Every finding on record at August Healthcare at Richmond

Based on observation, resident interview, family interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to address and implement interventions for significant weight loss for one Resident (Resident #20) in a survey sample of 16 residents, which constituted harm.The findings included:Resident #20 was admitted on [DATE]. The Resident's diagnoses included but were not limited to: Parkinsons's Disease, dementia, anemia, Stroke, Gastro-esophageal Reflux Disease (GERD), dysphagia, and esophageal obstruction.The most recent MDS (Minimum Data Set federal assessment) was completed as a quarterly assessment with an Assessment Reference Date (ARD) of 12-29-25. The assessment described the Resident with a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating mild cognitive impairment. The Resident required assistance from staff with eating to include supervision and touch assistance. The document recorded no rejections of care, no behaviors, and no problems with swallowing. The Resident was coded as weighing 150 pounds with no weight loss. All weights were conducted by wheelchair. The Resident was wheelchair bound.On 2-18-26 Resident #20 was observed during lunch and noted to not be eating. Staff encouraged her and fed her 3 spoonfuls of the meal and then departed to assist others. The Resident did not feed herself. On 2-19-26 the Resident was observed during lunch again and consumed a few spoonfuls with a very shaky hand, finally giving up and not eating. Staff were asked at that time what the Resident ate for breakfast and they replied, very little, just like lunch.On 2-18-26 a group council interview was held with Resident #20 in attendance. The Residents all stated that she needed help to eat, and sometimes there were no staff to help her which occurred most often on weekends and holidays.On 2-19-26 a family interview was held with a Resident present and the family member stated that feeding was an issue and that staff are too busy to just feed one person, the family further stated, they don't have enough staff to really take time with anyone.Weights were being completed monthly and documented in the clinical record. The weights follow below in a pattern of weight loss for 1 year.March 5, 2025, the weight recorded was 160.0 pounds.April 2, 2025, the weight recorded was 150.8 pounds. A loss of greater than 5 % in 1 month. May 6, 2025- 150.2 pounds, June 4, 2025- 152.6 pounds, July 2, 2025- 150.8 pounds, August 5, 2025- 152.8 pounds, September 30, 2025- 151 pounds, October 1, 2025- 149.8 pounds, November 5, 2025- 146.2 pounds, December 3, 2025- 149.8 pounds, January 1, 2026- 149.0 pounds, February 4, 2026- 139.4 pounds, which indicated a 10-pound weight loss in one month equaling a greater than 7.5% weight loss in one month.Physician's orders were reviewed and included no supplements nor orders for weight maintenance were implemented following the significant weight loss. According to the physician orders, Resident #20's diet order which was effective 10/27/25, read, Regular diet, mechanical soft texture, thin consistency. The Resident's care plan was reviewed and revealed that the Resident had a diagnosis of GERD (gastroesophageal reflux disease) and received medication to lessen symptoms. The care plan goal read, will maintain adequate nutritional status as evidenced by maintaining weight within 3% of 150 [pounds], no s/sx [signs or symptoms] of malnutrition, and consuming at least 75% of at least two mals daily through review date. Interventions included, but were not limited to: monitor for swallowing problems, pocketing, drooling, refusing to eat, or dysphagia. The interventions also listed monitoring for weight loss of 3 pounds in 1 week, greater than 5% in one month or greater than 7.5% in 3 months, should this issue arise as it would underscore a worsening condition. The focus of Nutritional Problem listed the Resident as overweight per BMI, revised on 12-29-25. The care plan also instructed for the RD (Registered Dietician) to evaluate and make diet change recommendations as needed. During the Resident's stay a continued decrease in weight, indicated a worsening condition. There is no indication that the doctor was ever notified of this. The RD placed a note in the clinical record every 3 months for the MDS and care plan assessment requirements during the past year. The notes were dated 3/29/25,6/21/25, 9/30/25, and 12/29/25. Each of the progress note entries by the RD noted, . Weight review without significant change . except one note dated 4/27/25, that noted the resisdent showing a weight change this month ., which listed no interventions to prevent further weight loss, and noted to continue with plan of care. The most recent and last RD note was on 12-29-25, documented by the RD which stated that the Resident remained overweight by BMI. There is no indication that she was ever made aware of the significant weight loss found again on 2-4-26, and the documentation pattern revealed that she would not know until the next assessment requirement for March 2026, as staff did not identify it and did not notify her.Attempts were made by telephone to reach the RD for interview, however, were unsuccessful.On 2-18-26 at 4:00 p.m., at the end of day debriefing held with the Director of Nursing (DON), and Administrator both were informed of the facility staff's failure to provide adequate nutrition for this dependent Resident. Both stated they would provide RD notes.On 2-19-26 at 2:00 p.m., at the end of day debriefing held with the Director of Nursing (DON), and Administrator the above findings were reviewed. The facility administration both stated they had nothing further to provide.

