Based on observations, interviews and record reviews, the facility failed to assure primary care provider orders were implemented for 3 of 5 sampled residents ( #3, #4 and #5) which included weekly weights (#3), weekly blood pressures (#4 and #5), and compression stockings (#4). The findings are: 1. Review of Resident #3's current FL-2 dated 06/18/18 revealed: -Diagnosis of dementia. -There was an order for weekly weights. Review of Resident #3's June 2018 Medication Administration Record (MAR) revealed: -There was a preprinted entry to check weights every Saturday. -There was a weight documented on 06/23/18 of 120 lbs. -There was no weight documented on the MAR for 06/30/18. -There were no refusals documented. Review of Resident #3's July 2018 MAR revealed: -There was a preprinted entry to check weights every Saturday. -There were no weights documented on the MAR. -There were no refusals documented. Review of Resident #3's August 2018 MAR revealed: -There was a preprinted entry to check weights every Saturday. -There was 1 weight documented on 08/04/18 of 117.5 lbs. -There were no weights documented on the MAR for 08/11/18, 08/18/18, and 08/28/18. -There were no refusals documented. Review of Resident #3's September 2018 MAR revealed: -There was a preprinted entry to check weights every Saturday. -There was a weight documented on 09/01/18 of 114 lbs. and on 09/15/18 of 124 lbs. -There were no weights documented on the MAR for 09/08/18, 09/22/18, and 09/29/18. -There were no refusals documented. Review of Resident #3's October 2018 MAR revealed: -There was a preprinted entry to check weights every Saturday. -There was a weight documented on 10/06/18 of 73.5 lbs. and on 10/20/18 of 73.5 lbs. -There were no weights documented on the MAR for 10/13/18 and 10/27/18. -There were no refusals documented. Review of Resident #3's November 2018 MAR revealed: -There was a preprinted entry to check weights every Saturday. -There were no weights documented on the MAR. -There were no refusals documented. Review of Resident #3's December 2018 MAR revealed: -There was a preprinted entry to check weights every Saturday. -There were no weights documented on the MAR. -There were no refusals documented. Review of Resident #3's January 2019 MAR revealed: -There was a preprinted entry to check weights every Saturday. -There were weights documented on 01/05/18, 01/12/18, and 01/19/18 of 85.5 lbs. for each date. Interview with the DRC on 01/22/19 at 5:45 pm revealed: -She had spoken with the staff on the SCU regarding Resident #3's weights in November 2018. -The weights were documented on Resident #3's MAR a few times, "then it fell off" (they were not done). Interview with third Personal Care Aide (PCA) on 01/18/19 at 9:56 am revealed: -She had been employed here at the facility since August 2018. -Residents were weighed monthly. Interview with Medication Aide (MA) on 01/18/19 at 11:11 am revealed: -The MA's were responsible to do weights and everyone helped. -She documented the weights on a piece of paper and "passed it on" to the Wellness Coordinator (WC) for the month of January 2019, but could not remember who she passed the documented weights to for prior months. -She was not sure what happened to the documented weights once she passed it on. Interview with WC on 01/18/19 at 3:25 pm revealed: -Weights were done monthly unless ordered more frequently by the doctor. -The MA would document weights on the MAR when weights were done more often than once a month. -The monthly weights were documented on the weight sheet or census sheet. -The weights were given to Director of Resident Care (DRC) when they were done. -She was not sure what happened to the weights after they were given to the DRC. -The MAs reported the weight to the DRC and/or WC. Interview with the DRC on 01/22/19 at 5:45pm revealed: -She had spoken with the staff on the SCU regarding Resident #3's weights after the pharmacy review dated 11/07/18. The weights were documented on Resident #3's MAR a few times, "then it fell off" (they did not weigh Resident #3). Telephone interview with the Clinical Director at Resident #3's Physician's office on 01/18/18 at 10:00 am revealed: -There are no weekly weights noted in Resident #3's office record. -There were no weight reports noted in Resident #3's office record. Interview with the Special Care Director (SCD) on 01/17/19 at 2:31pm revealed: -She was not sure who was responsible for checking resident weights. -The DRC would know. Interview with the DRC on 01/16/19 between 2:20pm revealed weights were documented in the weight book. Interview with the DRC on 01/22/19 at 11:50am revealed: -She was not aware the weekly weights for Resident #3 had not been documented on the MAR. -The staff on the SCU weighed residents every month by the 5th of the month. -The staff documented the weight on a resident roster and turned into the DRC. -Weekly weights would have been documented on the MAR. -Staff were expected to report any concerns regarding residents' weights directly to the SCD, the DRC or during the daily stand up meeting. Interview with the Executive Director on 01/18/19 at 4:06 pm revealed she did not have any further information to add to the DRC's interview. 