**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, employee record review, and facility document review, the facility staff failed to follow their policy/procedures for screening of new employees for 1 of 25 new employees, new employee #15. The findings included: The facility staff failed to follow their policy for screening of new employees. The facility staff failed to provide evidence of screening for new employee #15. New employee #15 was identified as the Medical Director and had a hire date of [DATE]. The Administrator provided the surveyor with a copy of their policy titled, Abuse, Neglect and Exploitation. This policy read in part, .Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screenings may be conducted by the facility itself, third-party agency or academic institution. 3. The facility will maintain documentation of proof that the screening occurred . During the employee record review the surveyor requested evidence of screening of new hires. New hire #15's employee record did not include a criminal background check or reference checks. The license in the employee file expired on [DATE]. The facility staff were able to pull a current license with an expiration date of 2026. The Administrator stated they were trying to obtain the screenings from a third-party company. On [DATE] at 11:40 a.m., during a team meeting with the Administrator, Director of Nursing, Regional Director of Clinical Services, and Area Director of Social Services, the issue with the missing screening/credentials regarding new employee #15 was reviewed. On [DATE] at 9:44 a.m., the Administrator stated they had contacted the Regional Medical Director and left messages with the Human Resource department. The Administrator stated when new employee #15 was hired they were licensed in the Commonwealth of Virginia a background check, and fingerprints had been completed and accepted by the previous company. They were currently merging with another company and that company was in the process of completing background checks. Prior to the exit conference on [DATE] the Administrator provided the survey team with a sworn statement and a copy of a Virginia State Police Background check that had been obtained on [DATE] the status read NO IDENTIFIABLE RECORD(S). 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** 3. For Resident #4, the facility staff coded the resident as having an indwelling catheter on the 7/18/24 minimum data set (MDS) assessment, however, the resident's catheter had been discontinued on 7/8/24. Resident #4's diagnosis list indicated diagnoses, which included, but not limited to, Alzheimer's Disease, Atrial Fibrillation, Diabetes Mellitus Type 2 (two), Neuromuscular Dysfunction of Bladder, Bipolar Disorder, and Chronic Viral Hepatitis C. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/18/24 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating the resident had severe impairment in cognitive abilities. Surveyor observed Resident #4 on 10/15/24 at 12:55 PM and no indwelling catheter was present at the time of the observation. Review of the comprehensive person-centered care plan included a focus area that read in part, .resident requires a catheter . On 10/15/24 at 3:44 PM, surveyor interviewed licensed practical nurse #2 (LPN#2). LPN#2 informed surveyor that Resident #4 did not have a catheter, and it had been discontinued. LPN#4 reviewed the electronic health record and informed surveyor the resident had been in the hospital in July 2024 and the catheter had been discontinued on 7/8/24. A review of the medical provider's orders confirmed the indwelling catheter had been discontinued on 7/8/24. Further review of the clinical record revealed the most recent MDS dated [DATE] had Section H-Bladder & Bowel, being coded in section H0100-Appliances with; A. Indwelling Catheter. This concern was discussed at the end of day meeting on 10/15/24 at 4:31 PM with the administrator, director of nursing, social worker, and assistant director of nursing and again on 10/16/24 at 11:40 AM with the regional director of clinical services, area social worker, director of nursing, and administrator. Surveyor was informed by the administrator that the facility utilizes the RAI (Resident Assessment Instrument) manual for MDS guidelines. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 with a revision date of October 2023, read in part, .Section 1.4 Problem Identification Using the RAI . on page 10, .a. Assessment-Taking stock of all observations, information, and knowledge about a resident from all available sources (e.g., medical records, the resident .) . No further information regarding this concern was presented to the survey team prior to the exit conference on 10/17/24. Based on staff interview and clinical record review, the facility staff failed to ensure accurate Minimum Data Set (MDS) assessments for 3 of 20 residents, Residents #29, #57, and #4. The findings included: 1. For Resident #29, the facility staff failed to code the residents dialysis status on an annual MDS assessment. Resident #29's diagnoses included end stage renal disease and dependence on renal dialysis. Section C (cognitive patterns) of Resident #29's annual