed not steady without staff assistance for moving from a seated to a standing position, walking, turning around and face the opposite direction while walking, moving on and off the toilet and surface to surface transfer. Resident #409 was coded continent of bowel and bladder. The resident was assessed to have fallen in the last month, last 2-6 months and since admission without fractures. The care plan dated 2/1/21 identified that Resident #409 had a self-care deficit. The goal set by the staff for the resident was that his needs would be met. Some of the approaches the staff would implement to accomplish this goal included assist with activities of daily living, dressing, grooming, toileting and oral care. The following observations were made of Resident #409: On 3/16/21 at 11:15 a.m., the resident was sitting in his wheelchair with overbed table across from the nurse's station dressed in a hospital gown and non-skid socks on both feet. The resident could make request for basic needs, but was unable to carry on connection of thoughts during a prolonged conversation. On 3/16/21 at 12:25 p.m., the resident remained dressed as previously observed and eating his lunchmeal. He stated his lunch was, Pretty good. On 3/16/21 at 1:00 p.m., the resident was walking around in his room without a hospital gown in just his brief and non-skid socks. On 3/16/21 at 1:25 p.m., the resident continued to walk around in his room without clothing as previously observed. The resident was holding onto foot of the bed to the end table, reaching out to this surveyor. Two staff persons were summoned to the room by this surveyor to assist the resident. Certified Nursing Assistant (CNA) #3 and Licensed Practical Nurse (LPN) #6 came to the resident's room and when asked if he had clothing, they stated that the resident had no family and no clothing. LPN #6 said the resident wore hospital gowns because he had no clothing. There was no clothes in any of the resident's drawers or hanging in his wardrobe, but there was a package of thick gray socks on his bedside table. LPN #6 put the resident's hospital gown back on and sat him in his wheelchair. CNA #3 said that the resident should have been at the nurse's station because he would try to stand up and possibly fall. The resident kept pointing to a package of thick gray socks and said They would feel good. The LPN stated to the resident that he needed to wear the non-skid socks so he would not slip on the floor. When asked where his clothes were, he stated he did not know. On 3/16/21 at 2:30 p.m., Resident #409 was sitting in his wheelchair at the nurse's station on Unit I fully clothed with shirt, pants and regular thick gray socks. The resident stated he was warmer today. The overbed table was in front of the resident and he was thumbing through magazines. LPN #6 stated the staff obtained the clothes from the lost and found. On 3/17/21 at 9:30 a.m., Resident #409 was fully clothed and also had on a zip up hoodie, sitting in his wheelchair at the nurse's station, finishing his breakfast meal. The Patient Care Assistant (PCA) stated there was clothes in the lost and found for any resident without clothing and that several volunteer churches often donate clothing. On 3/18/21 at 11:47 a.m., an interview was conducted with the Unit Manager (UM) LPN #1 and the Social Worker (SW). They stated that the nursing staff did not approach either of them about the resident not having clothing. The UM stated she expected the staff to have let her know and she would have called the resident's legal guardian. She stated the resident came with a cane, but no clothes and wore hospital gowns, but the staff got clothing the last couple of days from the laundry lost and found. The SW said reiterated that if the lack of clothing was an issue she knew about she would have called the resident's legally appointed guardian to ask for clothing and shoes. On 3/18/21 at 1:34 p.m., An interview was conducted with the Admission's Coordinator who was asked if she knew whether or not the resident was admitted with personal belongings. She who stated she remembered seeing Resident #409 wearing clothing when he was on Unit II. The resident did not have a record of his personal belongings. On 3/18/21 at 4:14 p.m., a debriefing was held with the Administrator, Director of Nursing (DON) and Regional [NAME] President of Operations (RVPO). The DON stated she was going to research why the resident did not have any clothing. They voiced no one approached them about having to only put hospital gowns on the resident because he had no clothing. On 3/18/21 at 6:11 p.m., the DON and the Admission's Coordinator said the resident had been transferred to the hospital from Unit II on 2/9/21 and returned on 2/11/21, spent time in quarantine and then transferred to Unit I on 2/25/21. The Admission's Coordinator said the CNA who packed up the resident's belongings was interviewed on the phone and stated she placed them in the soiled utility room on Unit II. They said, We have now found his clothes in the soiled utility room. They were never transferred on 2/26/21 to his current room on Unit I. If a resident is gone 3 days, they are discharged and clothes are then placed in the soiled utility room based on the policy guidance for room changes during the Pandemic. There was no explanation as to why there was no attempt to locate the resident's clothing prior to 3/18/21 and or ensure clothing was obtained prior to 3/16/21 which resulted in his needless exposure to public view, and had the potential to negatively impact his dignity. The facility's policy and procedure titled Resident Rights undated indicated that all residents had the right to dignity, respect and freedom, and to be treated with consideration, respect, dignity and security of possessions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to notify the physician of missed medication for one of 15 sampled residents, Resident #212. The findings included: Resident #212 was admitted to the facility on [DATE] with diagnoses that included but were not limited to chronic heart failure, closed fracture of the right tibia with healing, pain in right knee, and high blood pressure. Resident #212's most recent comprehensive MDS (Minimum data set) assessment was an admission assessment with an ARD (assessment reference date) of 7/4/21. Resident #212 was coded as being cognitively intact in the ability to make daily decisions; scoring 13 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #212 was coded in Section J0100. (Pain Management) as not receiving scheduled pain medications in the last 5 days from the ARD date (7/4/21). Resident #212 was coded as receiving prn (as needed) pain medications in the last 5 days AND recieved non medication interventions for pain in the last 5 days. Resident #212 was coded as not having pain. Review of Resident #212's medical record revealed that Resident #212 had an order for the following prn pain medication: Tylenol Tablet 325 mg (milligrams) Give 3 tablets by mouth every 6 hours as needed for pain. Review of Resident #212's July 2021 MAR (Medication Administration Record) revealed that Resident #212 received Tylenol 325 mg 3 tablets on 7/1/21 through 7/11/21. Review of the Emar Administration notes revealed that the Tylenol was effective on these dates for pain relief. Review of a therapy note dated 7/13/21 revealed that Resident #212 was having a pain of 8/10 during her therapy session. The following was documented in part, .Pt (patient) declined participation in therapy 2/2 (two attempts) to increased pain and fatigue. PTA (Physicial Therapy Assistant) encouraged pt (patient) to engage in seated therex (therpapy exercies), however, pt continued to decline at this time .Pt reported 8/10p (pain) in R (right knee) and requested pain meds (medications), NRSG (Nursing) made aware. Review of a note from the NP (Nurse Practitioner) dated 7/13/21 documented in part, the following: She is being seen today for c/o(complaints) right knee pain. Pt is sitting up in her w/c (wheelchair), appears comfortable and in no acute distress. A&O x3 (Alert and Oriented x3), pleasant and responsive. She has a history of repeated falls where she has a displaced fracture of her right tibia. She is c/o right knee pain that is unrelieved by Tylenol. Right knee is currently stable in a right knee brace. She currently c/o (complaints) 3-4/10 right knee pain, but tolerable . 