2. Review of Resident #5's current FL-2 dated 07/12/18 revealed diagnoses included dementia, atrial fibrillation, knee pain, tachycardia, aortic stenosis, hypertension, osteoporosis and cardiac pacemaker. Review of a pharmacy consultation report for Resident #5 dated 11/07/19 revealed: -Resident #5 was ordered to receive furosemide (a diuretic), lisinopril (an antihypertensive), and metoprolol (an antihypertensive) for hypertension. -There was a recommendation to monitor Resident #5's blood pressure (BP) at least weekly or as advised by the physician. -There was an order to check Resident #5's BP weekly and document. -There was an order to notify the primary care provider (PCP) if the systolic BP was greater than 180 or less than 100 and if the diastolic BP was greater than 100 or less than 50. -The order was signed by the PCP and dated 11/08/18. Review of Resident #5's November 2018 medication administration record (MAR) revealed there was no entry for weekly BP checks and there were no BP results documented. Review of Resident #5's December 2018 MAR revealed: -There was a preprinted entry to check BP once weekly and notify the primary care provider (PCP) if the systolic BP was greater than 180 or less than 100 and if the diastolic BP was greater than 100 or less than 50. -There was a hand mark "D/C" (discontinue) written over the preprinted entry. -There were no BP results documented. Review of Resident #5's January 2019 MAR revealed there was no entry for weekly BP checks and there were no BP results documented. Interview with a personal care aide (PCA) on 01/17/19 at 1:58pm revealed the medication aides (MAs) did resident BP checks and documented results. Interview with a MA on 01/18/19 at 11:11am revealed: -She did not know anything about an order for weekly BP checks for Resident #5. -Normally if there was an order to check a BP, the MAs checked residents' BPs and documented the result on the MAR. Telephone interview with Resident #5's Power of Attorney (POA) on 01/17/19 at 11:06am revealed: -Resident #5 had history of palpitations and a pacemaker. -Resident #5's blood pressure fluctuated with palpitations, but there were no other blood pressure issues. Interview with Resident #5's Physician's Assistant (PA) on 01/17/19 at 11:45am revealed: -She thought she might have seen some BP results on the MAR for Resident #5. -The staff did not give a reason for why Resident #5's BP had not been checked weekly as ordered, but it was possible that the resident had refused. -She had not been notified by staff of Resident #5 refusing BP checks between November 2018 and January 2019. -She had ordered the weekly BP checks because Resident #5 was on multiple BP medications. -The BP checks were so a trend could monitored for any needed medication adjustments; she did not want to adjust BP medications based on one result. -Resident #5's BP had been stable "as of lately" when she checked the resident's BP during the PA's visits at the facility. Interview with the Special Care Director (SCD) on 01/17/19 at 2:31pm revealed: -She was not sure who was responsible for checking resident BPs. -The Director of Resident Care (DRC) would know. Interview with the DRC on 01/16/19 at 2:20pm revealed BPs were done by the MAs and documented on the MAR. Interview with the Wellness Coordinator on 01/18/19 at 3:25pm revealed: -Vital signs including BPs were done as ordered on the MAR. -The MA was responsible for checking BPs and documenting the result on the MAR. -If there were written parameters to notify the doctor then the MA would notify the doctor and document in the resident service notes by the end of their shift. Based on observations, interviews and record reviews, it was determined Resident #5 was not interviewable. 