Based on staff interview and clinical record review, the facility staff failed to ensure residents receive treatment and care in accordance with the comprehensive person-centered care plan and medical provider orders for 1 of 24 sampled residents, Resident #61. The findings included: For Resident #61, the facility staff failed to follow the medical provider's order for the administration of the narcotic pain medication Oxycodone. Resident #61's diagnosis list indicated diagnoses, which included, but not limited to Displaced Intertrochanteric Fracture of the Left Femur, End Stage Renal Disease, and Chronic Obstructive Pulmonary Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/21/25 assigned the resident a brief interview for mental status (BIMS) summary score of 10 out of 15 indicating the resident was moderately cognitively impaired. Resident #61's comprehensive person-centered care plan included a focus area stating [Resident #61] has potential for pain r/t [related to] left femur fracture and decreased mobility with an intervention dated 2/15/25 to Administer pain medication as ordered. Report s/s [signs/symptoms] negative side effects. Resident #61's current medical provider orders included an order dated 2/14/25 for Oxycodone HCL 10 mg by mouth every four (4) hours as needed for severe pain 7-10. A review of Resident #61's February 2025 and March 2025 Medication Administration Records (MARs) revealed the resident received Oxycodone for a pain intensity (PI) level below seven (7) on 17 separate occasions from 2/15/25 through 3/06/25. Oxycodone 10 mg was administered with a PI below seven (7) on: 2/15/25 12:30 PM for PI of 1 2/17/25 9:00 AM for PI of 4 2/17/25 4:00 PM for PI of 4 2/18/25 3:00 PM for PI of 1 2/21/25 9:00 AM for PI of 4 2/21/25 3:29 PM for PI of 4 2/21/25 8:34 PM for PI of 5 2/22/25 1:42 AM for PI of 5 2/22/25 10:00 AM for PI of 4 2/22/25 2:00 PM for PI of 4 2/23/25 1:00 PM for PI of 4 2/27/25 9:31 PM for PI of 5 2/28/25 1:48 AM for PI of 5 2/28/25 5:57 AM for PI of 5 3/01/25 12:00 PM for PI of 5 3/02/25 8:00 AM for PI of 4 3/02/25 12:00 PM for PI of 4 On 3/06/25 at 10:15 AM, surveyor spoke with the Administrator, Director of Nursing (DON), and Clinical Service Specialist and discussed the concern of staff administering Resident #61's Oxycodone outside of the ordered parameters. No further information regarding this concern was presented to the survey team prior to the exit conference on 3/06/25.

Based on observation, staff interview and facility document review, the facility staff failed to store food in accordance with professional standards for food service safety in one of 3 resident refrigerators. The findings included: On 3/6/25 at 8:26 AM this surveyor checked the resident refrigerator on one of 3 units. The thermometer read 40 degrees. This surveyor noted an 8-ounce carton of Very Vanilla Soy Silk beverage with an expiration date of 12/19/24. This surveyor took the beverage to the Registered Dietician (RD) who stated, This isn't something we provide. It probably belonged to a patient who has been discharged . This surveyor pointed out that there was no name on the carton. The RD did verify the date and that the item was expired. This surveyor asked if dietary or nursing would have been responsible to check the date and discard the drink, they stated, I am not here all the time, so I hesitate to say, I don't want to give you the wrong information. They stated they would get the correct information to the survey team. This surveyor did request the food storage policy. On 3/6/25 at 11:15 AM the RD brought the policy and stated, according to our policy, dietary is supposed to check dates and maintain the nutrition room refrigerators. They stated that they did verify that the beverage did belong to a resident who had been discharged and would not been served to anyone else. This surveyor reiterated that there was no resident name on the carton. The RD stated the drink was discarded. With no name on the carton, there was no way to ensure staff would not have offered the beverage to another resident if this surveyor had not brought it to their attention. The policy entitled Outside Food and Storage of Food Brought in by Family or Visitors with a reviewed/revised date of 1/22/24 read in part, 2. All food items that are already prepared by the family or visitor brought in must be labeled with the patient's name and dated. a. The center may refrigerate labeled and dated prepared items in the nourishment refrigerator. b. Perishable food must be consumed by the patient within 3 days. c. If not consumed within 3 days, food will be thrown away by center staff. On 3/7/25 at 3:00 PM the survey team met with the Administrator, Regional Social Worker, the Clinical Services Specialist and the Director of Nursing. The above concern was discussed with them at that time. No further information was provided to the survey team prior to the exit conference.