1. Right knee pain: will give Tramadol (1) 50 mg 1 tab po (by mouth) Q (every) 12 x10 days. Review of Resident #212's July 2021 POS (Physician Order Summary) revealed the following order: Tramadol HCl Tablet 50 MG Give 1 tablet by mouth two times a day for Pain for 10 Days. Start Date: 7/13/21 2100 (9 p.m.). Further review of Resident #212's July 2021 MAR (Medication Administration Record) revealed that her Tramadol was to be scheduled for 9 AM and 2100 (9:00 PM). Resident #212 did not receive her 9 p.m. dose of Tramadol on 7/13/21. Review of Resident #212's July MAR revealed that nurses were signing off that they had administered the scheduled Tramadol on 7/14/21 at 9:00 a.m. and 9:00 p.m. Evidence (Narcotic sheets) could not be provided to show that the ordered Tramadol had made it to the facility from pharmacy. Evidence could not be shown that the nurses obtained the ordered Tramadol from the Omnicell (STAT box). Review of Resident #212's MAR also revealed that she missed her 9 a.m. dose of Tramadol on 7/15/21 (hours before her discharge home on 7/15/21). Further review of Resident #212's clincial record revealed that she was discharged home on 7/15/21 at 1:40 p.m. Review of the Omnicell list of STAT medications revealed that Tramadol 50 mg was a medication available in the Omnicell. On 8/4/21 at 12:02 p.m., and 4 p.m., a telephone interview was attempted with Resident #212's representative. She could not be reached for an interview. On 8/4/21 at 2:23 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #2, the nurse who worked day shift on 7/14/21. When asked the process if she were to go administer a scheduled medication; more specifically a narcotic, and it was not in the medication cart, LPN #2 stated that she would check to see if the medication was available in the STAT Omnicell. LPN #2 stated that she would then pull the medication from the Omnicell. When asked if Tramadol 50 mg was in the Omnicell, LPN #2 stated, Yes, I know that is in the STAT box. When asked if that is where she pulled Resident's #212's Tramadol on 7/14/21, LPN #2 stated, Yes, I pulled from the STAT box. On 8/4/21 at 2:30 p.m., an interview was conducted with LPN #3, the nurse who worked with Resident #212 on 7/13/21 evening shift. When asked why Resident #212 did not receive her ordered Tramadol on 7/13/21 at 9:00 p.m.; LPN #3 stated that the medication was not up from pharmacy. When asked the process if a medication such as a narcotic is not yet up from pharmacy and it is due to be administered, LPN #3 stated that she was new to the facility and did not have a code to get into the Omnicell system. When asked if she had asked for help regarding pulling the medication from the Omnicell system; LPN #3 stated that she told a nurse on the floor. LPN #3 stated that she wasn't sure what had happened after that. On 8/4/21 at 2:59 p.m., an interview was conducted with RN (Registererd Nurse) #2, the nurse who did not administer the scheduled Tramadol on 7/15/21. When asked if residents are to receive all scheduled medications prior to their discharge that are due prior to discharge; RN #2 stated, Yes. When asked if this included scheduled pain medications, RN #2 stated, Yes. When asked why Resident #212 did not receive her scheduled Tramadol on 7/15/21 at 9:00 a.m. prior to her discharge; RN #2 stated, She didn't have Tramadol. When asked what she had meant by that statement, RN #2 stated, She didn't have a narcotic card at all. RN #2 then stated that she had told the nurse (LPN #1) that she had been shadowing that day that Resident #212 did not have Tramadol on the medication cart. RN #2 stated that she did not have a code to access the Omnicell to see if the medication was in there. RN #2 stated that she was not sure if Tramadol was in the Omnicell as she still did not have a code to access Omnicell. RN #2 stated that she believed her preceptor did not administer the tramadol because the resident was being sent home with a script for Tramadol anyway.When asked if it was acceptable for residents to not receive their ordered medications, RN #2 stated that it wasn't. On 8/4/21 at 4:30 p.m., an interview was conducted with LPN #1, the nurse who was precepting RN #2. When asked what happened to Resident #212's tramadol on 7/15/21; why it was not administered, LPN #1 stated that it was not available in the medication cart. When asked the process if the medication is not in the medication cart, LPN #1 stated that she would call pharmacy to inquire about where the medication is, or what is needed to get the medication, such as a script. When asked if she recalled inquiring about Resident #212's Tramadol, LPN #1 stated that she did not. When asked if she attempted to pull the Tramadol from the Omnicell, LPN #1 stated that she did not have access to the Omnicell. LPN #1 stated that they have only had the Omnicell since June of 2021. When asked who she could ask to obtain a medication from the Omnicell, LPN #1 stated that she could ask LPN #2, who was also the unit manager. LPN #1 stated that she did not ask LPN #1 to obtain the Tramadol from the Omnicell. When asked if she should notify the MD (Medical Doctor) that a medication was missed, LPN #1 stated that the medical doctor should be aware of every missed dose of a medication. LPN #1 stated that she did not notify the MD at the time of the missed dose of Tramadol. On 8/4/21 at 4:40 p.m., an interview was conducted with ASM (Administrative Staff Member) #4, the Nurse Practitioner. She could not recall being made aware that Resident #211 had missed all her doses of scheduled ordered Tramadol. ASM #4 stated that the physician may have been aware. ASM #4 stated that she expected the nursing staff to make her aware in order for her to give further direction. On 8/5/21 at 5 p.m., an interview was conducted with ASM (Administrative Staff Member) #2, the DON (Director of Nursing). When asked the process if a scheduled narcotic is not available in the medication cart, what nursing staff should do, ASM #2 stated that the nurses should be calling pharmacy to see the status of the medication and whether or not the medication needs a prescription. ASM #2 stated that she would expect nursing staff to obtain a script from the physician, if that is what was needed and send to pharmacy. ASM #2 stated that it takes sometime for pharmacy to verify the prescription so the nurse may not be able to get it from the Omnicell system immediately. ASM #2 stated she would then expect nursing staff to alert the physician if a medication cannot be administered for further direction. ASM #2 stated that she did expect staff to pull the medication from Omnicell if a script was available. ASM #2 confirmed that not all nurses had access to the Omnicell but that there was always someone in the building who could assist. When asked if all nurses should have access to the Omnicell if they are adminisering medications, ASM #2 stated, Yes. When asked who was responsible for ensuring all nurses had access to the Omnicell, ASM #2 stated that she was as the DON. When asked what had happened to Resident #212's Tramadol, ASM #2 stated that she didn't see where the Tramadol was ever delivered to the facility. ASM #2 stated that she remembered personally getting the script for the Tramadol has she recalled telling the NP (Nurse Practitioner) to assess Resident #212 for an increase in pain and yelling out. ASM #2 stated that she didn't personally hear the resident yell out, but that she recalled hearing a nurse tell her this information that day. ASM #2 could not recall the nurse. ASM #2 stated that she recalled putting the order into the electronic system and scheduling it for 9:00 p.m. because the medication would have had plenty of time to get to the facility by then. ASM #2 could not recall if she was the nurse who faxed the script to the pharmacy. On 8/5/21 at 10:25 a.m., an interview was conducted with the medical records personnel at the facility's pharmacy (OSM (Other Staff Member) #3). OSM #3 stated that the pharmacy had never received an order for the scheduled tramadol or a script (Prescription). OSM #3 stated that a script must also be in place for the nurse to access a STAT dose from the Omnicell. On 8/5/21 at 11:19 a.m., an interview was conducted with ASM #5, the physician. He could not recall being made aware that Resident #211 had missed all her scheduled doses of Tramadol. On 8/5/21 during a pre-exit meeting at 12:30 p.m., ASM (Administrative Staff Member) #1, the administrator, and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. Facility policy titled, Facility policy titled, Medication Shortage/Unavailable Medications documents in part, the following: Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication shortage is discovered at the time of medication administration facility staff should immediately take the action specified . 2. If a medication shortage is discovered during normal pharmacy hours: 2.1 Facility nurse should call pharmacy to determine the status of the order. If the medication has not been ordered, the licensed facility nurse should place the order or reorder for the next scheduled delivery. 2.2 If the next available delivery causes delay or missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. 2.3 If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery. 3. If the medication shortage is discovered after normal pharmacy hours: 3.1 A licensed nurse should obtain the ordered medication from the Emergency Medication Supply. 