MDS assessment with an assessment reference date (ARD) of 08/08/24 included a brief interview for mental status (BIMS) score of 4 out of a possible 15 points. Per the MDS manual a score of 4=severe impairment in cognitive skills for daily decision making. Section O (special treatments/procedures/programs) was not coded to indicate this resident was receiving dialysis services. On 10/15/24, during initial tour of the facility the facility staff identified this resident as being out of the building for a dialysis treatment. Resident #29's comprehensive care plan included the focus area requires hemodialysis. Resident #29's clinical record included a provider order for Hemodialysis three times a week for kidney failure. The date of the order was documented as 12/20/23. On 10/15/24 at 1:16 p.m., the Administrator was made aware of the inaccurate MDS assessment and stated this resident had been on dialysis since they had been at the facility, and they would have the staff complete a modification MDS. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #57, the facility staff coded the residents discharge MDS assessment as they had discharged to a short-term general hospital when in fact they were discharged home. Resident #57's diagnoses included pleural effusion and atrial fibrillation. Section C (cognitive patterns) of Resident #57's discharge MDS assessment with an assessment reference date (ARD) of 08/30/24 included a brief interview for mental status (BIMS) score of 11 out of a possible 15 points. Per the MDS manual a score of 11=moderately impaired in cognitive skills for daily decision making. Section A (identification information) was coded to indicate this was a planned discharged , return not anticipated, and was coded to indicate Resident #57 was discharged to a short-term general hospital. Resident #57's clinical record included a progress note dated 08/30/24 that read in part, .requested to be d/c'd (discharged ) today with days remaining . On 10/16/24 at 11:40 a.m., during a meeting with the Administrator, Director of Nursing, Regional Director of Clinical Services, and the Area Director of Social Services the issue with the inaccurate coding of the discharge MDS assessment was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, family interview, and clinical record review, the facility staff failed to develop and/or implement a person-centered, comprehensive dietary care plan for 1 of 17 sampled residents, (Resident #6). The findings included: For Resident #6 the facility staff failed to develop and implement a comprehensive person-centered dietary care plan to address the resident's medical needs and/or preferences of being lactose intolerant. Resident #6's diagnosis list indicated diagnoses that included, but were not limited to, Arteriosclerotic Heart Disease, Hypertension, Old Myocardial Infarction, Atrial Fibrillation, Dementia, Age-Related Osteoporosis, Gastro-Esophageal Reflux Disease, and Diabetes Mellitus Type 2 (two). The most recent minimum data set (MDS) with an assessment reference date (ARD) of 9/20/24 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating the resident had severe impairment in cognitive abilities. Surveyor interviewed resident's daughter via phone conversation on 10/15/24 at 7:06 PM. Daughter informed surveyor Resident #6 was lactose intolerant, and that facility continued to send milk on resident's tray at times after she had informed them of resident being lactose intolerant on several occasions. A review of the progress notes revealed a Social Services note dated 7/2/24 that read in part, .Care plan meeting w (with) resident's daughter and IDT (interdisciplinary team) .Discussed diet . A review of the comprehensive person-centered dietary care plan revealed no indication that Resident #6 was lactose intolerant. On 10/16/24 at 8:15 AM, surveyor interviewed dietary manager #1 (DM#1) and requested and received a copy of Resident #6's tray ticket dated 10/16/24 that read in part, .Allergies .Lactose .Milk . On 10/16/24 at 1:09 PM, surveyor interviewed dietary manager #1 (DM#1) and he stated he does resident preferences, and he does not do the care plans, the registered dietician does the care plans. On 10/16/24 at 1:16 PM, surveyor attempted to contact registered dietician via phone call and left a voice message. At 3:58 PM, the administrator informed surveyor the dietician does not update the care plan, the MDS nurse does the updates for care plans. This concern was discussed on 10/16/24 at 11:40 AM with the regional director of clinical services, area social worker, director of nursing, and administrator. Surveyor requested but did not receive a care plan policy and was informed by the administrator that the facility utilizes the RAI (Resident Assessment Instrument) manual for care planning guidelines. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 with a revision date of October 2023, read in part on page 10, .d. Care Planning-Establishing a course of action with input from the resident (resident's family .) .that moves a resident toward resident-specific goals .e. Implementation-Putting that course of action (specific interventions derived through interdisciplinary individualized care planning) . No further information regarding this concern was presented to the survey team prior to the exit conference on 10/17/24.