Based on resident interviews, family interviews, staff interviews, clinical record review, and review of facility documents, the facility staff failed to allow for a neutral binding arbitration process. The findings included: On 2-18-26 at 1:20 PM an interview was conducted with the Administrator who stated that the admissions Director had all admissions documented signed, and that they did as a company have Arbitration in the contract for admissions. A copy was requested and supplied.The facility Binding Arbitration Agreement was reviewed, and the review revealed the following.The facility had chosen the arbitrator group and chose the location (as would coincide with this chosen entity). That declaration was applied to the admission contract for signature agreement which was binding to the Resident and their Representative. This Binding Arbitration Agreement document, which was embedded in the admission contract, also included fees with the percentage payment outlined for both parties to pay in the event of arbitration. The Administrator stated all Residents admitted to the facility would be affected as the Arbitration agreement was located in the admission contract.On 2-18-26 several interviews with cognitively intact Residents and family members were conducted by several surveyors. None agreed to have been aware of Binding Arbitration Agreements removing their rights to a court decision in cases of legal disputes with the facility. When asked if they understood and agreed that by entering into this arbitration agreement, they were giving up and waiving their constitutional right to have claims decided in a court of law before a judge and jury, they all answered No.On 2-19-26 at approximately 2:20 p.m., a final interview was conducted with the [NAME] President of Operations, and it was explained that the Arbitrator could not be prechosen by the facility, and fees could not be delegated as the Virginia Bar Association will provide Arbitrators free of charge. He was asked if they had any further information to present, and he stated no.

Based on observation, staff interviews, clinical record review and facility document review, the facility staff failed to ensure Resident #5 was free from unnecessary medications, an anti-psychotic medication, for 1 of 12 residents in the survey sample (Resident #5).Findings include:Resident #5 was admitted to the facility on [DATE] with diagnoses to include but not limited to: urinary tract infection with toxic encephalopathy, hypertension, major depressive disorder, anxiety disorder, anemia, pain in left hip, dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and Parkinson's disease with dyskinesia. Resident #5's most recent MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 1/5/26 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 7 out of a possible 15 indicating severe cognitive impairment (severe problems with thinking).A review of the clinical record revealed that Resident #5 was admitted to the facility from the hospital on [DATE] with an order for Quetiapine/Seroquel 25 mg (milligram) tablet, give one half tablet by mouth every morning and one and one half tablets every evening for anxiety (Seroquel is an antipsychotic medication used to treat several kinds of mental health conditions including schizophrenia and bipolar disorder). On 12/31/25, the Nurse Practitioner gave orders to wean Resident #5 off Seroquel, starting with order to decrease Seroquel to 25mg by mouth every night for anxiety and for an evaluation by the Psych Nurse Practitioner. A review of a nurse progress note dated 1/6/2026 read, NP (nurse practitioner) gave orders to d/c (discontinue) Seroquel, RP (Responsible Party) updated. Resident #5 is her own Responsible Party.Review of Resident #5's physician orders and the Medication Administration Records from 12/31/25 through 4:05 PM on 2/19/26, revealed an order for: Quetiapine Fumarate (generic for Seroquel) tablet 25 mg, give 1 tablet by mouth at bedtime for Anxiety. The order was not discontinued as indicated in the nurse progress note dated 1/6/26. On 1/7/2026, a Multidisciplinary Care Conference was held with Resident #5 and a family member where they expressed desire for her to be seen by psych services. No review of Resident #5's order for quetiapine/Seroquel by the interdisciplinary team. On 1/24/26, Resident #5 was seen and evaluated by the Psych Nurse Practitioner with a new order to increase Sertraline 50 mg every day to 75 mg every day (Sertraline is a prescription anti-depressant used to treat depression, panic disorders, post-traumatic stress disorders, obsession compulsive disorders, social anxiety, and pre-menstrual dysphoric disorders).On 2/3/26, Resident #5 was seen by her attending physician for a 30-day recertification Resident was seen and examined. All her medications, labs and medical record were reviewed. Resident is pleasantly confused at base line, but she has been sleeping well at night. Resident #5 receives sertraline 75 mg once daily with quetiapine 25 mg at bedtime for MDD with mood disorder (major depressive disorder). There is no history of tearful moments, suicidal ideations, visual or auditory hallucinations.A review of clinical record revealed several progress notes by the nurse practitioner and the physician which read in part, Psychiatric: Resident is pleasant without any confusion, agitation or signs of depression or anxietyA review of ADL records (Activity of Daily Living documentation by the certified nursing assistants) for January and February 2026 revealed section entitled Behavior Monitoring & Interventions was coded as NB meaning no behaviors observed.On 2/19/26 an interview was conducted with LPN #1 regarding whether Resident #5 exhibited any signs of agitation, aggression, nervousness, tearfulness, or anxiety as she had an order for quetiapine 25 mg by mouth every night and she responded, No, I have not seen Mrs. (name redacted) exhibiting any behaviors, she is usually very quiet and pleasant. On 2/19/26, an interview was conducted with C.N.A #1, regarding whether Resident #5 had exhibited any signs of agitation, aggression, nervousness, tearfulness, or anxiety and she responded, Oh, no, I don't have any