3.2 If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: 3.2.1 Emergency Delivery 3.2.2 Use of an emergency (back up) third party pharmacy. 4. If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions. (1) Tramadol- analgesic used to treat moderate to severe pain. This information was obtained from Davis's Drug Guide for Nurses, 11th edition p. 1197. COMPLAINT DEFICIENCY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on representative interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to ensure medications were procured for two of 15 residents in the survey sample; Resident #212 and #211. The findings included: 1. Resident #212 was admitted to the facility on [DATE] with diagnoses that included but were not limited to chronic heart failure, closed fracture of the right tibia with healing, pain in right knee, and high blood pressure. Resident #212's most recent comprehensive MDS (Minimum data set) assessment was an admission assessment with an ARD (assessment reference date) of 7/4/21. Resident #212 was coded as being cognitively intact in the ability to make daily decisions; scoring 13 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #212 was coded in Section J0100. (Pain Management) as not receiving scheduled pain medications in the last 5 days from the ARD date (7/4/21). Resident #212 was coded as receiving prn (as needed) pain medications in the last 5 days AND recieved non medication interventions for pain in the last 5 days. Resident #212 was coded as not having pain. Review of Resident #212's medical record revealed that Resident #212 had an order for the following prn pain medication: Tylenol Tablet 325 mg (milligram) Give 3 tablets by mouth every 6 hours as needed for pain. Review of Resident #212's July 2021 MAR (Medication Administration Record) revealed that Resident #212 received Tylenol 325 mg 3 tablets on 7/1/21 through 7/11/21. Review of the Emar Administration notes revealed that the Tylenol was effective on these dates for pain relief. Review of a therapy note dated 7/13/21 revealed that Resident #212 was having a pain of 8/10 during her therapy session. The following was documented in part, .Pt (patient) declined participation in therapy 2/2 (two attempts) to increased pain and fatigue. PTA (Physicial Therapy Assistant) encouraged pt (patient) to engage in seated therex (therpapy exercies), however, pt continued to decline at this time .Pt reported 8/10p (pain) in R (right knee) and requested pain meds (medications), NRSG (Nursing) made aware. Review of a note from the NP (Nurse Practitioner) dated 7/13/21 documented in part, the following: She is being seen today for c/o(complaints) right knee pain. Pt is sitting up in her w/c, appears comfortable and in no acute distress. A&O x3 (Alert and Oriented x3), pleasant and responsive. She has a history of repeated falls where she has a displaced fracture of her right tibia. She is c/o right knee pain that is unrelieved by Tylenol. Right knee is currently stable in a right knee brace. She currently c/o (complaints) 3-4/10 right knee pain, but tolerable . 1. Right knee pain: will give Tramadol (1) 50 mg 1 tab po (by mouth) Q (every) 12 (hours) x (for) 10 days. Review of Resident #212's July 2021 POS (Physician Order Summary) revealed the following order: Tramadol HCl Tablet 50 MG Give 1 tablet by mouth two times a day for Pain for 10 Days. Start Date: 7/13/21 2100 (9 p.m.). Further review of Resident #212's July 2021 MAR (Medication Administration Record) revealed that her Tramadol was to be scheduled for 9 AM and 2100 (9:00 PM). Resident #212 did not receive her 9 p.m. dose of Tramadol on 7/13/21. Review of Resident #212's July MAR revealed that nurses were signing off that they had administered the scheduled Tramadol on 7/14/21 at 9:00 a.m. and 9:00 p.m. Evidence (Narcotic sheets) could not be provided to show that the ordered Tramadol had made it to the facility from pharmacy. Evidence could not be shown that the nurses obtained the ordered Tramadol from the Omnicell (STAT box). Review of Resident #212's MAR also revealed that she missed her 9 a.m. dose of Tramadol on 7/15/21 (hours before her discharge home on 7/15/21). Further review of Resident #212's clincial record revealed that she was discharged home on 7/15/21 at 1:40 p.m. Review of the Omnicell list of medications revealed that Tramadol 50 mg was a medication available in the Omnicell. On 8/4/21 at 12:02 p.m., and 4 p.m., a telephone interview was attempted with Resident #212's representative. She could not be reached for an interview. On 8/4/21 at 2:23 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #2, the nurse who worked day shift on 7/14/21. When asked the process if she were to go administer a scheduled medication; more specifically a narcotic, and it was not in the medication cart, LPN #2 stated that she would check to see if the medication was available in the STAT Omnicell. LPN #2 stated that she would then pull the medication from the Omnicell. When asked if Tramadol 50 mg was in the Omnicell, LPN #2 stated, Yes, I know that is in the STAT box. When asked if that is where she pulled Resident's #212's Tramadol on 7/14/21, LPN #2 stated, Yes, I pulled from the STAT box. On 8/4/21 at 2:30 p.m., an interview was conducted with LPN #3, the nurse who worked with Resident #212 on 7/13/21 evening shift. When asked why Resident #212 did not receive her ordered Tramadol on 7/13/21 at 9:00 p.m.; LPN #3 stated that the medication was not up from pharmacy. When asked the process if a medication such as a narcotic is not yet up from pharmacy and it is due to be administered, LPN #3 stated that she was new to the facility and did not have a code to get into the Omnicell system. When asked if she had asked for help regarding pulling the medication from the Omnicell system; LPN #3 stated that she told a nurse on the floor. LPN #3 stated that she wasn't sure what had happened after that. On 8/4/21 at 2:59 p.m., an interview was conducted with RN (Registererd Nurse) #2, the nurse who did not administer the scheduled Tramadol on 7/15/21. When asked if residents are to receive all scheduled medications prior to their discharge that are due prior to discharge; RN #2 stated, Yes. When asked if this included scheduled pain medications, RN #2 stated, Yes. When asked why Resident #212 did not receive her scheduled Tramadol on 7/15/21 at 9:00 a.m. prior to her discharge; RN #2 stated, She didn't have Tramadol. When asked what she had meant by that statement, RN #2 stated, She didn't have a narcotic card at all. RN #2 then stated that she had told the nurse (LPN #1) that she had been shadowing that day that Resident #212 did not have Tramadol on the medication cart. RN #2 stated that she did not have a code to access the Omnicell to see if the medication was in there. RN #2 stated that she was not sure if Tramadol was in the Omnicell as she still did not have a code to access Omnicell. RN #2 stated that she believed her preceptor did not administer the tramadol because the resident was being sent home with a script for Tramadol anyway.When asked if it was acceptable for residents to not receive their ordered medications, RN #2 stated that it wasn't. On 8/4/21 at 4:30 p.m., an interview was conducted with LPN #1, the nurse who was precepting RN #2. When asked what happened to Resident #212's tramadol on 7/15/21; why it was not administered, LPN #1 stated that it was not available in the medication cart. When asked the process if the medication is not in the medication cart, LPN #1 stated that she would call pharmacy to inquire about where the medication is, or what is needed to get the medication, such as a script. When asked if she recalled inquiring about Resident #212's Tramadol, LPN #1 stated that she did not. When asked if she attempted to pull the Tramadol from the Omnicell, LPN #1 stated that she did not have access to the Omnicell. LPN #1 stated that they have only had the Omnicell since June of 2021. When asked who she could ask to obtain a medication from the Omnicell, LPN #1 stated that she could ask LPN #2, who was also the unit manager. LPN #1 stated that she did not ask LPN #1 to obtain the Tramadol from the Omnicell. When asked if she should notify the MD (Medical Doctor) that a medication was missed, LPN #1 stated that the medical doctor should be aware of every missed dose of a medication. LPN #1 stated that she did not notify the MD at the time of the missed dose of Tramadol. On 8/5/21 at 5 p.m., an interview was conducted with ASM (Administrative Staff Member) #2, the DON (Director of Nursing). When asked the process if a scheduled narcotic is not available in the medication cart, what nursing staff should do, ASM #2 stated that the nurses should be calling pharmacy to see the status of the medication and whether or not the medication needs a prescription. ASM #2 stated that she would expect nursing staff to obtain a script from the physician, if that is what was needed and send to pharmacy. ASM #2 