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team for one (1) of 17 sampled residents, (Resident #4). The findings included: For Resident #4, the facility staff failed to review and revise the resident's comprehensive person-centered care plan to discontinue the focus for indwelling catheter that had been discontinued on 7/8/24. Resident #4's diagnosis list indicated diagnoses, which included, but not limited to, Alzheimer's Disease, Atrial Fibrillation, Diabetes Mellitus Type 2 (two), Neuromuscular Dysfunction of Bladder, Bipolar Disorder, and Chronic Viral Hepatitis C. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/18/24 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating the resident had severe impairment in cognitive abilities. Surveyor observed Resident #4 on 10/15/24 at 12:55 PM and no indwelling catheter was present at the time of the observation. Review of the comprehensive person-centered care plan included a focus area that read in part, .resident requires a catheter . with a revision date of 8/8/24. On 10/15/24 at 3:44 PM, surveyor interviewed licensed practical nurse #2 (LPN#2). LPN#2 informed surveyor that Resident #4 did not have a catheter, and it had been discontinued. LPN#4 reviewed the electronic health record and informed surveyor the resident had been in the hospital in July 2024 and the catheter had been discontinued on 7/8/24. A review of the medical provider's orders confirmed the indwelling catheter had been discontinued on 7/8/24. This concern was discussed at the end of day meeting on 10/15/24 at 4:31 PM with the administrator, director of nursing, social worker, and assistant director of nursing and again on 10/16/24 at 11:40 AM with the regional director of clinical services, area social worker, director of nursing, and administrator. Surveyor requested but did not receive a care plan policy and was informed by the administrator that the facility utilizes the RAI (Resident Assessment Instrument) manual for care planning guidelines. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 with a revision date of October 2023, read in part on page 10, .f. Evaluation-Critically reviewing individualized care plan goals, interventions and implementation .assessing the need to modify the care plan (i.e., change interventions) to adjust to changes in a resident's status, goals, or improvement or decline . No further information regarding this concern was presented to the survey team prior to the exit conference on 10/17/24.

Based on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to obtain a physician's order for oxygen for one of 17 residents in the survey sample, resident # 23. The findings included: Resident # 23's diagnoses included but were not limited to chronic obstructive pulmonary disease (COPD), morbid obesity, heart failure and hypertension. The minimum data set (MDS) assessment with an assessment reference date of 8/29/24 assigned the resident a brief interview for mental status (BIMS) score of 15 out 15, indication intact cognition. On 10/15/24 This surveyor observed resident # 23 in their room. They were using oxygen via nasal cannula and the setting was 4 liters per minute (LPM). When asked if they knew how much oxygen they were getting they stated, Two (2) I believe. When asked if they needed the oxygen all the time or just sometimes they stated, I use it all the time. During a review of the clinical record an order that read, C-PAP on at QHS (every hour of sleep) and off in the AM with settings- IP-18, EP-5, back up rate-10 and PRN (as needed) during the day with oxygen at 2 LPM bleed in two times a day related to chronic respiratory failure. The order was dated 8/15/24. There was no order in the record for resident to have oxygen during the day at 4 LPM. On 10/15/24 at 4:06 PM this surveyor interviewed Registered Nurse (RN) # 2. They stated they knew that resident used oxygen but was unsure of the order and needed to look it up. They were unable to locate an order for resident to have oxygen at 4 LPM via nasal cannula. They stated they would check with charge nurse who was more familiar with the resident. On 10/15/24 at 4:10 PM this surveyor interviewed Licensed Practical Nurse (LPN) # 2. They stated, I feel like he did have an order but it was prn (as needed). He's been back and forth to the hospital so that is probably what happened. I don't think he has ever had an order for 4 liters. He doesn't need it all the time. I checked his O 2 sat and it was 92% so I called the provided and got an order for oxygen at 2 LPM PRN. I already put it in the record. This surveyor reviewed the policy entitled, Medical Gas (Oxygen) with an implementation date of 1/1/24, that read in part, 1. Oxygen is administered under orders of a physician, except in the case of an emergency. On 10/15/24 at 4:35 PM the survey team met with the Administrator, Director of Nursing, Assistant Director of Nursing and the Admissions Director. This concern was discussed at that time. No further information was provided to the survey team prior to the exit conference.