problems with her, she is easy to work with, no behaviors, very quiet, sweet lady''.On 2/19/26 at 9:45 AM, an interview was conducted with the DON (Director of Nursing) regarding her expectations of when an antipsychotic medication would be warranted for a resident and management of antipsychotic medications. According to the DON, an antipsychotic would be appropriate to treat a psychiatric diagnosis or when the nurse practitioner or physician justifies a diagnosis to treat other symptoms. We manage antipsychotic medications by monitoring the behaviors and for any side effects and attempt GDR's (gradual dose reduction) as appropriate. On 2/19/26 at 2:30 PM, an interview was conducted with the DON (Director of Nursing) regarding the two pharmacy progress notes for MRR complete, see consultant pharmacist report for physician recommendations (medication regimen review by the consultant pharmacist), dated 1/22/26 and 2/14/26.Unable to locate the consultant pharmacist reports for physician recommendations in the electronic medical record. According to the DON, the consultant pharmacist recommendations for 1/22/26 had been followed up on and should have been scanned into the clinical record, however the 2/14/26 had not been returned to her from the nurse practitioner. The DON provided a copy of the recommendation dated 1/22/26 which revealed: This resident is currently receiving psychotropic medications with required Behavior Monitoring and Adverse effect tracking orders per shift for quetiapine 25 mg by mouth for anxiety. Nursing Recommendation: Please add behavior monitoring for all anti-psychotics, antidepressants, anxiolytics, hypnotics including melatonin to ensure that behaviors being treated are being helped and adverse effects are also being tracked. Please note that any medication used as a psychotropic, including antihistamines or seizure medications must be tracked for behaviors and adverse effects which will facilitate more appropriate GDR (gradual dose reduction) attempts. Please add AIMS (Abnormal Involuntary Movement Scale) monitoring baseline and every three months, unless already ordered for this resident. Report any significant changes to the prescriber as soon as possible.Resident#5 had an AIMS completed on 12/30/25 with score of 0, no abnormal movement noted.Unable to locate Behavior Monitoring and Adverse Effect Tracking on the Medication Administration Record for use of the antipsychotic medication. On 2/19/26 at 3:20 PM, during the end of the day meeting with the Administrator, Director of Nursing, and Regional Director of Operations, Resident #5's order for quetiapine/Seroquel with diagnosis of anxiety was reviewed as an unnecessary medication, and an opportunity was offered to the facility staff to present additional information. At 4:05 PM, the DON presented a copy of the 2/14/26 consultant pharmacist recommendation signed by the Nurse Practitioner to discontinue the quetiapine/Seroquel and a copy of the Nurse Practitioner's visit summary which read in part: 2/19/26 Nurse Practitioner - The resident is also being monitored for a history of generalized anxiety disorder. She was admitted from the hospital with a prescription for quetiapine (Seroquel) 25 mg orally daily. Since admission, she has demonstrated no behavioral disturbances, no agitation, no mood instability, and no observable or reported symptoms consistent with active generalized anxiety disorder. She has remained calm, cooperative, and psychiatrically stable without evidence of increased anxiety, insomnia, restlessness, or emotional distress. Given the absence of current symptoms and considering the well-documented risks associated with antipsychotic use in elderly patients, including increased risk of sedation, orthostatic hypotension, falls, metabolic effects, and black box warnings regarding mortality in older adults, it is clinically appropriate to discontinue Seroquel at this time. The potential risks of continued antipsychotic therapy outweigh any benefit in the absence of active psychiatric symptoms.Recommendation is to discontinue Seroquel 25 mg orally daily and continue to monitor closely for any recurrence of anxiety symptoms or behavioral changes. Nursing staff should observe for and report any changes in mood, behavior, sleep pattern, or functional status. The resident remains stable, and ongoing monitoring will continue to ensure safety and appropriate management.A review of the facility's policy Antipsychotic Medication Use, Paragraph entitled, Policy Interpretation and Implementation which reads in part. 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 5. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indication for use. The interdisciplinary team will: a. Complete a PASRR screening preadmission screening for mentally ill and intellectually disabled individuals), if appropriate; or b. Re-evaluate the use of antipsychotic medication at the time of admission and periodically to consider whether the medication can be reduced, tapered, or discontinued.c. Based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing antipsychotic medication.7. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with definition(s)in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): a. Schizophrenia; b. Schizo-affective disorder; c. Schizophreniform disorder; d. Delusional disorder; e. Mood disorders (e.g. bipolar disorder, depression with psychotic features, and treatment refractory major depression); f. Psychosis in the absence of dementia; g. Medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania (e.g., high-dose steroids); h. Tourette's disorder; i. Huntington disease; j. Hiccups (not induced by other medications); or k. Nausea and vomiting associated with cancer or chemotherapy.8. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others; and (1) The symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); (2) Behavioral interventions have been attempted and included in the plan of care, except in an emergency.On 2/19/26 at 4:20 PM, an exit conference was held with the Administrator, Director of Nursing, Regional Director of Operations and Regional [NAME] President of Clinical Services. No further information was provided.