stated that it takes sometime for pharmacy to verify the prescription so the nurse may not be able to get it from the Omnicell system immediately. ASM #2 stated she would then expect nursing staff to alert the physician if a medication cannot be administered for further direction. ASM #2 stated that she did expect staff to pull the medication from Omnicell if a script was available. ASM #2 confirmed that not all nurses had access to the Omnicell but that there was always someone in the building who could assist. When asked if all nurses should have access to the Omnicell if they are adminisering medications, ASM #2 stated, Yes. When asked who was responsible for ensuring all nurses had access to the Omnicell, ASM #2 stated that she was as the DON. When asked what had happened to Resident #212's Tramadol, ASM #2 stated that she didn't see where the Tramadol was ever delivered to the facility. ASM #2 stated that she remembered personally getting the script for the Tramadol has she recalled telling the NP (Nurse Practitioner) to assess Resident #212 for an increase in pain and yelling out. ASM #2 stated that she didn't personally hear the resident yell out, but that she recalled hearing a nurse tell her this information that day. ASM #2 could not recall the nurse. ASM #2 stated that she recalled putting the order into the electronic system and scheduling it for 9:00 p.m. because the medication would have had plenty of time to get to the facility by then. ASM #2 could not recall if she was the nurse who faxed the script to the pharmacy. On 8/5/21 at 10:25 a.m., an interview was conducted with the medical records personnel at the facility's pharmacy (OSM (Other Staff Member) #3). OSM #3 stated that the pharmacy had never received an order for the scheduled tramadol or a script (Prescription). OSM #3 stated that a script must also be in place for the nurse to access a STAT dose from the Omnicell. On 8/5/21 at 10:41 a.m., further interview was conducted with LPN (Licensed Practical Nurse) #2, the nurse who worked day shift on 7/14/21. When asked how she signed off that she had administered a 9 a.m. dose of Tramadol on 7/14/21 if the pharmacy had not yet recevied an order or a script for the medication; LPN #2 stated, I don't remember why I signed that off. When asked if it was acceptable to sign off that medications were administered, if they were not in fact given to the resident, LPN #2 stated, No ma'am. When asked what why the Tramadol had not made it to the facility, LPN #2 stated, I don't know exactly the cause. On 8/5/21 during a pre-exit meeting at 12:30 p.m., ASM (Administrative Staff Member) #1, the administrator, and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. Facility policy titled, Medication Shortage/Unavailable Medications documents in part, the following: Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication shortage is discovered at the time of medication administration facility staff should immediately take the action specified . 2. If a medication shortage is discovered during normal pharmacy hours: 2.1 Facility nurse should call pharmacy to determine the status of the order. If the medication has not been ordered, the licensed facility nurse should place the order or reorder for the next scheduled delivery. 2.2 If the next available delivery causes delay or missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. 2.3 If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery. 3. If the medication shortage is discovered after normal pharmacy hours: 3.1 A licensed nurse should obtain the ordered medication from the Emergency Medication Supply. 3.2 If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: 3.2.1 Emergency Delivery 3.2.2 Use of an emergency (back up) third party pharmacy. 4. If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions. (1) Tramadol- analgesic used to treat moderate to severe pain. This information was obtained from Davis's Drug Guide for Nurses, 11th edition p. 1197. 2. Resident #211 was admitted to the facility on [DATE] with diagnoses that included but were not limited to cerebral infarction (stroke), right sided hemiplegia (paralysis) following stroke, type two diabetes mellitus, and end stage renal disease requiring dialysis. Resident #211's most recent comprehensive MDS (minimum data set) assessment was an admission assessment dated [DATE]. Resident #211 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #211 was coded in Section J0100. (Pain Management) as receiving scheduled pain medications in the last 5 days from the ARD date (7/5/21). Resident #211 was coded not receiving prn (as needed) pain medications in the last 5 days AND receiving non medication interventions for pain in the last 5 days. Resident #211 was coded as not having pain. Resident #211 was discharged from the facility on 8/3/21. On 8/4/21 at 9:58 a.m., a telephone interview was conducted with Resident #211's emergency contact as a number was not listed for Resident #211. Resident #211's emergency contact was her son, and did not feel comfortable giving out his mother's telephone number. The son did have a concern regarding his mother's gabapentin (1) for her nerve pain. The son stated that there was quite some time where his mother was out and that nursing staff were not following up with obtaining the medication. The son stated that he eventually had to go to the facility to speak with the DON (Director of Nursing) who then took care of the issue. The son stated that his mother was not yet experiencing pain but was overall sick to her stomach and feeling itchy all over which was usually a withdrawal side effect for her. The son was upset that it took his involvement to finally get his mother's prescribed gabapentin. Resident #211's care plan dated 6/24/21 documented the following for pain: Resident is at risk for pain related to CVA (Stroke) with right hemiparesis .Administer analgesics/medications per physician's orders . Review of Resident #211's June, July and August 2021 POS (Physician Order Summary) revealed the following order: Gabapentin 100 mg (milligrams) 100 mg capsule by mouth Three Times Daily. This order was initiated on 6/24/21. Review of the June, July, and August 2021 MARS (Medication Administration Record) revealed that gabapentin was scheduled for 6:00 a.m., 2:00 p.m., and 9:00 p.m. Review of the narcotic logs revealed on 6/24/21 the pharmacy had delivered 28 capsules of gabapentin. The first dose of gabapentin was given at 2100 (9:00 p.m.) on 6/24/21. Further review of the narcotic sheets revealed that Resident #211 had completed her gabapentin on 7/4/21 at 9:00 p.m; where it was documented she had (zero) capsules left. Review of the second narcotic sheet for gabapentin revealed that pharmacy had delivered 30 capsules of gabapentin on 7/9/21. Resident #211's first dose of gabapentin was on 7/9/21 at 2100 (9:00 p.m.). There was no narcotic sheets/logs to account for days 7/5/21 through 7/9/21 at (2:00 p.m.) (13 administrations). Review of the facility STAT Omnicell list revealed that Gabapentin 100 mg was in the Omnicell STAT box. Further review of Resident #211's July 2021 MAR revealed that staff had not administered the gabapentin on the following dates: 7/5/21 at 2 p.m. and 9 p.m. 7/7/21 at 6:00 a.m., 2:00 p.m., and 9:00 p.m. 7/8/21 at 6:00 a.m. and 9:00 p.m. and 7/9/21 at 6:00 a.m. The following administration note was documented on 7/5/21 at 7:51 p.m.: On hold until received per NP (Nurse Practitioner). The following note was documented on 7/6/21 by the Nurse Practitioner: .Denies pain and has no complaints, SOB (Shortness of breath), and (abdominal pain) or N/V (nausea/vomiting) .Neuropathy: Continue Neurontin (Gabapentin) 100 mg TID, script renewed. On 7/7/21 the following administration note was documented: Gabapentin Capsule 100 mg- Give 1 mg by mouth three times a day for pain .pharmacy to send. On 7/8/21 the following administration note was documented: Gabapentin Capsule 100 mg .needs hard script. MD (medical doctor) aware. On 7/9/21 at 10:29 a.m., the following administration note was documented: Gabapentin 100 mg three times a day for pain .per MD, administrator, DON (Director of Nursing) ok to give now. Further review of Resident #211's MAR revealed that gabapentin was documented as administered on the following dates; however there was no evidence that facility staff had pulled gabapentin from the facility STAT box: 7/5/21 at 6:00 a.m., 7/6/21 at 6:00 a.m., 2:00 p.m., and 9:00 p.m., 7/8/21 at 2:00 p.m. On 8/4/21 at 2:45 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #6, the nurse who worked the 11-7 shifts with Resident #211 and who did not administer her scheduled gabapentin at 6:00 a.m. When asked the process if she were to administer a narcotic and it was not available on the medication cart, LPN #6 stated that she would check to see if the medication was already ordered. LPN #6 stated that if the medication says its on order she would wait for the next shift