Based on interviews, clinical record review, and facility document review, the facility staff failed to provide medication in accordance with provider orders for 1 of 6 residents in the survey sample, Resident #3. The findings were: For Resident #3, the facility staff failed to administer the antibiotic as ordered by the provider. Resident #3's admission record listed diagnoses to include but not limited to, monoplegia of lower limb following cerebrovascular disease affecting right dominant side, type 2 diabetes mellitus with diabetic neuropathy, mood (affective) disorder, anxiety disorder, pneumonia, and urinary tract infection. An Admissions/Social Services Assistant's worksheet, provided by the administrator, assigned the resident a brief interview for mental status summary score of 15 out of 15. During a phone conversation with the facility ombudsman on 6/28/23 at 8:50 a.m., the ombudsman reported Resident #3 had not received antibiotics upon admission as ordered. Resident #3 was interviewed on 6/28/23 at 1:00 p.m. and said she had not received her antibiotic on the day she was admitted , nor had she received it for two more days. The clinical record included a provider's order for Augmentin Oral Tablet 500-125 mg (Amoxicillin and Pot Clavulanate), give 1 tablet by mouth every 12 hours for infection for 7 days with a start date of 06/24/23 at 21:00. The first dose on 06/24/23 at 21:00 was not administered. A licensed practical nurse's (LPN) progress note regarding that dose read, resident refused due to allergy to penicillin's [sic]. The next dose due, 06/25/23 at 09:00, was not administered with a different LPN's progress note which read, Awaiting arrival from pharmacy. The unit manager, a registered nurse (RN) documented a progress note on 06/25/23 at 16:40 that read, Resident verbalized she could take the Augmentin with her penicillin allergy. This was reported to pharmacy so they could send medication ordered. Pharmacy advised the nurse could pull from stat box one Augmentin 250-125mg and on [sic] Amoxicillin 250mg to equal prescribed dose. MD notified and gave order to pull one Augmentin 250-125mg capsule and one amoxicillin 250mg capsule to equal the prescribed dose of Augmentin 500-125mg until correct dose arrives from pharmacy. According to the medication administration record (MAR), the following two doses were given as ordered. The antibiotic order was updated to include the diagnosis of acquired pneumonia and extend the dates for administration to ensure the resident received all ordered doses. The 06/26/23 21:00 dose was not administered. The LPN's progress note read, medication not available from pharm or pull box. This LPN was not available for interview however the administrator, who was the facility's previous director of nursing, reported she had spoken to that LPN who was a new nurse and did not realize she could pull the two medications from the Cubex (medication dispenser machine) and combine them to equal the ordered medication. The administrator acknowledged this dose should have been given. The current DON had provided education to staff regarding pulling the medications from the Cubex. The administrator stated the first two doses Resident #3 did not receive was because the staff were awaiting clarification regarding the resident's penicillin allergy. The facility's Cubex medication list was reviewed with the administrator and DON. The list included AMOX TR-K CLV 250-125 MG TAB and AMOXICILLIN 250 MG CAPSULE. The administrator reported that these two medications given together would equal Resident #3's ordered antibiotic. The off-site pharmacy manager was interviewed via phone on 06/28/23 at 2:59 p.m. He acknowledged Resident #3's antibiotic order was going back and forth since 6/25/23 due to resident's allergies. The manager acknowledged the two medications available in the Cubex would be the same as the ordered antibiotic. The pharmacy manager and the facility's medical director had approved the medication and the extended time frame to ensure the resident received all ordered doses. This surveyor attempted to re-interview Resident #3 at approximately 3:30 p.m. however the administrator reported the resident had just been discharged home. The policy titled, Medication Administration. Policy 5.3 GENERAL GUIDELINES FOR MEDICATION ADMINISTRATION with an effective date of 06/21/2017 was reviewed and read in part, Procedure . 9. If a medication is unavailable, contact the pharmacy and document accordingly. The administrator denied having a policy or procedure for how to pull medications from their Cubex. No further information was provided before the exit conference.