Based on observation, resident interview, family interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain an available call bell system for one Resident (Resident #14) in a sample of 16 residents as a means to call for assistance from the bedside where the call would go directly to a staff member or central location with no alternate means to call for assistance. The findings included;Resident #14 was most recently readmitted to the facility on [DATE]. The Resident's diagnoses included; Diabetes, chronic inflammatory demyelinating poly neuritis, disc degeneration, malnutrition, dementia, impaired cognitive function, and impaired mobility.The most recent MDS (Minimum Data Set federal assessment) was most recently completed as a quarterly assessment with an Assessment Reference Date (ARD) of 1-5-26. The assessment described the Resident with a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating mild cognitive impairment. The Resident required assistance from staff with eating to include foam handle utensils and staff feeding at times. The Resident was dependent on staff for self-care and hygiene and had contractures, a urinary catheter, and pressure wounds. The Resident had recently on 2-3-26 been ordered for hospice care. The document recorded no rejections of care, and no behaviors. The Resident was mostly bed bound.On 2-17-26 during initial tour of the facility surveyors found no call bell device in the room for Resident #14.On 2-18-26 A second surveyor found no call bell device in the room for Resident #14. A staff member was in the hallway just outside of the Resident's room and was asked why the Resident had no call bell device. The staff member stated, her hands are so contracted she can't use it. The staff member was asked how they know if the Resident needs help, and she stated, we round on her more often.On 2-19-26 The Resident was again visited, and her son was visiting and sitting in a chair at the bedside. He was asked if she could use the call device around her neck, and he stated, no way. The Resident was now wearing a clearly seen call bell device the size of a quarter coin around her neck on a short lanyard that reached only her upper sternum like a necklace. The Resident was asked to push the button on the call device around her neck. The Director of Nursing (DON) approached the room and stated, she can use the call device. The Resident was noted to have a washcloth rolled up in both of her contracted hands to protect her palms from the pressure of her fingers pressing into them. The Resident shook her head and said What?. The instructions were given again, and she looked down but seemingly could not see the device. The DON was told at that time that the Resident could not access the device, and an alternative would be needed such as a large pancake device which is an example of widely used devices in the industry for those with dexterity issues. Those devices can be struck with a fist or back of hand to summon help and are easily seen and identified by residents with mobility issues. The Resident's care plan was reviewed and interventions for contracture to the left hand were denoted as a focus with a hand splint ordered for 4-6 hours per day as tolerated, however, nothing was included for the right hand which was also found to be contracted.On 2-19-26 at 3:00 PM, a facility corporate officer came to surveyors and stated the facility is process of getting a more accessible call bell device for Resident #14.Review of 3 months of the resident council minutes did not reveal concerns of this type, nor did the Resident council meeting during survey reveal issues of this type.On 2-19-26 at 3:35 PM, the facility DON and Administrator were notified of the above findings, and they stated they had nothing further to provide.

Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to implement interventions, care and services to prevent the development of a pressure ulcer for one resident in a survey sample of five residents (Resident #1), which resulted in harm for Resident #1. The findings included:For Resident #1, who was identified to be at risk for pressure ulcer development, the facility staff failed to provide interventions to prevent the development of (2) two pressure-related injuries which were at an advanced stage at the time of discovery, which constituted harm.Resident #1 was originally admitted to the facility on [DATE]. On 11/8/2025, Resident #1 was re-admitted to the facility after hospitalization for a clotted arteriovenous (AV) fistula (linking a vein to an artery for medical use) following a dialysis session (medical treatment that cleans the blood by removing waste, toxins and extra fluid when one's kidneys cannot do the job) and a urinary tract infection. Resident #1 was re-admitted with diagnoses including but not limited to end stage renal disease on hemodialysis, dementia, legally blind with cataracts, hypertension, congestive heart failure, type 2 diabetes and history of a sacral ulcer stage II. Resident #1 was incontinent of bowel and bladder and wore incontinence products.Resident #1's most recent MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 10/9/25 coded the resident in Section M: Skin Conditions, as having no open wounds and was at risk for development of wounds. Review of the Nursing admission assessment dated [DATE] indicated that Resident #1's skin was intact. A review of the most recent Weekly Skin Reviews dated 8/1/25 noted skin intact and 11/20/25 revealed pressure sore on buttocks and right heel DTI (deep tissue injury), treatment in place. No Weekly Skin Reviews were found between 8/1/25 and 11/20/25. A review of the Wound Care Nurse Practitioner's assessment 11/20/25 revealed two newly acquired pressure-related injuries. An unstageable pressure injury (meaning the depth of the wound cannot be measured) to the sacrum measuring 3 x 3 x 0.3 cm with a calculated area of 9 sq cm with a wound bed of 100% slough (wet, yellow/white stringy tissue in a wound) and a pressure-induced deep tissue injury to the right heel measuring 2.5 cm x 2.5 cm x 0 cm with a calculated area of 6.25 sq cm.On 12/30/25 at 11:10AM, an interview was conducted with the facility's Wound Care Nurse (LPN#3) who stated that Resident #1's pressure injury to her sacrum and the Deep Tissue Injury to her right heel was identified during a facility skin sweep. When asked why a facility skin sweep was done, LPN#3 stated they had identified that the weekly skin reviews were not being done weekly per the facility policy. When asked if the facility conducted skin risk assessments, LPN#3 replied, Yes, we do the Braden Assessment upon admission and then weekly for (4) four weeks and if or when a resident should develop any new areas. When asked what the Braden Assessment was used for, LPN#3 stated To identify any risk factors such as moisture or poor nutrition and then putting interventions in place to address those areas to help the resident from developing a pressure wound. When asked who updates the care plans, LPN#3 stated, The Director of Nursing or the MDS (Minimum Data Set) Nurse.A review of Resident #1's Braden Scale for Predicting Pressure Sore Risk dated 11/8/25 upon re-admission revealed a Braden Score of 17 which indicates the resident is at risk for developing a pressure injury: Resident #1's Braden scale included findings of:1. Sensory perception - Ability to respond meaningfully to pressure-related discomfort - coded as 4. No impairment2. Moisture - Degree to which skin is exposed to moisture - coded as 3. Occasionally moist3. Activity - Degree of physical activity - coded as 2. Chairfast4. Mobility - Ability to change and control body position - coded as 3. Slightly limited5. Nutrition - Usual food intake pattern - coded as 2. Probable inadequate6. Friction and Shear - risk from skin rubbing or sliding against surfaces - coded as 3. No apparent problemOn 12/30/25 at 11:54AM, an interview was conducted with the Director of Nursing who stated they had completed a facility wide skin sweep after they had identified weekly skin reviews were not being completed per facility policy. During the skin sweep, Resident#1 was identified with two newly acquired pressure-related