to follow up as she is night shift. When asked what happened with Resident #211's gabapentin, LPN #6 stated that she remembered the medication not being up from pharmacy for a couple of days. When asked what was going on with the gabapentin, LPN #6 stated, No Idea. LPN #6 denied following up personally with the gapabentin to see why it had been missing for several days. LPN #6 denied Resident #211 having an increase in pain. She could not recall the resident complaining of nausea or an itchy feeling. On 8/4/21 at 3:45 p.m., during an interview with the pharmacist (OSM) Other Staff Member #2; it was determined that the pharmacy did not receive a script for the gabapentin until 7/9/21. OSM #2 stated that the only time nursing accessed the Omnicell to retrieve gabapentin for Resident #211 was on 7/9/21 at 10:24 a.m. OSM #2 stated that staff cannot pull gabapentin from the Omnicell unless a script is renewed so he could not explain why staff were documenting that they had administered the gabapentin on the above dates. OSM #2 stated that the pharmacy initially sent out 28 capsules of gabapentin on 6/24/21 which had run out on 7/4/21. OSM #2 stated that the second time they sent out gabapentin was on 7/9/21 and it was for 30 capsules. OSM #2 confirmed again that the only time Resident #211 received gabapentin in between dates 7/5/21 through 7/9/21 was on 7/9/21 at 10:24 a.m. OSM #2 stated that the request to retrieve the gabapentin was made from the DON (Director of Nursing). When asked if there was any side effects or withdrawal effects to missing 12 doses of gabapentin, OSM #2 stated that there was not necessarily any withdrawal effects, that missing that many doses would lead to pain returning back. OSM #2 stated that he would expect pain to return by the second missed dose. When asked if missing 12 administrations was considered a significant error, OSM #2 stated that he wouldn't say significant but that the resident would be uncomfortable. When asked if missing 12 doses could make someone who uses it for pain feel nauseous or itchy all over; OSM #2 stated that he could imagine it would make someone feel anxious which could lead to an upset stomach. OSM #2 was not familiar with gabapentin withdrawals causing an itchy feeling unless it was the really the pins and needles feeling. Further review of Resident #211's clinical record revealed no evidence of an increase in pain or a decrease in appetite during the time of her missed doses of gabapentin. The following; however was documented in a physical therapy note dated 7/8/21: Pt found supine in bed c/o (complaints) of not receiving her meds the last 3 days and says she is having withdrawal symptoms as she is itchy all over. PT attempts to consult nurse regarding this issue with PT unable to locate nurse. The next therapy note dated 7/9/21, documented in part, the following: Pt (Patient) found supine in bed, empathetic discussion had as pt reports she has not had her meds on the last 4 days. Nurse consulted regarding issue. Pt reports feeling itchy all over and nauseous. On 8/4/21 at 5:00 p.m., an interview was conducted with the DON (Director of Nursing) (ASM (Administrative Staff Member) #2. When asked if there was has been issues obtaining scripts for narcotics or getting those scripts to the pharmacy; ASM #2 stated, Yes. When asked what had happened with Resident #211's gabapentin as the NP had documented that she wrote a script on 7/6/21; ASM #2 stated that she was unaware that Resident #211's gabapentin prescription had run out until the son had come into the building on 7/9/21. ASM #2 stated that he was upset that his mom had missed her gabapentin for several days and wanted to know what was going on with it. ASM #2 stated that she had called the medical doctor to obtain a script that day. ASM #2 stated that she pulled the medication out of the Omnicell and the nurse administered the medication, but could not remember the time. ASM #2 stated that she realized the resident had been out sometime before she initiated getting the resident her gabapentin. When asked if the son really had initiated obtaining his mom's medication, ASM #2 stated, Yes, it was in response to the son coming in. ASM #2 stated that she expected her nurses to follow up with gabapentin and not wait days later before obtaining the medication. ASM #2 stated that she was not sure what they did do, didn't do for the gabapentin. When asked if Resident #211 had an increase amount of pain related to missing 12 doses of gabapentin, ASM #2 stated that she didn't think so, that this information was never reported to her. When asked if nursing staff should be documenting that medications are being administered when they are not in fact given, ASM #2 stated, Absolutely not. When asked if nursing staff should have pulled gabapentin from the Omnicell and administered the medication, ASM #2 stated that nursing staff could do that if there was a script for the medication. ASM #2 stated that she expected her staff to inquiring on why the gapabentin was not available and if it needed a script to call the physician, obtain a script and fax that to the pharmacy. ASM #2 stated that once the pharmacy has a script, the medication can be pulled from the Omnicell. ASM #2 confirmed that not all nurses had access to the Omnicell but that there was always someone in the building with access. ASM #2 stated that she was not aware that not all nurses had access and didn't realize this was the responsibility of the DON to ensure their access. ASM #2 confirmed that all nurses should have access to the Omnicell if they are responsible for passing out medications, and that she was going to work on getting all nurses access. On 8/5/21 during a pre-exit meeting at 12:30 p.m., ASM (Administrative Staff Member) #1, the administrator, and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. (1) Gabapentin is commonly used to treat neuropathic pain (pain due to nerve damage). This information was obtained from the National Institutes of Health. https://pubmed.ncbi.nlm.nih.gov/28597471/. COMPLAINT DEFICIENCY

Based on staff interview and clinical record review, the facility staff failed to ensure accurate MDS (minimum data set) assessments for 2 of 24 Residents, Resident #22 and #62. The findings included: 1. For Resident #22, the facility staff failed to code the Residents hospice status on the Residents significant change in status MDS assessment. The clinical record review revealed that Resident #22 had been admitted to the facility 08/22/18. Diagnoses included, but were not limited to, hypertension, dementia, Parkinson's disease, and malignant neoplasm of prostate. Section C (cognitive patterns) of the Resident significant change in status MDS assessment with an ARD (assessment reference date) of 02/08/19 included a BIMS (brief interview for mental status) summary score of 7 out of a possible 15 points. Section O (special treatments, procedures, programs) had NOT been coded to indicate the Resident was receiving hospice care. The clinical record included a care plan that indicated the Resident was receiving hospice care effective 02/01/19. On 03/27/19 at 10:13 a.m., MDS coordinator #1 reviewed this MDS with the surveyor. After reviewing the MDS, the coordinator stated that the Residents hospice was not coded and they would complete a correction. The administrator and DON (director of nursing) were notified of the inaccurate MDS assessment during a meeting with the survey team on 03/27/19 at 3:11 p.m. Prior to the exit conference the facility provided the surveyor with a corrected copy of this MDS assessment that indicated the Resident was receiving hospice care. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #62, the facility coded the Residents discharge MDS (minimum data set) assessment as the Resident was discharged to an acute care hospital when in fact they had been discharged home. The clinical record review revealed that Resident #62 had been admitted to the facility 01/21/19. Diagnoses included, but were not limited to, sepsis, hypertension, chronic atrial fibrillation, and benign prostatic hyperplasia. Section C (cognitive patterns) of the Residents discharge MDS assessment with an ARD (assessment reference date) of 01/22/19 included a BIMS (brief interview for mental status) summary score of 13 out of a possible 15 points. Section A (identification information) had been coded to indicate the Resident had been discharged on 01/22/19 to an acute care hospital. A review of the nursing notes revealed that nursing staff had documented on 01/22/19 that the Resident was discharged home with a family member at 5:30 p.m. 03/27/19 at 3:21 p.m., the surveyor reviewed the EHR (electronic health record) with the MDS staff. After reviewing the EHR the MDS staff verbalized that the MDS was coded incorrectly. The administrator and DON (director of nursing) were notified of the inaccurate MDS during a meeting with the survey team on 03.28.19 at 12:10 p.m. 