3. Review of Resident #4's current FL-2 dated 12/10/18 revealed: -Diagnoses included gastrointestinal bleed, atrial fibrillation, coronary artery disease, bradycardia, chronic combined systolic and diastolic congestive heart failure, acute kidney injury, anemia, and Alzheimer's dementia. -The resident was intermittently disoriented. -The resident required assistance with bathing and dressing. Review of Resident #4's assessment and care plan dated 05/21/18 revealed: -The resident was oriented and his memory was adequate. -The resident was ambulatory with use of a "walking stick". -The resident was independent with eating, toileting, ambulation, bathing, dressing, grooming, and transferring. a. Review of Resident #4's physician order dated 05/21/18 revealed an order for compression stockings to be put on in the morning and removed at bedtime. Review of Resident #4's measure form for compression stockings dated 5/31/18 revealed the resident was measured for knee high compression stockings. Review of Resident #4's resident service notes revealed: -On 05/02/18, the resident complained about his legs being swollen. -On 10/02/18, the resident's feet were still swollen where he could not put on his compression stockings. -On 10/08/18, the resident's swelling in his feet had gone down but the left foot still had some swelling. -On 10/15/18, the resident has gotten his compression stockings on today. -On 12/05/18, the resident's left leg was swollen and red and he complained of itching. The primary care provider (PCP) was notified. -On 12/06/18, the resident was seen by the PCP for red, swollen legs. Observations of Resident #4 revealed: -The resident was not wearing compression stockings on 01/15/19 at 10:20am, 01/17/19 at 6:05pm, 01/18/19 at 3:50pm, and 01/22/19 at 11:14am. -Both of the resident's lower extremities were swollen during each observation. -The left ankle was always swollen more than the right ankle. Interview with Resident #4 on 01/17/19 at 6:05pm and 01/22/19 at 11:14am revealed: -He had worn compression stockings but he stopped wearing them about 3 to 4 weeks ago. -He was not wearing compression stockings because he did not know where the stockings were located. -His compression stockings were white but he had not seen them "in a while". -He would wear the compression stockings if he could find them. -His legs were swollen so badly "about 3 months ago" that the compression stockings would not fit. -No one offered to get a bigger pair of compression stockings during that time. -Staff did not offer to help the resident put on the compression stockings. -Staff did not usually check to see if he was wearing his compression stockings except about once a week someone would ask him but that stopped too. -One staff asked the resident a couple of days ago if he was wearing the compression stocking and he told her no. -The compression stockings helped "a little bit" with the swelling in his legs. -The swelling in his legs were not improving much. Review of Resident #4's June 2018 MAR revealed: -There was a computer printed entry to apply compression stockings every morning and remove at bedtime. -The compression stockings were scheduled to be applied at 9:00am and removed at 9:00pm. -Compression stockings were not documented as applied on 5 days including 06/01/18, 06/02/18, 06/04/18, 06/05/18, and 06/25/18 with no reasons noted. Review of Resident #4's July 2018 MAR revealed: -There was a computer printed entry to apply compression stockings every morning and remove at bedtime. -The compression stockings were scheduled to be applied at 9:00am and removed at 9:00pm. -Compression stockings were not documented as applied on 07/24/18 and not documented as removed on 07/17/18 with no reasons noted. Review of Resident #4's August 2018 MAR revealed: -There was a computer printed entry to apply compression stockings every morning and remove at bedtime. -The compression stockings were scheduled to be applied at 9:00am and removed at 9:00pm. -Compression stockings were not documented as removed on 08/29/18 with no reason noted. Review of Resident #4's September 2018 MAR revealed: -There was a computer printed entry to apply compression stockings every morning and remove at bedtime. -The compression stockings were scheduled to be applied at 9:00am and removed at 9:00pm. -Compression stockings were documented as applied from 09/01/18 - 09/13/18. -The resident was in the hospital from 09/13/18 - 09/19/18. -Documentation for compression stockings was blank from 09/20/18 - 09/24/18 with no reasons noted. -There was a handwritten entry for compression stockings on at 9:00am and remove at 9:00pm that was dated 09/24/18. -Staff initials were circled for the application of compression stockings at 9:00am from 09/25/18 - 09/27/18 and 09/29/18 - 09/30/18 with no reasons noted. -Staff initials were circled for the removal of compression stockings at 9:00pm from 09/25/18 - 09/27/18. -Staff documented