pressure injuries.On 12/30/25 at 12:44PM, a telephone interview was conducted with the facility's Wound Care Nurse Practitioner (ADM#3) regarding her assessment of Resident #1's newly acquired pressure injuries dated 11/20/25. Per the Wound Care Nurse Practitioner (ADM#3), she stated that the facility had identified weekly skin reviews had not been done consistently and wanted to complete a full house head to toe assessment on all residents, and that is when they identified Resident #1 had developed (2) newly acquired wounds. When asked to provide information on how the wounds were considered to be unavoidable as Resident #1 was re-admitted on [DATE] with skin intact and 12 days later she had developed a pressure injury at an advanced stage, she stated she had obtained information from the facility wound care nurse about the resident recently being admitted to Hospice services, she was showing an overall general decline, refusing to go to her dialysis treatments and her decreased mobility. So, my main thought process was due to her co-morbidities such as her end stage renal disease, diabetes and heart failure and she was incontinent of bowel and bladder and basically her rapid decline I determined the wounds to be unavoidable. When discussing what preventative measures were in place to prevent the development of pressure injuries (PI), the Wound Care Nurse Practitioner stated she had recommended an air mattress and gave the nurses treatment orders. On 12/30/25 at 1:05PM, the Director of Nursing provided copies of Resident #1's Skin Monitoring: Comprehensive C.N.A. Shower Reviews revealing 11/11/25 no issues observed on skin, 11/18/25 noted resident refused shower, and on 11/21/25 revealed bruise and swelling from dialysis .On 12/30/25 at 2:40PM, an interview was conducted with the Director of Nursing who confirmed that Resident #1 had a history of pressure injuries to her sacrum and provided copies of the Weekly Skin Review from her original admission dated 11/10/21 revealing redness with scabs and open areas on bilateral lower extremities and redness with a scab on her sacrum and a Wound Evaluation by a Certified Wound Nurse Practitioner dated 4/6/22 revealing a re-opened Stage 2 pressure injury on the sacrum and a Wound Evaluation dated 4/19/22 pressure injury Stage 2 sacrum, healed.A review of Resident #1's care plan did not reveal a care plan to address resident's risk for development of a pressure ulcer and had no interventions to address prevention of the development of pressure related injuries. On 12/30/25 at 2:40PM, during an interview with the Director of Nursing on what preventive measures were put in place prior to Resident #1 acquiring two new pressure related wounds that were identified at an advanced stage on 11/20/25, she stated they were turning and repositioning the resident and had changed her mattress to a pressure relief mattress (air mattress) on 11/20/25. According to the Director of Nursing all the facility beds have pressure reducing mattresses. When asked why the air mattress wasn't placed when Resident #1 was identified as being at risk for development of pressure injuries and had a history of a previous sacral wound she stated it had always been her practice to place an air mattress once a wound was identified. When asked about Resident #1 being turned and repositioned, would she expect staff to see changes in skin integrity prior to identification of a wound at advanced stage she replied, she was declining rapidly, not eating and declining her dialysis treatments. When asked about preventive measures on Resident #1's care plan she stated the resident had a care plan for addressing potential impairment to skin integrity related to fragile skin, advanced age, chronic illness. A review of the care plan with the Director of Nursing revealed no preventive measures to prevent the development of pressure wounds and no care plan to address Resident #1's refusal of care such baths, skin assessments, dialysis treatments, etc.A review of the facility's Documentation Survey Report ( C.N.A documentation) for turning and re-positioning revealed on 11/11/25 all 3 shifts was coded as (NA) Not Applicable, 11/12/25, 11/15/25, 11/16/25 was coded NA for Day and Evening shifts, 11/18/25 coded as NA for evening and night shift, 11/20/25 coded as NA for day shift and on 11/21/25 was coded as NA for evening and night shift. (Legend: Did you turn and reposition the resident? Y - Yes, N - No, NA- Not Applicable). A review of Resident #1's most recent MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 10/9/25 Section GG coded the resident as requiring substantial/maximal assistance or being totally dependent for turning/repositioning, lying to sitting, dressing, chair to bed to chair transfers and toileting.A review of the facility's policy, entitled Skin Assessment, Policy Explanation and Compliance Guidelines revealed: 1.A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition.A review of the facility's policy, entitled Pressure Injury Prevention and Management, Policy Explanation and Compliance Guidelines 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate.3. Assessment of Pressure Injury [NAME]. Licensed nurses will conduct a pressure injury risk assessment, using the [NAME] Scale, on all residents upon admission/re-admission and whenever the resident's condition changes significantly. Section M0150 of the Minimum Data Set may also be utilized to assess the resident's risk for skin integrity impairment.b. This data will be used in conjunction with other risk factors. Examples of risk factors include, but are not limited to:i. Impaired/decreased mobility and decreased functional ability.ii. Co-morbid conditions, such as end stage renal disease, thyroid disease, or diabetes mellitus.iii. Drugs such as steroids that may affect healing,iv. Impaired diffuse or localized blood flow.v. Exposure of skin to urinary and fecal incontinence.vi. Under nutrition, malnutrition, and hydration deficits, andvii. The presence of a previously healed pressure injury.c. Licensed nurses, or contracted agencies which provide wound care and skin assessments on the facility's behalf, will conduct a full body skin assessment on all residents upon admission/re-admission and weekly. Findings will be documented on the weekly shower sheets or in the electronic medical record Skin Assessment.d. Assessments of pressure injuries will be performed by a licensed nurse and documented.e. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task.4. Interventions for Prevention and to Promote Healinga. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan the includes measurable goals for prevention and management of pressure injuries with appropriate interventions.b. Interventions will be based on specific factors identified in risk assessment, skin assessment and any pressure injury assessment (moisture management, impaired mobility, nutritional deficit, staging and wound characteristics)c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to:i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc)ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination.iii. Provide appropriate, pressure-redistributing, support surfaces.iv. Maintain or improve nutrition and hydration status, where feasible.f. Interventions will be documented in the care plan and communicated to all relevant staff.On 12/30/25 during the exit meeting with the Director of Nursing and Administrator, the above findings were discussed, and an opportunity was offered to the facility staff to present additional information. The Director of Nursing stated she would be providing a copy of the Hospice admission assessment for Resident #1. No further comments or additional information was provided upon exit.The survey team offered to delay survey exit until the following day if the facility felt they had additional information to provide. The facility chose to proceed with the survey exit. The following day, 12/31/25, the facility administration submitted via email, a document that was titled, Recapitulation of Stay- [Resident #1's name redacted]. The document was not part of Resident #1's clinical record, nor provided to the survey team during the survey.

Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to develop a comprehensive person-centered care plan for (1) one resident (Resident #1) in a survey sample of 5 residents.The findings included:For Resident #1, who was identified to be at risk for pressure ulcer development, the facility staff failed to develop a comprehensive person-centered care plan to address the development of pressure injuries.Resident #1 was originally admitted to the facility on [DATE]. On 11/8/2025, Resident #1 was re-admitted to the facility after hospitalization with diagnoses including but not limited to a history of a sacral ulcer stage II.Resident #1's most recent MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 10/9/25 coded the resident in Section M: Skin Conditions, as having no open wounds and was at risk for development of pressure ulcers.Review of the Nursing admission assessment dated [DATE] revealed skin was intact.On 12/30/25 at 11:10AM, an interview was conducted with the facility's Wound Care Nurse (LPN#3) who stated that Resident #1's pressure injury to her sacrum and the Deep Tissue Injury to her right heel was identified during a facility skin sweep. When asked why a facility skin sweep was done, LPN#3 stated. we had identified that weekly skin reviews were not being done weekly per the facility policy. When asked if the facility conducted skin risk assessments, LPN#3 replied, Yes, we do the Braden Assessment upon admission and then weekly for (4) four weeks and if or when a resident should develop any new areas. When asked what the Braden Assessment was used for, LPN#3 stated, To identify any risk factors such as moisture or poor nutrition and then putting interventions in place to address those areas to help the resident from developing a pressure wound. When asked who updates the care plans, LPN#3 stated, The Director of Nursing or the MDS (Minimum Data Set) Nurse.A review of Resident #1's Braden Scale for Predicting Pressure Sore Risk dated 11/8/25 upon re-admission revealed a Braden Score of 17 which indicates the resident was at risk for developing a pressure injury:On 12/30/25 during an interview with the facility's Wound Care Nurse Practitioner, she was asked if preventive measures such as placing the air mattress when Resident #1 was identified as at risk for development of a pressure injury and having a history of a sacral pressure injury in the past, adding a protein supplement, more frequent turning and repositioning and incontinence care and off-loading of her heels wound have perhaps prevented the development of the pressure injuries she stated, I was not aware of her having a history of a previous sacral wound, I did see her in August of this year but she refused to have me assess her sacrum, so perhaps more aggressive preventive measures may have prevented or delayed development, but again she was in a general decline. On 12/30/25 at 2:40PM, an interview was conducted with the Director of Nursing who confirmed that Resident #1 had a history of pressure injuries to her sacrum. A review of Resident #1's care plan did not reveal a care plan to address resident's risk for development of a pressure ulcer and had no interventions to address prevention of the development of pressure related injuries. On 12/30/25 at 2:40PM, an interview was conducted with the Director of Nursing (DON) on what preventive measures were put in place prior to Resident #1 acquiring two new pressure related wounds that were identified at an advanced stage on 11/20/25. The DON stated they were turning and repositioning the resident and had changed her mattress to an air mattress on 11/20/25. When asked if Resident #1 had a care plan to address preventive measures on development of pressure ulcers, the DON stated Resident #1 had a care plan for addressing potential impairment to skin integrity related to fragile skin, advanced age, chronic illness. A review of the care plan with the Director of Nursing revealed no preventive measures to prevent the development of pressure wounds and no care plan to address Resident #1's refusal of care such baths, skin assessments, dialysis treatments, etc.A review of the facility's policy, entitled Pressure Injury Prevention and Management, Policy Explanation and Compliance Guidelines, was conducted. The policy read in part, .a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan the includes measurable goals for prevention and management of pressure injuries with appropriate interventions .c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present .f. Interventions will be documented in the care plan and communicated to all relevant staff.On 12/30/25 during the exit meeting with the Director of Nursing and Administrator, the above findings were discussed, and an opportunity was offered to the facility staff to present additional information. No further comments or additional information was provided upon exit.