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 implement the CCP (comprehensive care plan) for 1 of 24 Residents, Resident #53. The findings included: For Resident #53 the facility staff failed to implement a care plan for the use of bed rails. Resident #53 was admitted to the facility on [DATE]. Diagnoses included but not limited to atrial fibrillation, end stage renal disease, hyperlipidemia, arthritis, osteoporosis, pelvic fracture, Alzheimer's disease, seizure disorder, malnutrition, and dementia. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 03/12/19 coded the Resident as 10 out of 15 is section C, cognitive patterns. Section G, functional status coded the Resident as 3/3 in the areas of bed mobility and transfer, which is the equivalent of extensive assistance/ two person physical assist. This is an admission MDS. Resident #53's CCP (comprehensive care plan) was reviewed and contained a care plan for Bed Rails are used to enhance the quality of life due to: impaired physical mobility R/T (related to): pelvic fracture and L (left) shoulder fracture. Goals for this care plan included With the use of the bed rail, the Resident will have an enhanced quality of life as evidenced by: Able to turn and position self in the bed with the use of bed rails and With the use of bed rail, the Resident will be able to have an enhanced quality of life as evidenced by: Able to transfer from bed to a chair/wheelchair with the use of bed rails and with 1 person assistance. Interventions for this care plan are listed as assist Resident with transfers and mobility; ensure caretaker remains at bedside. Resident #53's clinical record was reviewed on 03/27/18. It contained a Bedrail Consent Form dated 03/07/19, which read in part Assessment: The facility has conducted a comprehensive assessment and has determined that . (Resident name omitted) would benefit from the use of bedrails. The use of alternative devices and/or approaches has been considered by the interdisciplinary team. The physician has recommended: ¼ side rails both sides. Benefit: The bedrail(s) is/are being used to: Promote safety while Resident is receiving care in bed. The Resident's representative and a facility representative signed this consent form. The surveyor observed the Resident on 03/27/19 at approximately 1115. The Resident was up in wheelchair with sitter in attendance. Surveyor did not observe ¼ side rails on the Resident's bed. Surveyor spoke with the Resident's daughter via telephone on 03/27/19 at approximately 1230. Resident's daughter stated that she had requested bed rails be placed on the Resident's bed upon admission, due to her confusion. Resident's daughter stated that Resident would try to get up on her own, not realizing that she has a broken pelvis. Resident's daughter also stated that on the day of admission, she was concerned about leaving the Resident at the facility without a sitter, but was assured that the staff would be frequently observing the Resident. The Resident's daughter stated that within 30 minutes of her departure from the facility, she received a call from the facility stating that the Resident had fallen out of bed. The concern of no ¼ side rails on the Resident's bed was discussed with the administrative staff during a meeting on 03/27/19 at approximately 1510. DON (director of nursing) stated that Resident's daughter had requested full side rails on the bed. DON also stated facility staff had explained to daughter that full side rails could not be used. DON offered no explanation why the ¼ side rails were not implemented per the physician's order. Surveyor observed Resident #52 on 03/27/19 at approximately 1545. Resident #53 was sitting up in bed with sitter in attendance. Surveyor did not observe ¼ side rails on the bed. Surveyor observed Resident #53 on 03/28/19 at approximately 0930. Surveyor observed ¼ side rails on the bed at this time. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility staff failed to provide adequate ADL (activities of daily living) services to 1 of 18 residents at the facility (Resident #113). Findings: The facility staff failed to provide adequate ADL (activities of daily living) services for Resident #113. The resident's clinical record was reviewed. Resident #113 was admitted to the facility for skilled care on 3/19/19. Her diagnoses included diverticulitis, arthritis, hypertension, and gastrointestinal hemorrhage (due to diverticulitis). The latest MDS assessment dated [DATE] coded the resident as cognitively unimpaired. Her ADL status was incomplete at the time of the survey. The resident 's initial CP (care plan), effective 3/20/19 coded the resident with significant ADL requirements. Due to weakness related to acute diverticulitis and post hemorrhagic anemia the resident required assistance with all self-care ADLs, bed mobility, transfers from bed to chair, and ambulation. The CP included interventions for staff assistance from physical and occupational therapy staff members, but none were listed for nursing staff (nurses or CNAs). Resident #113 was interviewed on 3/27/19 at 11:06 AM. The resident said she required help to get out of the bed but no one would answer the call light when she needed to get up and use the toilet. The resident stated, I know when I need to go, but they won't come help me and I'm not supposed to get up out of the bed because I fell at home. The resident said she could walk with assistance but was afraid to walk without help because she didn't want to fall again. The resident said at three AM the night previous she had called for help and someone answered the light and told her she didn't need to go to the bathroom, that she had just had a bad dream. The resident was said she was adamant that she knew when she needed to go and finally persuaded the staff member to get her up so she could use the bathroom. Then when they left the room they left my call light over there in the other chair where I could not reach it. This information was relayed to the administrator on 11:15 AM as she was entering Resident's room to inquire about a complaint the resident made about her treatment the previous night. She assured the resident she would inform the staff and they would be inserviced on answering the call lights and toileting care. On 3/28/19 at 10:24 AM the resident was interviewed again about her care at the facility. The resident said she was itching and asked the surveyor why she could get a shower while she was the the facility. The resident stated, They won't take me to the shower for a bath or shower and I haven't had one since I've been here. Why do you think that is? The resident said a couple of a times she had been assisted to take a bird bath at her sink in the room while she was in a wheelchair, but had never been out for a shower. The resident scratched her head and stated, I've asked them when I could get a real bath but they never get around to it. I sure could use a good soaking too. The surveyor could not find any evidence in the clinical record that the resident had any showers or any assistance with her personal hygiene needs. The physician's orders, signed and dated on 3/19/19, did not include any orders that would preclude the resident from getting out of the bed for shower/baths or toileting. At 10:30 AM staff member #1 was asked what the shower schedule was for Resident #113. She pulled a book off the shelf at the nursing desk and said, She's scheduled for showers on Tuesday and Friday. The staff member was asked to look into the clinical record to determine if there was any documentation the resident had received any assistance to bathe or perform other hygiene tasks ny the nursing staff. Staff member #1 produced copies of the OT's (occupational therapist) notes that indicated the the resident was getting therapy to improve her strength and ability to perform these tasks for herself when she returned home. The OT notes indicated the staff assisted the resident to bath at the sink in her wheelchair and in the bed for partial baths. The resident had not received a full bath or shower as she had requested. On 3/28/19 at 10:27 AM the DON was asked why the resident had not received her requested baths/showers and was asked to provide the ADL documentation from the clinical record since the resident's stay. The DON said she was unable to find any ADL record on Resident #113 and could not say why she had not been receiving ADL assistance or showers. The DON stated, I know if (name of Resident #113) says she hasn't had a bath, it hasn't been done. The CNA's have not documented any activity on her since her admission. I'm going to find out why. The DON did find some partial documented ADL records for 3/19-3/21/9. She copied them for the surveyor and said she had no other answers as to why the CNAs were not documenting assistance for bathing, hygiene ot toileting for the resident. No other information was provided prior to the survey team exit.