Based on observation, staff interview, facility document review, and during the course of a medication pass and pour observation, the facility staff failed to maintain processes to prevent the spread of infection and disease, and to ensure that Point of Care Devices are utilized safely, when used on multiple residents, by properly cleaning a glucose monitor between residents. The findings included: On 10/16/24 at 8:24 AM this surveyor observed Licensed Practical Nurse (LPN) # 1 during a medication pass, obtain a blood sugar level on a resident. They returned to the medication cart and used two alcohol prep pads to clean the glucometer they had used. When asked what the facility policy is for cleaning glucometers they stated, We use alcohol pads, that's what we've always done. We clean them before and after each patient. On 10/16/24 AT 9:06 AM this surveyor interviewed the Assistant Director of Nursing. When asked what the policy for cleaning glucometers was, they stated, We clean them with alcohol preps before and after we use them. Surveyor asked for the policy and the manufacturers recommendations. When they returned with the policy they stated, We've already started the education with all the nurses. This surveyor reviewed the booklet EvenCare Blood Glucose Monitoring System User's Guide. On page 45, the booklet read in part, EvenCare G 2 Meters and lancing device are validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products are validated for disinfecting the EvenCare G 2 meter and lancing device: Dispatch Hospital Cleaner Disinfectant Towels with Bleach (EPA registration Number: 56392-8), Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipes with alcohol (EPA Registration Number: 59894-10), Clorox Healthcare Bleach Germicidal Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: 67619-12), Medline Micro-Kill Bleach Germicidal Bleach Wipes (EPA Registration Number: 37549-1). The policy entitled, Glucometer Disinfection with a revised date of 9/2/24 was reviewed. The policy read in part, 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 2. If the manufacturers are unable to provide information specifying how the glucometer should be cleaned and disinfected then the meter will not be used for multiple residents. 3. The glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus. On 10/16/24 at 11:40 AM the survey team met with the Director of Nursing, Regional Director of Clinical Services and the Administrator. This concern was discussed. The Director of Nursing stated, I think they were doing that because it is what we did during COVID, alcohol kills the virus. No further information was provided to the survey team prior to the exit conference.

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 2 facility medication carts. The findings were: During a medication pass and pour observation on 10/16/24 at 8:03 AM, this surveyor observed Licensed Practical Nurse (LPN) # 1 leave the medication cart unattended with a vial of DuoNeb (ipratromium/albuterol liquid medication that is inhaled as a mist through a nebulizer machine). LPN # 1 left the cart on the A hall while they went to the medication room to look for another medication. During a medication pass and pour observation on 10/16/24 at 8:45 AM, this surveyor observed Registered Nurse (RN) # 1 leave a cup of Miramax (powdered laxative) mixed with 3 ounces of water on the medication cart unattended while they went to the medication room to look for another medication. When asked if leaving medication on the cart is acceptable, they stated, What should I have done? The policy entitled, Medication Storage with a revised date of 8/28/24 was reviewed and read in part, 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. On 10/16/24 at 11:40 AM the survey team met with the Director of Nursing, Administrator, and the Regional Director of Clinical Services. This concern was discussed 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 and staff interview, the facility staff failed to ensure proper disposal and/or containment of the facility's garbage/waste. The findings included: On 10/15/24 at 11:47 AM this surveyor employee # 1 made an observation of the facility's garbage disposal area located outside the facility but on the campus. There was one dumpster noted. All of the doors on the dumpster were shut. However, there was a large pile of debris beside the dumpster that included 5 computer screens and key boards, at least 5 wooden pallets, multiple wet, decorative [NAME] of hay, a case of outdated chicken noodle soup, two nightstands, multiple drinking straws, medication cups, drinking cups and surgical masks. Employee # 1 stated, They came and emptied it this morning, I don't know why they didn't pick this stuff up too. We couldn't put it in there because it was too full so we had to put it here. On 10/15/24 at 4:35 PM the survey team met with the Administrator, Director of Nursing, Assistant Director of Nursing and the Admission's Coordinator. This concern was discussed. The Administrator stated, We had to have our dumpster switched out because it had holes in it and they replaced it with that smaller one. They are coming back to pour a concrete pad and I am going to tell them to bring me the bigger size back. No further information was presented to the survey team prior to the exit conference.