Based on staff interviews and facility documentation review, the facility staff failed to maintain an active facility wide Infection Prevention Control Program (IPCP) with regards to infection surveillance and tracking for one Resident (Resident #27) in a survey sample of 15 Residents, but had the potential to affect multiple Residents within the facility. The findings included: On 4/5/22, during the survey entrance conference, the facility Administrator identified Employee G as the facility Infection Preventionist. The Administrator stated that Employee G was out on vacation, but they had access to all of her information and files, as well as Employee G being available via telephone. On 4/6/22, the facility Administrator submitted the infection line listing/infection surveillance for the months of November and December 2021, and January 2022. These documents were reviewed and noted that only Residents with infections being treated with antibiotics, were listed. It was also noted, that Resident #27's infection for pneumonia, which was treated with an antibiotic in January 2022, was not noted on the line listing. Also, Resident #27's episodes of watery stools on 12/29/21 and 12/31/21, had not been recorded on any of the infection tracking documents. On 4/6/22 at 3:44 PM, a telephone interview was conducted with Employee G, the infection preventionist. Employee G stated that she tracks infections when Residents are put on an antibiotic so she can monitor and it is also a visual cue if someone has been on an antibiotic multiple times, she can evaluate if there is a colonization issue, identify trends, etc. Employee G was asked if there is any reason why someone would be on an antibiotic and not on the infection surveillance/line listing. Employee G said, If it is an antibiotic following surgery, such as someone had cataract surgery and following that is on antibiotic eye drops, I wouldn't put them on there, or if it is treating something that is not a healthcare associated infection. Employee G was asked about a Resident having completed a course of antibiotics and then approximately two weeks later develops watery stools. Employee G said she would immediately think about C-diff [[CONDITION(S)], an infection of the large intestine (colon) caused by the bacteria [CONDITION(S)]. Long-term use of antibiotics reduces the normal bacterial population in the intestine and triggers the C. difficile overgrowth in the intestine] which is highly contagious. Employee G was asked if she monitors systems such as this or gastro-intestinal virus symptoms such as noro-virus on a surveillance log, to identify potential infection outbreaks. Employee G said, No, but I see where that could be beneficial now that you mention it. Review of the facility policy titled, Surveillance for Infections was conducted. This policy read, The Infection Preventionist (IP) will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions .The resident line list and staff line list should contain relevant data which will help tracking, contact tracing and disease analysis. The facility staff submitted evidence that Employee G completed the CDC Nursing Home Infection Preventionist Training Course. In module 4 of this training the CDC stated, The purpose of infection surveillance is to identify infections and to monitor adherence to recommended IPC (Infection Prevention and Control) practices in order to reduce infections and prevent the spread of pathogens among residents, staff, and visitors. An IPC program uses surveillance data to: Monitor trends in infections and pathogens, including detecting outbreaks. Monitor staff adherence to IPC practices. Identify performance improvement opportunities. Track progress toward priorities identified on the annual facility IPC risk assessment and inform the development of future risk assessments. On 4/7/22, the Administrator and Director of Nursing were made aware of the findings. On 4/7/22, the facility Administrator shared with the survey team, that she had previously discussed the surveillance and tracking of infections and symptoms with Employee G and didn't know why this wasn't being done. No further information was provided by the facility.

Based on staff interviews, facility documentation review, and clinical record review, the facility staff failed to administer medications due to a lack of availability on 11 occasions, to one Resident (Resident #27) in a survey sample of 15 Residents. The findings included: On 4/5/22, Surveyor B conducted a clinical record review for Resident #27. This review revealed a physician order dated 11/27/21, that read, [MEDICATION(S)] Nebulization Solution 0.63 MG/3ML ([MEDICATION(S)] HCl) 1 vial inhale orally via nebulizer two times a day for Pneumonia. Review of the MAR (medication administration record) revealed that Resident #27 did not receive this medication as prescribed on 11 occasions on the following dates: 11/28/21, 1/4/22, 1/5/22, 1/6/22, 1/7/22, 1/8/22, 1/9/22, and 1/10/22. Review of the nursing notes revealed entries that noted pending delivery and not available. There was no indication that the physician had been notified of the medication not being available to administer as per the physician order. On 4/6/22 and 4/7/22, interviews were conducted with LPN B, LPN C, LPN D, and Employee G, who is an RN and the facilities' infection preventionist. Each of the 4 nurses confirmed that the pharmacy makes two deliveries to the facility daily and there is a back-up pharmacy. If a medication is urgent or needed immediately, all four nurses said the pharmacy could send the prescription to a local pharmacy that could be picked up for immediate administration. On 4/6/22, the facility Administrator provided a copy of the STAT (emergency) box contents. This box is a supply of medications maintained on-hand at the facility that can be used in the event of an emergency or new order. Review of this document revealed that the [MEDICATION(S)] was not kept on-hand in the STAT box. Review of the facility policy titled, Medication Pass/Administration was reviewed. This policy read, .If any ordered medication is not available, call the physician to get an alternate substitute to administer or get an order from the physician to administer the unavailable medication at a time when it is available from the pharmacy. The physician will have to make a clinical judgement if the delay in the medication will have no impact in the resident quality of care . The facility policy titled, Medication Ordering was reviewed. This policy stated, .6. If any ordered medication is not available despite been ordered/reordered, call the physician to get an alternate substitute medication available in the emergency kit. The nurse may also get an order from the physician to administer the unavailable medication at a time when available from the pharmacy. The physician will have to make a clinical judgement if the delay in the medication administration will have no impact in the resident quality of care . On 4/6/22, during an end of day meeting, the facility Administrator and Director of Nursing were made aware that Resident #27 had a delay in receiving medications as ordered. No further information was received.