Based on Resident interview, staff interview, and clinical record review, the facility staff failed to ensure the highest practicable well-being for 3 of 24 Residents, Resident #6, #23, and #64. The findings included: 1. For Resident #6, the facility staff failed to ensure the Residents physician ordered pain medication was available and administered per the physicians order. The clinical record review revealed that Resident #6 had been admitted to the facility 02/15/15. Diagnoses included, but were not limited to, complex regional pain syndrome I, depressive disorder, sleep apnea, and deep vein thrombosis. Section C (cognitive patterns) of the Residents significant change in status MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/31/18 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. During an interview with Resident #6 on 03/28/19 at 10:40 a.m., the Resident verbalized to the surveyor that the facility had not applied her pain patch. Immediately after this interview, the surveyor approached LPN (licensed practical nurse) #1 and asked them about the Residents pain patch. LPN #1 reviewed the Residents EHR (electronic health record) and identified this medication as being buprenophine 20 mcg/hour transdermal patch. The instructions for this medication was for the transdermal patch to be applied one time weekly starting on 03/20/19. Further review of the clinical record revealed that the nursing staff had documented that this medication was not available for administration on 03/20 and 03/27/19. LPN #1 stated she would call the physician and obtain a script for the medication. On 03/28/19 at 10:46 a.m., the DON (director of nursing) and administrator were notified that Resident #6 did not have her physician ordered pain patch available for administration on 03/20 and again on 03/27/19. Resident #6 did have other scheduled pain medications ordered and these medications were given per the physicians orders. The Residents comprehensive care plan included the problem area requires pain management. Interventions included, but were not limited to, institute associated medical orders and administer analgesic and/or adjuvant analgesics. Prior to the exit conference LPN #1 verbalized to the survey team that she had obtained the medication. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #23, the facility staff failed to follow up on a recommendation from the wound clinic for the medications zinc and vitamin c. The clinical record review revealed that Resident #23 had been admitted to the facility 07/18/18. Diagnoses included, but were not limited to, stage III pressure ulcer to sacrum, dementia, degenerative disease of nervous system, essential tremor, spondylosis, and cerebrovascular disease. Section C (cognitive patterns) of the Residents significant change in status MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/12/19 had been coded 1/1/2 to indicate the Resident had problems with long and short term memory and was moderately impaired in cognitive skills for daily decision making. Section M (skin conditions) had been coded to indicate the Resident had a stage III pressure ulcer. The clinical record included a WOUND EVALUATION & MANAGEMENT SUMMARY report dated 03/07/19. Page 2 and 3 of this document included a recommendation for Vitamin C 500mg twice daily PO (by mouth); Zinc sulphate 220mg once daily PO for 14 days. The surveyor was unable to locate any further information regarding this recommendation in the Residents EHR (electronic health record). The administrator was asked about the recommendation on 03/27/19 at 11:46 a.m. During a meeting with the DON (director of nursing) and administrator on 03/27/19 at 3:11 p.m., the DON verbalized that this recommendation had been missed. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #64, the facility staff failed to administer the resident's caltrate as ordered by the physician. The clinical record review revealed that Resident #64 had been admitted to the facility 06/15/18. Diagnoses included, but were no limited to, fracture of right femur, pain, constipation, Alzheimer's disease, hypertension, cerebral infarction, chest pain, and depression. Section C (cognitive patterns) of the Residents admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 06/22/18 included a BIMS (brief interview for mental status) summary score of 3 out of a possible 15 points. The clinical record included an order for caltrate 600+D three times daily. The nursing staff had documented on the eMARs (electronic medication administration records) for 06/22/18 at 9:00 a.m. that this medication was not administered as the medication was not available. 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, family interview and clinical record review the facility staff failed to ensure an accident free environment for 1 of 24 Residents, Resident #53. The findings included: For Resident #53 the facility staff failed to follow physician's orders for fall mats at the bedside and failed to provide ¼ side rails per the physician's recommendation. Resident #53 was admitted to the facility on [DATE]. Diagnoses included but not limited to atrial fibrillation, end stage renal disease, hyperlipidemia, arthritis, osteoporosis, pelvic fracture, Alzheimer's disease, seizure disorder, malnutrition, and dementia. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 03/12/19 coded the Resident as 10 out of 15 is section C, cognitive patterns. Section G, functional status coded the Resident as 3/3 in the areas of bed mobility and transfer, which is the equivalent of extensive assistance/ two person physical assist. This is an admission MDS. Resident #53's CCP (comprehensive care plan) was reviewed and contained a care plan for Bed Rails are used to enhance the quality of life due to: impaired physical mobility R/T (related to): pelvic fracture and L (left) shoulder fracture. Goals for this care plan included With the use of the bed rail, the Resident will have an enhanced quality of life as evidenced by: Able to turn and positon self in the bed with the use of bed rails and With the use of bed rail, the Resident will be able to have an enhanced quality of life as evidenced by: Able to transfer from bed to a chair/wheelchair with the use of bed rails and with 1 person assistance. Interventions for this care plan are listed as assist Resident with transfers and mobility; ensure caretaker remains at bedside. Resident #53's CCP also contained a care plan for Actual fall on 03/05/19. Goals for this care plan included Will be without further falls with injury over the next 90 days. Interventions for this care plan included Initiate fall prevention protocol interventions as indicated (Fall mats at bedside when in bed). Resident #53's clinical record was reviewed on 03/27/18. It contained a signed physician's order summary, which read in part, Fall mats continuous. This order was dated 03/06/19. The Resident's clinical record also contained a Bedrail Consent Form dated 03/07/19, which read in part Assessment: The facility has conducted a comprehensive assessment and has determined that . (Resident name omitted) would benefit from the use of bedrails. The use of alternative devices and/or approaches has been considered by the interdisciplinary team. The physician has recommended: ¼ side rails both sides. Benefit: The bedrail(s) is/are being used to: Promote safety while Resident is receiving care in bed. The Resident's representative and a facility representative signed this consent form. The surveyor observed the Resident on 03/27/19 at approximately 1115. The Resident was up in wheelchair with sitter in attendance. Surveyor did not observe fall mats in the Resident's room, not did the surveyor observe ¼ side rails on the Resident's bed. Surveyor spoke with the Resident's daughter via telephone on 03/27/19 at approximately 1230. Resident's daughter stated that she had requested bed rails be placed on the Resident's bed upon admission, due to her confusion. Resident's daughter stated that Resident would try to get up on her own, not realizing that she has a broken pelvis. Resident's daughter also stated that on the day of admission, she was concerned about leaving the Resident at the facility without a sitter, but was assured that the staff would be frequently observing the Resident. The Resident's daughter stated that within 30 minutes of her departure from the facility, she received a call from the facility stating that the Resident had fallen out of bed. Surveyor spoke with unit manager on 03/27/19 at approximately 1400. Surveyor asked unit manager if Resident #53 has an order for fall mats and unit manager stated that she would have to check and see. Unit manager then stated to surveyor that Resident #53 does have an order for fall mats. Surveyor then asked unit manager where the fall mats were located and unit manager stated they were in the Resident's room. Unit manager also stated that mats did not need to be at bedside unless Resident is in bed, and can be propped against the wall when not in use. Surveyor then asked unit manager to accompany her to the Resident's room to observe the mats. Unit manager and surveyor observed Resident #53 on 03/27/19 at approximately 1415. Resident was resting in bed with sitter in attendance. Surveyor and unit manager observed no mats at the bedside or in the room. Unit manager stated that she would have the mats placed at bedside. Surveyor asked unit manager if the use of fall mats should be documented on the Resident's TAR (treatment administration record) and the unit manager stated that the order was entered as a standing order. The unit manager stated the order was not showing by shift, so that each shift knew to check for the mats. Unit manager stated that she would correct the order in the computer. The concern of no fall mats and no ¼ side rails on the Resident's bed was discussed with the administrative staff during a meeting on 03/27/19 at approximately 1510. DON (director of nursing) stated that Resident's daughter had requested full side rails on the bed. DON also stated facility staff had explained to daughter that full side rails could not be used. DON offered no explanation why the ¼ side rails were not implemented per the physician's order. Surveyor observed Resident #52 on 03/27/19 at approximately 1545. Resident #53 was sitting up in bed with sitter in attendance. The surveyor observed fall mats at the Resident's bedsides at this time. Surveyor did not observe ¼ side rails on the bed. Surveyor observed Resident #53 on 03/28/19 at approximately 0930. Surveyor observed fall mats at the bedsides and ¼ side rails on the bed at this time. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to follow up on pharmacy recommendations for 2 of 24 Residents, Residents #8 and #23. The findings included: 1. For Resident #8, the facility staff failed to follow up on a pharmacy recommendation from April 2018 in regards to the Residents prn (as needed) tramadol. The clinical record review revealed that Resident #8 had been admitted to the facility 11/09/17. Diagnoses included, but were not limited to, heart failure, cardiomyopathy, difficulty in walking, chronic atrial fibrillation, dementia, and chronic obstructive pulmonary disease. Section C (cognitive patterns) of the Residents annual MDS (minimum data set) assessment with an ARD (assessment reference date) of 01/17/19 included a BIMS (brief interview for mental status) summary score of 12 out of a possible 15 points. The clinical record included a pharmacy recommendation dated 04/13/18 that read Recommendation: Seroquel, Tramadol, and Hydrocodone APAP have not be used in the last 45 days. Please consider discontinuing. A review of the March 2019 eMAR (electronic administration record) revealed that the order for the tramadol was a current order and had been administered on 03/01/19. On 03/28/19 at 8:19 a.m., the administrative staff were asked to provide the surveyor with documentation that the pharmacy recommendation from April 2018 had been reviewed by the physician. This information was not provided to the surveyor prior to the exit conference on 03/28/19. 2. For Resident #23, the facility staff failed to follow up on a pharmacy review from 08/16/18 in regards to lab tests. The clinical record review revealed that Resident #23 had been admitted to the facility 07/18/18. Diagnoses included, but were not limited to, stage III pressure ulcer to sacrum, dementia, degenerative disease of nervous system, essential tremor, spondylosis, and cerebrovascular disease. Section C (cognitive patterns) of the Residents significant change in status MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/12/19 had been coded 1/1/2 to indicate the Resident had problems with long and short term memory and was moderately impaired in cognitive skills for daily decision making. The clinical record included a pharmacy recommendation for August 2018 for the laboratory test lipid and vitamin D. The surveyor was unable to find any results for these lab tests in the clinical record. On 03/28/19 at 12:11 p.m., the administrator and DON (director of nursing) were asked to provide the surveyor with documentation that the pharmacy recommendation for April 2018 had been reviewed by the physician. This information was not provided to the surveyor prior to the exit conference on 03/28/19.