the compression stockings were removed on 09/29/18 and 09/30/18 but they were not documented as applied on those two days. Review of Resident #4's October 2018 MAR revealed: -There was a computer printed entry to apply compression stockings every morning and remove at bedtime. -The compression stockings were scheduled to be applied at 9:00am and removed at 9:00pm. -Compression stockings were not documented as applied on 5 days from 10/02/18 - 10/06/18 with no reasons noted. -Compression stockings were not documented as removed on 6 days including 10/02/18, 10/03/18 and 10/05/18 - 10/08/18. -Compression stockings were documented as removed on 10/04/18 but not documented as applied on that day. -Compression stockings were documented as applied on 10/08/18 but not documented as removed that night. Review of Resident #4's November 2018 MAR revealed: -There was a computer printed entry to apply compression stockings every morning and remove at bedtime. -The compression stockings were scheduled to be applied at 9:00am and removed at 9:00pm. -Compression stockings were documented as applied and removed daily from 11/01/18 - 11/30/18. Review of Resident #4's December 2018 MAR revealed: -There was a computer printed entry to apply compression stockings every morning and remove at bedtime. -The compression stockings were scheduled to be applied at 9:00am and removed at 9:00pm. -Compression stockings were documented as applied and removed daily from 12/01/18 - 12/04/18. -Compression stockings were not documented as applied or removed on 12/05/18 with no reason noted. -Compression stockings were documented as applied on 12/06/18. -The resident was in the hospital from the evening of 12/06/18 - 12/10/18. -Documentation for application and removal of the compression stockings was blank from 12/11/18 - 12/31/18 with no reasons noted. Review of Resident #4's January 2019 MAR revealed: -There was a computer printed entry to apply compression stockings every morning and remove at bedtime. -The compression stockings were scheduled to be applied at 9:00am and removed at 9:00pm. -Compression stockings were documented as applied at 9:00am from 01/01/19 - 01/22/19. -Compression stockings were documented as removed at 9:00pm from 01/01/19 - 01/20/19 except it was blank on 01/03/19. -Compression stockings were documented as applied on 01/18/19 and 01/21/19 but not documented as removed on those two days due to the stockings were "not on". Interview with a medication aide (MA) on 01/18/19 at 4:15pm revealed: -Resident #4 had white compression stocking and he kept them in his room. -She usually worked second shift and Resident #4 did not usually have his compression stockings on when she would check to remove them at night. -The resident could remove the compression stockings himself so she thought the resident removed them at night and she would document them as removed on the MAR. -She did not realize the resident was not wearing the compression stockings. -She last saw the resident's compression stockings "about a week ago" in his room hanging on his walker. -The resident's legs had been swollen for "a couple of months" and the left lower leg was usually swollen more than his right leg. Interview with a medication aide (MA) on 01/22/19 at 11:32am revealed: -Resident #4 usually put the compression stockings on himself. -If he had any difficulty getting them on, he could use his call bell and get staff. -She thought Resident #4 was wearing his compression stockings this morning (01/22/19) since she documented they were on the MAR. -She could not recall for sure if they were on and she did not remember the color of his compression stockings but she thought they were beige. She usually tried to visually check to see if the resident was wearing the compression stockings on the mornings she worked. -She could not explain why she would document the resident's compression stockings were on when she did not always physically check to see if they were on. -She could not recall the last time she saw Resident #4 wearing the compression stockings. -Resident #4's lower legs were always swollen but some days they were swollen more than other days. -The resident's left leg was always swollen more than the right leg. -Second shift staff were supposed to remove the compression stockings. -Resident #4 would sometimes take off his compression stockings before he was supposed to. -The resident's compression stockings were supposed to be kept in his room. -She would check his room for the compression stockings. Observation on 01/22/19 at 11:55am revealed: -The MA checked Resident #4's bedroom and living room for his