Based on staff interview, clinical record review, facility document review and during a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5%. There were 2 errors in 32 opportunities for a medication error rate of 6.25 %. These errors affected Resident #38. For Resident #38 the facility staff failed to administer the correct doses of the medications Vitamin D3 (cholecalciferol) and Diltiazem. Diltiazem is a calcium channel blocker used to treat hypertension. The findings included: Resident #38's face sheet listed diagnoses which included but not limited to hypertension, atherosclerotic heart disease, chronic kidney disease, anxiety, depression, and asthma. Resident #38's most recent quarterly Minimum Data Set with an assessment reference date of 04/12/22 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. The Surveyor observed registered nurse (RN) #1 during a medication pass and pour on 05/16/22 at 8:00 A.M. RN #1 prepared Resident #38's medications and administered them to the resident. Surveyor observed RN #1 prepare Vitamin D3 25 mcg (1000 units), one tablet and Diltiazem 90 mg, one tablet. The Surveyor reconciled Resident #38's medications on 05/16/22 at 9:30 A.M. Resident #38's clinical record contained a physician's order summary for the month of May 2022, which read in part Cholecalciferol tablet. Give 2000 unit by mouth one time a day for supplement and Diltiazem HCl Tablet. Give 180 mg by mouth one time a day related to atherosclerotic heart disease of native coronary artery without angina pectoris (I25.10); Essential (primary) hypertension (I10). Surveyor spoke with RN #1 on 05/16/22 at 10:00 A.M. regarding Resident #38's medications. Surveyor asked RN #1 to confirm the dosages for Vitamin D3 and Diltiazem. RN #1 read the resident's orders and confirmed to the surveyor that they had only administered one tablet of each medication, when it should have been two tablets of each. Surveyor requested and was provided with a facility policy entitled, Safe medication administration practices, long-term care, which read in part, Introduction: To promote a culture of safety and prevent medication errors, nurses must adhere to the 'rights of medication administration'. The rights are to identify the right resident by using at least two resident identifiers, select the right medication, give the right dose, give the medication at the right time, give the medication by the right route, and provide the right documentation. The concern of the facility failing to ensure a medication error rate of less than 5 % was discussed with the Administrator and Director of Nursing on 05/17/22 at 12:30 P.M. No further information was provided prior to exit.

Based on observations, staff interviews, and review of a facility document, it was determined the facility staff failed to ensure ensure that residents receive treatment and care for one (1) of 18 sampled residents (Resident #23) as evidenced by a failure to follow physician orders concerning the administration of digoxin. The findings included: Resident #23 was a resident in the facility at the time of this survey on 3/9/2020 through 3/12/2020. The resident had the admitting diagnoses of, but not limited to atrial fibrillation, high blood pressure, diabetes, end stage renal disease, dementia and depression. On the most recent MDS (Minimum Data Set) coded the resident as having a BIMS (Brief Interview for Mental Status) score of 10 out of a possible score of 15. Resident #23 was also coded as requiring extensive assistance with (2) or more staff members for dressing and personal hygiene and being totally dependent on (1) or more staff members for bathing. During the medication pass observation on 03/10/20 at 08:40 AM LPN (licensed practical nurse) #1 was preparing medications on the top of the medication cart outside the resident's room. As LPN #1 prepared the medication in which she stated it was Coreg to the surveyor she continued to verbally state to the surveyor, LPN #1 stated to the surveyor, I have to check her heart rate before I give this medicine. The nurse placed the medication in which she had stated earlier to the surveyor that it was Coreg and continued to place this pill in a medicine cup. The surveyor observed LPN #1 place this cup to the side and the LPN did not place any other medications in this medicine cup. The surveyor continued to observe LPN #1 check the medication cards with the residents MARs (Medication Administration Records). When LPN #1 had placed another pill in the second medication cup that had other medications in it. After this pill was placed in this cup, LPN #1 handed this medication card to the surveyor. The surveyor wrote this medication information from the label of the medication card in which was handed to her after this statement which read in part, .Digoxin 125 mcg (micrograms) 1 po (by mouth) daily. Hold if HR (heart rate) BELOW <60 . At 8:47 am, LPN #1 took both medicine cups and entered Resident #23's room along with the surveyor accompanying the nurse. The nurse gave the medicine cup that was full with the resident's medications to the resident and the resident proceeded to take all of these medications. This medicine cup was the cup that contained the Digoxin and the surveyor did not observe the nurse checking the resident's pulse before the Digoxin was administrated. After that, LPN #1 checked the pulse of the resident and gave the Coreg from the medication cup that only had this one pill in it. At 9 am, the surveyor asked LPN #1, why she checked the resident's pulse before she gave the resident the medication Coreg. LPN #1 stated, I checked the pulse before I gave the Digoxin. The surveyor had notified her of the above documented observations. The nurse stated, I'm so sorry I checked the pulse before I gave the Coreg but I should had checked it before I gave her the Digoxin. The surveyor notified the regional nurse on 3/10/2020 at 9:15 am, of the above documented findings. The surveyor requested and received the policy titled, 6.0 General Dose Preparation Products and Services from Pharmacy which read in part, .4.1.2 Confirm that the MAR reflects the most recent medication order . The surveyor reviewed the physician order for the Digoxin medication. The physician order read Digoxin Tablet 125 MCG Give 1 tablet by mouth one time a day .Hold if HR (heart rate) below 60 . This medication order had a date of 2/26/2020 as the order and start date of 2/26/2020 as documented on the Order Summery Report for Resident #52. The administrator, chief nursing officer, regional nurse, director of nursing, regional director of maintenance and regional director of human resources were notified of the above documented findings on 3/10/2020 at 4:45 pm in the conference. The surveyor again notified all named parties in the next end of the day conference on 3/11/2020 at approximately 4:30 pm. No further information was provided to the surveyor prior to the exit conference on 3/12/2020.