Based on staff interview and clinical record review, the facility staff failed to ensure 1 of 24 Residents were free of unnecessary medications, Resident #22. The findings included: The Residents clinical record included a prn (as needed) order for the antipsychotic medication haldol. The clinical record did not include any information to indicate the physician had reviewed this order and/or provided a rationale for the continued use of this medication. The clinical record review revealed that Resident #22 had been admitted to the facility 08/22/18. Diagnoses included, but were not limited to, hypertension, dementia, Parkinson's disease, and malignant neoplasm of prostate. Section C (cognitive patterns) of the Resident significant change in status MDS assessment with an ARD (assessment reference date) of 02/08/19 included a BIMS (brief interview for mental status) summary score of 7 out of a possible 15 points. The Residents clinical record included orders for haldol oral concentrate as needed every 4 hours starting 02/05/19. The diagnosis was documented as restlessness and agitation. On 03/27/19 at 3:11 p.m., the administrator and DON (director of nursing) were notified that Resident #22 had a PRN order for the antipsychotic medication haldol for greater than 14 days. The DON stated the order was obtained by hospice. On 03/28/19 at 8:51 a.m., the DON stated she had spoken with the hospice nurse via phone and that hospice was managing the haldol. The DON added I can't say the physician laid eyes on the Resident we have no documentation. The DON then stated the process was broken. The administrative staff provided the surveyor with copies of haldol orders transcribed on 02/15/19, 03/01/19, and 03/15/19. The facility also provided the surveyor with a copy of an order to discontinue the haldol effective 03/27/19. These order had been signed by an RN (registered nurse). The physician had not signed any of these orders. On 03/28/19 at 11:04 a.m., the surveyor and LPN (licensed practical nurse) #1 checked the medication cart for the Residents haldol. LPN #1 provided the surveyor with 1 bottle of haldol with the Residents name. There was 20 ml's present in bottle LPN #1 confirmed this bottle was a 25 ml bottle indicating 5 ml's had been administered. No further information regarding this issue was provided to the survey team regarding the haldol prior to the exit conference.

Based on observation, staff interview, and facility document review, the facility staff failed secure the narcotic box on unit 2 and on the back hall nursing cart on unit 1. The findings included: The narcotic box in the unit 2 medication room was not permanently affixed and the narcotic box on the back hall medication cart on unit 1 was unlocked. On 03/27/19 at 10:25 a.m., the surveyor and LPN (licensed practical nurse) #2 checked the unit 1 back hall medication cart. The narcotic box on this cart was found to be unlocked during this observation. This narcotic box included the following controlled medications oxycodone, lyrica, and lorazepam. There were 15 medication cards in this narcotic box. The medication cart was located in the hall LPN #2 was observed to be down the hall when the surveyor approached the medication cart. On 03/27/19 at 10:34 a.m., the surveyor and RN (registered nurse) #2 checked the medication room on unit 2. This medication room included a locked refrigerator inside this refrigerator the surveyor observed a narcotic box. The surveyor was able to remove this narcotic box from the refrigerator. This narcotic box included 2-30 ml multiuse vials and 2-1 ml vials (2 mg) of lorazepam. RN #2 stated the box had been previous affixed but the refrigerator had been changed out about 3 months ago. The facility provided the surveyor with their policy titled storage of medications with a revision date of 02/15/18. This policy read in part, .Schedule II-V controlled medication are stored separately from other medication in a locked drawer or compartment designated for that purpose . During a meeting with the survey team on 03/27/19 at 3:11 p.m., the administrator and DON (director of nursing) were notified of the above issues. Prior to the exit conference, the administrator verbalized to the surveyor that the narcotic box was now permanently affixed.

Based on staff interview and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for 1 of 24 Residents, Resident #23. The findings included: The facility staff failed to determine the Resident DNR (do not resuscitate) status. The clinical record review revealed that Resident #23 had been admitted to the facility 07/18/18. Diagnoses included, but were not limited to, stage III pressure ulcer to sacrum, dementia, degenerative disease of nervous system, essential tremor, spondylosis, and cerebrovascular disease. Section C (cognitive patterns) of the Residents significant change in status MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/12/19 had been coded 1/1/2 to indicate the Resident had problems with long and short term memory and was moderately impaired in cognitive skills for daily decision making. The clinical record included a face sheet that listed the Resident as being a full code. Under the title of Advance Directive on the Residents comprehensive care plan the facility staff had documented that the Resident was a full code. However, the clinical record included a DDNR (durable do not resuscitate order) dated 11/01/18 that indicated the Resident was a DNR. The physician and the patients authorized representative had signed this DDNR . During a meeting with the DON (director of nursing) and administrator on 03/27/19 at 3:11 p.m., the DON verbalized that the Resident was a DNR. 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 staff interview, clinical record review, and facility document review, facility staff failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan for 1 of 21 residents in the survey sample (Resident #45). Resident #45 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease with hemodialysis, diabetes mellitus, cardiopulmonary disease with oxygen dependence, hypertension, enteritis as a result of clostridium difficile infection, and chronic pain. On the admission minimum data set assessment with assessment reference date 2/23/19, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. During an interview, the resident reported receiving hemodialysis treatments 3 days per week., Clinical record review revealed a physician order fro hemodialysis treatments on Tuesday, Thursday, and Saturday. On 3/26/19, the surveyor asked the nurse where to find the resident's hemodialysis documentation and was told that it would be in a dialysis binder which traveled with the resident to and from dialysis. The electronic clinical record contained a copy of a dialysis communication sheet dated 2/23/19. On 3/28, the surveyor spoke with the medical records department head, who said the department received the completed sheets and scanned them into the clinical record. On 3/28/19, the surveyor received printed documents faxed from the dialysis center on 3/27/19 containing the dialysis center [NAME] (orders) and lab results from 2/19, 2/21, 2/26, 3/5, 3/12, and 3/26. The paperwork from the dialysis center did not include assessmens of the resident's vital signs, weight, or dialysis site. There were no nursing notes concerning pre- and post- dialysis condition of the resident. There were no recorded vital signs on dialysis dates 2/19, 2/21, 2/26, or 3/23. Blood pressures were documented taken in both the right and left arms. Weights were recorded for 2/21/19 and 3/19/19. No documentation of dialysis site condition was recorded. The resident's comprehensive care plan included the problem potential weight fluctuations due to ESRD and need for dialysis with interventions including weigh resident pre and post dialysis. DOCUMENT IN MEDICAL RECORD. Under the problem altered health maintenance R/T end stage renal disease (ESRD) AEB hemodialysis, interventions included Monitor access site for s/s (signs and symptoms) of infection, do not take B/P in ext. (extremity) of access site, report abnormal findings to MD. The surveyor reported the concern with lack of monitoring during summary meetings on 3/27 and 3/28/19.

The facility failed to comply with regulations requiring the participation of the medical director at quarterly QAA meetings. Findings: The facility failed to comply with regulations requiring the participation of the medical director at quarterly QAA meetings. The administrator and DON were interviewed regarding the QAA committee on 3/28/19 at 2:45 PM. The facility administrator was asked how often the QAA committee held meetings. She stated the committee meet for quarterly meetings. The administrator provided the quarterly sign-up sheet for the committee members. The medical director had not signed the sheets for 12/18/18 or 3/19/19. The surveyor asked if anyone was designated to take the medical director's place on the two dates in question. The administrator said, no one had been designated to take his place but they sent the committee minutes to him after each meeting. The facility had no additional information to offer prior to the survey team's exit.