compression stockings. -She could not find the compression stockings. Interview with Resident #4's primary care provider (PCP) on 01/17/19 at 12:35pm revealed: -Resident #4 had swelling in both lower extremities. -The resident had an order to wear compression stockings and that order had not been discontinued. -The resident should wear the compression stockings every day. Interview with the Director of Resident Care (DRC) on 01/22/19 at 12:45pm revealed: -She had seen Resident #4 wear his compression stockings. -She thought the last time she observed the resident wearing his compression stockings was one day last week. -The resident would sometimes take the compression stockings off himself. -The MAs were supposed to physically check and make sure the resident was wearing the compression stockings prior to documenting on the MAR. -If the resident was not wearing the compression stockings, the MAs should notify her and the PCP. A second interview with the DRC on 01/22/19 at 6:20pm revealed: -They had ordered a new pair of compression stockings for Resident #4. -The new compression stockings would be delivered by the pharmacy later tonight. b. Review of Resident #4's physician order dated 10/04/18 revealed an order to check blood pressure weekly, notify PCP if systolic blood pressure (SBP) is greater than (>) 170 or less than (<) 100, diastolic blood pressure (DBP) > 100 or <50. Review of Resident #4's October 2018 medication administration record (MAR) revealed: -There was a handwritten entry to check blood pressure once weekly, notify physician if SBP >170 or <100, DBP >100 or <50. -The blood pressure was scheduled to be taken on 3pm to 11am shift once a week. -The blood pressure scheduled to be checked on 10/19/18 was blank with no reason documented. -The blood pressure was taken 3 out 4 weeks and ranged from 126/72 - 130/70. -The resident was receiving 3 medications that lowered blood pressure including Furosemide, Metoprolol, and Hyzaar. Review of Resident #4's November 2018 MAR revealed: -There was a computer printed entry to check blood pressure once weekly, notify physician if SBP >170 or <100, DBP >100 or <50. -There was no time scheduled and no dates marked to check the blood pressure. -There were no blood pressures documented for November 2018. -The resident was receiving 3 medications that lowered blood pressure including Furosemide, Metoprolol, and Hyzaar. Review of Resident #4's December 2018 MAR revealed: -There was a computer printed entry to check blood pressure once weekly, notify physician if SBP >170 or <100, DBP >100 or <50. -The blood pressure was scheduled to be taken on 3pm to 11am shift once a week. -The blood pressure scheduled to be checked on 12/07/18 was not done due to the resident being in the hospital from 12/06/18 - 12/10/18. -The blood pressures scheduled to be checked on 12/14/18, 12/21/18, and 12/28/18 were blank with no reason documented. -The resident was receiving 3 medications that lowered blood pressure including Furosemide, Metoprolol, and Hyzaar. Review of Resident #4's January 2019 MAR revealed: -There was a computer printed entry to check blood pressure once weekly, notify physician if SBP >170 or <100, DBP >100 or <50. -There was no time scheduled and no blood pressure was documented for January 2019. -There was a handwritten note, "D/C" (discontinue), but no initials or date documented. -The resident was receiving 2 medications that lowered blood pressure including Furosemide and Hyzaar. Interview with Resident #4's primary care provider (PCP) on 01/17/19 at 12:35pm revealed: -Resident #4's blood pressure was supposed to be checked weekly. -She was not aware the resident's blood pressure was not being checked as ordered. -No one had contacted her about the resident's blood pressure order. -The resident's blood pressure had been stable during his visits with her. Interview with Resident #4 on 01/18/19 at 3:50pm revealed he could not recall when staff last checked his blood pressure. Interview with a medication aide (MA) on 01/18/19 at 4:15pm revealed: -She had not checked Resident #4's blood pressure this month because it was noted as discontinued on the MAR. -For the previous months, if the resident's blood pressure was checked it would be documented on the MAR. -She did not know why the resident's blood pressure had not been checked as ordered. Interview with the Director of Resident Care (DRC) on 01/22/19 at 12:45pm revealed: -Resident #4's weekly blood pressures should have been done and documented on the MARs. -There was no order to discontinue the blood pressure checks.

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