Based on staff interview and clinical record review the facility staff failed to maintain a complete and accurate clinical record for 2 of 21 residents, Residents #104 and #255. 1. For Resident #104, the facility staff failed to obtain a physician order for a foley catheter. 2. For Resident #255, the facility staff failed to accurately complete a Durable Do Not Resuscitate (DDNR) order form. The findings included: 1. Section C (cognitive patterns) of Resident #104's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 05/19/22 included a brief interview for mental status summary score (BIMS) of 9 out of a possible 15 points. Section H (bladder and bowel) was coded to indicate the resident had a foley catheter in place. The clinical record included the diagnoses diabetes and chronic kidney disease. The residents comprehensive care plan included the focus area has an indwelling foley catheter in place. 06/01/22 1:10 p.m., the surveyor observed a foley catheter on the right side of the residents bed draining dark colored urine. During a review of the clinical record, the surveyor was unable to locate an order for the foley catheter. On 05/19/22 the nursing staff documented .foley cath intact and patent. Yellow urine noted . 06/01/22 1:11 p.m., Licensed Practical Nurse (LPN) #2 reviewed the clinical record and stated they were unable to locate order for the foley catheter. LPN #2 then stated the order was probably not put in when the resident had been readmitted (05/12/22). 06/01/22 1:15 p.m., the Director of Nursing (DON) was made aware that Resident #104 did not have an order for the foley catheter. 06/01/22, the facility staff transcribed an order for an indwelling catheter. The medical reason was documented as obstructive uropathy. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. There was no completed minimum data set (MDS) assessment on this resident. The clinical record included the diagnoses cerebrovascular disease and vascular dementia. The clinical record included an original DDNR order form from the Virginia Department of Health dated 05/13/22. Section 2 of this form had been left blank. Under section 1, the DDNR read in part, I further certify [must check 1 or 2]: 1. The patient is CAPABLE of making an informed decision . 2. The patient is INCAPABLE of making an informed decision . The box bedside of #2 had been marked. Section 2 read If you checked 2 above, check A, B, or C below: All three boxes (A, B, and C) had been left blank (unchecked). The residents clinical record included an order for comfort measures (06/01/22) and a do not resuscitate (DNR) order dated 05/18/22. 06/01/22 11:37 a.m., the Director of Nursing (DON) was made aware of the incomplete DNR. 06/01/22 4:35 p.m., the Administrator and DON were notified of the incomplete DNR. Prior to the exit conference, the DON provided the surveyor with an updated DNR form. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to ensure that residents receive treatment and care by not following physician's orders for 1 of 20 residents (Resident #74) in the survey sample as evidenced by the staff not administrating the physician ordered medications on dialysis days. The findings included: The facility staff failed to administer medications as ordered by the physician on dialysis days. Resident #74 was a resident in the facility at the time of this survey. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/8/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15/15. Resident #74 was also coded as requiring limited assistance of 1 staff member for dressing, personal hygiene and bathing. The resident had the following diagnoses of, but not limited to high blood pressure, end stage renal disease, diabetes, congested heart failure and high cholesterol. The surveyor conducted a review on 1/8/2020 of Resident #74's clinical record and noted the following physician orders for medications: Eliquis 2.5 mg (milligram) BID (twice a day) for blood clot prevention Hydralazine 10 mg 1 tablet every 12 hours for high blood pressure Metoprolol 50 mg BID for high blood pressure The surveyor also reviewed the MAR (medication administration record) for Resident #74. During such review, the surveyor noted the documentation of 3 which by the chart code 3 meant Absent from home. The code of 3 was noted on the December, 2019 and January, 2020 for the above documented physician ordered medications for the following dates and times: Metoprolol was not administered to the resident at 9 am on 12/4, 12/6, 12/9, 12/11, 12/13, 12/16, 12/18, 12/20, 1/6/2020 and 1/8/2020. Eliquis was not administrated to the resident at 9 am on 12/3, 12/6, 12/9, 12/11, 12/13, 12/16, 12/18, 12/20, 12/22, 12/24, 12/27, 1/6/2020 and 1/8/2020. Hydralazine was not administrated to the resident at 9 am on 12/4, 12/6, 12/9, 12/11, 12/13, 12/16, 12/18, 12/20, 1/6/2020 and 1/8/2020. The surveyor notified the DON (director of nursing) on 1/8/2020 at 1 pm of the above documented findings. DON stated, We will get this fixed. The surveyor notified the administrator, DON, and regional nurse of the above documented findings at 4:30 pm. On 1/8/2020 at approximately 11 am, the surveyor reviewed a physician order which read as follows: Omit AM (morning) medication when the resident is at dialysis every Monday, Wednesday and Friday. No further information was provided to the surveyor prior to the exit conference on 1/8/2020 at 1:15 pm.