2. The facility staff failed to ensure a provider acted on the pharmacist's medication regimen review, dated 01/22/2020, related to fluoxetine (given daily for depression) for Resident #48. Resident #48's clinical record was reviewed on 03/11/2020 and 03/12/2020. Within the admission record, the resident's diagnoses included, but were not limited to, Parkinson's disease, chronic obstructive pulmonary disease, type 2 diabetes mellitus, and other specified depressive episodes. Section C (cognitive patterns) of the resident's MDS (minimum data set) assessment, with an assessment reference date of 02/18/2020 included a BIMS (brief interview for mental status) summary score of 14 out of 15. The progress notes included a pharmacy note, dated 01/22/2020, that indicated the pharmacist's completed medication regimen review recommendation(s) would be found in a separate report. No report dated 01/22/2020 regarding pharmacy recommendations was found within Resident #48's clinical record. The facility's regional director of clinical services was asked about this referenced report on the morning of 03/12/2020. At 3:45 p.m. on 03/12/2020, the facility's director of nursing (DON) and administrator provided the surveyor with the pharmacist's consultation report dated 01/22/2020. The administrator acknowledged the report was not found in Resident #48's clinical record; the report had been emailed to the facility. The pharmacist's consultation report, dated 01/22/2020, read that Resident #48 received fluoxetine 40mg daily for depression and the recommendation read, Please reduce fluoxetine to 20mg daily with the end goal of discontinuation. Rationale for Recommendation: Fluoxetine has a high incidence of anorexia and decreased appetite. The area within the report for a physician's response was blank; no notation whether the pharmacist's recommendation would be accepted or declined and no signature or date. The DON acknowledged the pharmacist's recommendation had not been addressed. Resident #48's clinical record included an order, dated 11/12/19, for FLUoxetine HCl Capsule 40 MG Give 1 capsule by mouth one time a day related to OTHER SPECIFIED DEPRESSIVE EPISODES to be started on 11/13/19. The resident's medication administration record (MAR) provided evidence Resident #48 had received FLUoxetine HCL Capsule 40 MG every morning at 9:00 a.m. in the month of January and February 2020 and through the 12th day in March 2020. The administrator provided two printed forms from the clinical record progress notes: 1) C-Health Nursing Facility Progress Note dated 02/25/2020, signed by a nurse practitioner and 2) a Psychiatric Evaluation with a date of service being 02/24/2020 electronically signed by a psychiatric-mental health nurse practitioner (PMHNP). The administrator stated that since both of these providers had seen Resident #48 after the pharmacist's consultation on 01/22/2020, either of them could have reviewed and acted on the pharmacist's recommendations but there was no evidence that either of them reviewed the pharmacist's recommendations. The facility's Omnicare policy titled, 9.1 Medication Regimen Review with the latest effective date of 11/28/16 read in part, 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR (medication regimen review) and the Director of Nursing to act upon the recommendations contained in the MRR. And, 8. Facility should alert the Medication Director when MRRs are not addressed by the attending physician in a timely manner. The administrative team including the facility's chief nursing officer, administrator, DON, regional maintenance director, corporate human resources director, and regional director of clinical services were informed of the above described concern during a meeting on 03/12/2020 at 4:51 p.m. No further information regarding this issue was provided prior to the exit conference. Based on interviews and document review, it was determined the facility staff failed to ensure pharmacist medication regimen reviews were acted on by a provider for two (2) of 18 sampled residents (Resident #38 and Resident #48) as evidence by the absence of provider response documentation. The findings include: 1. The facility staff failed to ensure a provider acted on Resident #38's medication regimen review, dated 1/22/2020. Resident #38's diagnoses included, but were not limited to: high blood pressure, kidney disease, coronary artery disease, anxiety, depression, and chronic respiratory failure. Resident #38's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 1/24/2020, had the residents Brief Interview for Mental Status (BIMS) scored as a 14 out of 15 and the Resident Mood Interview scored as 16 out of 27. Resident #38 was assessed as requiring extensive assistance of two (2) or more individuals with bed mobility, transfers, dressing, and toilet use. Resident #38's progress notes included a pharmacy note, dated 1/22/2020, that indicated the pharmacist's completed medication regimen review recommendation(s) would be found in a separate report. No report dated 1/22/2020 regarding pharmacy recommendations was found within Resident #38's clinical record. On 3/12/2020 at 11:05 a.m., the facility's Regional Director of Clinical Services (RDCS) provided the surveyor with the aforementioned pharmacist's medication regimen review report dated 1/22/2020. The following information was found in this pharmacist report: Comment: (resident's name omitted) has a PRN [as needed] order for a sedative/hypnotic without a stop date. Temazepam 30 mg Q [every] hs [bedtime] PRN [as needed] for insomnia. Recommendation: Please consider discontinuing or adding a stop date to the current order . The area within the report for a physician's response was blank; no notation was made of whether the pharmacist's recommendation would be accepted or declined and no provider signature and date were documented. The RDCS confirmed this pharmacy recommendation dated 1/22/2020 had not been acted on by a provider until 3/12/2020 at 10:43 a.m. when the Temazepam order in question was discontinued; this was after the surveyor had asked about the 1/22/2020 pharmacist recommendations. The RDCS reported that providers including physicians, nurse practitioners, and physician assistants were allowed to address pharmacist's medication regimen review recommendations. Resident #38's clinical documentation included evidence of provider visits document on the following dates and times: 1/23/2020 at 12:50 p.m.; 1/27/2020 at 12:37 p.m.; 2/6/2020 at 1:00 p.m.; 2/7/2020 at 12:20 p.m.; 2/17/2020 at 1:05 p.m.; 2/21/2020 at 12:25 p.m.; and 2/24/2020 at 4:53 p.m. At none of the aforementioned visits did the provider address the Resident #38's 1/22/2020 pharmacist recommendation. The following information was found in the facility's Omnicare policy titled, 9.1 Medication Regimen Review (with the latest effective date of 11/28/16): 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR (medication regimen review) and the Director of Nursing to act upon the recommendations contained in the MRR . 8. Facility should alert the Medication Director when MRRs are not addressed by the attending physician in a timely manner. During a survey team meeting on 3/12/2020 at 4:51 p.m., the failure of facility staff members to ensure Resident #38's 1/22/2020 pharmacist's recommendation was addressed by a provider was discussed for a final time with the facility's administrative team (Chief Nursing Officer, Administrator, Director of Nursing , Regional Maintenance director, Corporate Human resources Director, and RDCS). No additional information regarding this issue was provided prior to the exit conference.