Based on staff interview, clinical record review, and facility document review, the physician failed to act upon a pharmacy recommendation for the month of June 2019 for 1 of 23 residents, Resident #41. Resulting in this same recommendation being made by the consultant pharmacist in October 2019. This recommendation was completed in October 2019. The findings included: The physician failed to act upon a pharmacy recommendation. The consultant pharmacist had recommended an AIMS (Abnormal Involuntary Movement Scale) test be completed on June 10, 2019. This test was not completed until a second pharmacy recommendation was made on October 8, 2019. A review of the clinical record was completed on January 9, 2020. The electronic health record included, but was not limited to the following diagnoses, vascular dementia without behavioral disturbance, major depressive disorder, unspecified psychosis, and generalized anxiety disorder. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of November 18, 2019 included a BIMS (brief interview for mental status) summary score of 9 out of a possible 15 points. The clinical record included the following pharmacy consultant notes. Jun 10, 2019, Medications and chart reviewed + Buspar 7.5mg TID (three times a day), Seroquel 25mg HS (bedtime/hour of sleep), Depakote 125mg Q (every) 12 (hours) Recommendation for nursing-AIMS. October 8, 2019, Medications and chart reviewed Recommendation for nursing-AIMS. The surveyor was unable to find any pharmacy recommendations regarding these progress notes. On January 9, 2020 at 10:43 a.m., the administrator and DON (director of nursing) were made aware of the missing pharmacy recommendations. On January 9, 2020 at 11:26 a.m., the DON verbalized to the surveyor that the facility failed to complete the AIMS test for June and a second recommendation was made in October and an AIMS was completed on October 8, 2019. The DON also provided the surveyor with a copy of the recommendations made by the consulting pharmacist. For June 10, 2019 the pharmacist had wrote, This resident is currently receiving antipsychotic therapy with Seroquel 25mg HS and therefore requires an Abnormal Involuntary Movement Test (AIMS) at baseline and every 6 months while on antipsychotic therapy. I was unable to locate a recent AIMS test in the chart. Please complete an AIMS test now, and every 6 months while the resident remains on antipsychotic therapy. This same recommendation was made on October 8, 2019. Prior to the exit conference, the facility provided the surveyor with a copy of their policy/procedure titled MEDICATION REGIMEN REVIEW POLICY. This policy read in part, The pharmacist must report any irregularities to the Attending Physician, the facility's Medical Director and Director of Nursing, and these reports must be acted upon in a manner that meets the needs of the residents .If the Attending Physician declines or otherwise rejects the Consultant Pharmacist's recommendation, an explanation as to the rationale for the rejection shall be documented in the resident's medical record . No further information regarding this issue was provided to the survey team prior to the exit conference on January 9, 2020.

Based on observations and staff interviews the facility staff failed to ensure that the storage of all expired drugs and biologicals including expired laborary blood tubes in (one) of 3 (three) medication storage rooms (West Hall medication storage room) were disposed of from storage. The following findings were noted: 1. The facility staff failed to dispose of expired Aspirin suppositories and expired Promethazine suppositories. The facility's medication storage room on [NAME] Hall was observed by one surveyor along with facility staff on 01/07/2020 at 3:25 p.m. The medication refrigerator contained 10 (ten) 25mg Promethazine suppositories with an expiration date of 10/20/19 and 12 (twelve) 600mg Aspirin suppositories with an expiration date of 10/20/19. The facility's registered nurse (RN) working on [NAME] Hall acknowledged the suppositories were out of date and was unsure who was responsible for disposing of those expired medications. One of the facility's LPNs (licensed practical nurse) said the box the suppositories were kept in was referred to as the omnicell box (Omnicell is an automated medication supply system, omnicell box contained medications that required refrigeration) and therefore, the pharmacy staff was responsible for checking those medications. The LPN said the pharmacy staff was in the facility checking on the omnicell medications last week. The facility's director of nursing (DON) was informed of the above findings on 01/07/2020 at 4:14 p.m. The DON stated the suppositories were stock medications and were not for any specific resident and acknowledged that the pharmacy staff was supposed to check those medications, remove the expired medications and replace them. The DON was not sure why the pharmacy staff did not remove the expired suppositories. No further information was provided to the survey team prior to the exit conference. 2. The facility staff failed to remove expired laboratory blue top tubes (used for blood collection) from a supply cabinet. The facility's medication storage room on [NAME] Hall was observed by one surveyor along with facility staff on 01/07/2020 at 3:25 p.m. In an upper supply cabinet, an open pack of laboratory blue top tubes for blood collection were found with an expiration date of 12/31/19. One of the facility's RNs (registered nurses) acknowledged the blue top tubes were expired and removed them from the cabinet. The RN was not certain who was responsible for checking laboratory supplies for expiration dates. The facility's director of nursing (DON) was informed of the above findings on 01/07/2020 at 4:14 p.m. The DON stated there was no written policy that addressed who was responsible for checking expiration dates of laboratory tubes. The DON said it was everyone's responsibility to look for expired items but the facility's house supervisors were supposed to check for expired items/medications regularly. No further information was provided to the survey team prior to the exit conference.