Based on observations, staff interviews, and the review of a facility document, it was determined the facility staff failed to accurately label a medication for one (1) of 18 sampled residents as evidenced by the label not corresponding with the correct duration of the medication to be administrated to the resident (Resident #52). The findings include: Resident #52 was in the facility in the time of this survey, 3/9/2020 thorough 3/12/2020. On the most recent MDS (Minimum Data Set), the resident was coded as requiring extensive assistance of 2 staff members for dressing and personal hygiene and being totally dependent on 2 staff members for bathing. Resident #52 was also coded as having a BMS (Brief Interview for Mental Status) had problems with long and short term memory and was moderately impaired in decision making Resident #52's admitting diagnoses included, but not limited to atrial fibrillation, high blood pressure, diabetes, dementia and depression. During the medication observation on 3/10/22020 at 8:12 am with LPN (licensed practical nurse) #1, the surveyor observed LPN #1 prepared medications to be given to Resident #52. The nurse handed me the medication card for the medication Eliquis which read in part, Eliquis 5 MG (milligram) Tablet EA (each) Give 10 MG by mouth two times a day for 7 days . LPN #1 proceed to administrator this medication to the resident. When the nurse returned to the medication cart, the surveyor asked LPN #1 according to the directions on the MAR (Medication Administration Record) when was the date that the Eliquis was to be stopped on the 7th day. The nurse researched the MAR and stated The label hasn't been changed because the doctor changed that on 3/3/2020 to be given two times a day with no stop date. The surveyor notified the regional nurse of the above documented findings at 8:25 am at which time the surveyor requested a copy of the facility's policy on medication labels or what to do when the dosage or the duration of the medication had been changed. The regional nurse provided the surveyor with a copy of the policy titled Labeling of Medications at 11 am on 3/10/2020, which read in part as follows: .10. Only the issuing pharmacy may place a drug label on a medication container. 11. The pharmacy must be informed of any changes in directions for the use of drug . 13. Only a physician or pharmacist may change a medication label . The surveyor notified the administrator, chief nursing officer, regional nurse, director of nursing, regional maintenance officer and regional human resources officer of the above documented findings on 3/10/2020 at approximately 4:30 pm and again on 3/12/2020 at 4:45 pm. No further information was provided to the surveyor prior to the exit conference on 3/12/2020.

Based on observations, staff interviews, and review of a facility document, it was determined the facility staff failed to maintain an infection prevention and control program for one (1) of 18 sampled residents as evidenced by bringing a bottle of blood glucose strips into the resident's room and not cleaning the bottle before storing them in the medication cart and by not changing a pair of dirty gloves before opening the resident's blinds (Resident #23) The findings included: Resident #23 resided in the facility while an unannounced Medicare/Medicaid survey was conducted from 3/9/2020 through 3/12/2020. The resident had the admitting diagnoses of, but not limited to atrial fibrillation, heart failure, arthritis, dementia and chronic obstructive pulmonary disease. On the most recent MDS (Minimum Data Set) coded the resident as having a BIMS (Brief Interview for Mental Status) score of 10 out of a possible score of 15. Resident #23 was also coded as requiring extensive assistance with two (2) or more staff members for dressing and personal hygiene and being totally dependent on one (1) or more staff members for bathing. During the medication pass observation on 3/10/2020 at 8:45 am, the surveyor observed LPN (licensed practical nurse) #1 administrated the medications the physician had ordered to be given at the 8am medication pass. While LPN #1 was in the room with the resident, the resident requested LPN #1 to open her blinds. LPN #1 proceeded to open the blinds with the gloves that LPN #1 had previously had on while she was sticking the resident's finger to obtain blood for the blood glucose level. LPN #1 removed her gloves and washed her hands. The surveyor had also observed LPN #1 bring in a bottle of blood glucose strips that had several strips in it. After washing her hands, LPN #1 exited the resident's room, placed the bottle of blood glucose strips in the medication cart drawer for storage. The surveyor did not observe LPN #1 clean and wipe down the bottle of blood glucose strips prior to putting them in the medications cart. At 8:47 am, the surveyor asked LPN #1 what should she had done prior to opening the resident's blinds in her room. LPN #1 stated, I should had taken my dirty gloves off and washed my hands before I opened the blinds. The surveyor then asked what she should had done before bringing the bottle of blood glucose strips and storing them in the medication cart drawer. LPN #1 stated, I should had wiped the bottle down with a cleaning wipe. At 9 am, the surveyor notified the regional nurse of the above documented findings. The surveyor requested the facility's policy on the cleaning of multi-use resident supplies once they are brought out of the resident's room. At 11:25 am, the chief nursing officer provided the surveyor with the policy titled, 6.0 General Dose Preparation and Medication Administration which read in part, .6.4 Clean any reusable equipment or supplies . The surveyor notified the administrator, chief nursing officer, regional nurse, director of nursing, regional maintenance officer and regional human resources officer of the above documented findings on 3/10/2020 at approximately 4:30 pm and again on 3/12/2020 at 4:45 pm. No further information was provided to the surveyor prior to the exit conference on 3/12/2020.