Based on staff interviews, facility documentation review, and clinical record review, the facility staff failed to follow professional standards of practice for one Resident (Resident #27) in a survey sample of 15 Residents. For Resident #27, the facility staff failed to notify the physician when a medication was not available. The findings included: On 4/5/22 and 4/6/22, a closed clinical record review was conducted for Resident #27. This review revealed: On 11/26/21 at 4:50 PM, the facility nursing staff spoke with the attending physician and obtained treatment orders which included an antibiotic and nebulizer treatments. On 1/4/22-1/10/22, Resident #27 missed 7 consecutive days of his nebulizer treatment doses, due to the medication not being available. There was no indication in the clinical chart that the physician had been notified of the unavailability to assess if alternate treatments were needed. A review was performed of the facility policy titled, Change in Condition/Notification of Physician & Responsible Party. This policy read, The facility will immediately inform the Resident, consult with the resident's physician, and notify responsible party/appointed guardian when there is: .*A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications) .A need to alter treatment significantly . On 4/6/22, during an end of day meeting, the facility Administrator and Director of Nursing were made aware of the findings. The Director of Nursing stated the facility follows Lippincott for professional standards of practice for nursing services. Lippincott's Manual of Nursing Practice Eighth Edition, addresses on pages 13-14 Examples of Ethical Dilemmas and Possible Responses. This document read, .Nonresponse by Physician. Page 17 discusses, The Standards of Professional Nursing Practice and stated, Standards of professional performance include Resource Utilization. Page 18 read, Common Legal Claims for Departure from Standards of Care: Failure to communicate or document a significant change in a patient's condition to appropriate professional. Failure to administer medications properly and in a timely fashion, or to report and administer omitted doses appropriately. No further information was received/provided.

Based on observation, staff interview, and facility document review, and in the course of a complaint investigation, the facility staff failed to provide Registered Nurse coverage 8 consecutive hours per day for 3 days out of 30 days in June 2021 and for 6 days out of 31 days in July 2021. The findings include: Facility staff failed to provide Registered Nurse (RN) coverage in June 2021 on 6/11, 6/21, 6/30, and in July 2021 on 7/14, 7/15, 7/16, 7/17, 7/28, and 7/31. On 4/5/22, an interview was conducted with Employee F who confirmed he was responsible for payroll records at the facility. A copy of the payroll records for all Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs), to include time clocked in and out, for the months of June 2021 and July 2021 was requested and provided by Employee F who verified the records were accurate and complete. On 4/6/22, a review of the payroll records revealed the following: For June 2021, there was no RN coverage on 6/11, there was partial RN coverage for 6.75 hours on 6/21, and no RN coverage on 6/30. For July 2021, there was no RN coverage for 7/14 and 7/15, there was partial RN coverage for 3.75 hours on 7/16, no RN coverage for 7/17, no RN coverage on 7/28, and partial RN coverage for 4.5 hours on 7/31. On 4/6/22, an interview was conducted with the Director of Nursing (DON) who stated, it is facility practice for all nursing staff, including the DON, to use the timeclock when coming to work and when leaving. Review of the payroll records confirmed several timeclockings for the DON concurrently with other facility RNs. No further information was provided.

Based on observation, Resident interview, staff interview, and clinical record review, the facility staff failed to provide a homelike environment for one Resident (Resident #20) in a sample size of 15 Residents. For Resident #20, the facility staff failed to ensure Resident #20 had easy access to his bathroom sink. The findings included: On 04/05/2022 at 10:15 A.M., Resident #20 was observed seated in his wheelchair self-propelling in his room. When asked if he had any concerns about the care he receives at the facility, Resident #20 stated that his concern is that he cannot get to his sink while seated in his wheelchair. Resident #20 then stated that there was a bar in the way. This surveyor observed that the commode and sink were side by side on the left wall upon entry to the bathroom. In between the commode and the sink, there was an L-shaped bar attached to the wall, extending out the length of the commode and bolted into the floor. There was a side bar that extended into the pathway of the sink and was also bolted to the floor. On 04/06/2022 at 1:55 P.M., Resident #20 was observed seated in his wheelchair self-propelling in his room. A follow-up interview with Resident #20 was conducted. When asked how he would brush his teeth or wash up in the morning, Resident #20 stated that staff provide a pink basin for him and put it on his tray table. Resident #20 then self-propelled into the bathroom to demonstrate how he could not fit the wheelchair into the space between the side bar and the wall to access the sink. On 04/06/2022 at 2:20 P.M., Certified Nursing Assistant E (CNA E) was interviewed. CNA E verified she assisted Resident #20 this morning with set up for brushing teeth. When asked how that was done, CNA E stated that she filled a basin and placed it on the tray table and put it in front of him. When asked why Resident #20 did not use the bathroom sink, CNA E stated another Resident who shares the bathroom with Resident #20 was using the bathroom at the time. On 04/06/2022 at 3:35 P.M., this surveyor and Employee H, the Maintenance Director, entered Resident #20's room. Resident #20 again stated he couldn't get to his sink. The Maintenance Director measured Resident #20's wheelchair width to be 26.5 inches and the distance between the side bar and the wall in the bathroom to be 26.5 inches. Upon exiting the room, the Maintenance Director stated that it needed to be fixed and that it was an easy fix. On 04/06/2022, Resident #20's clinical record was reviewed. Resident #20's most recent Minimum Data Set with an Assessment Reference Date of 03/14/2022 was coded as an admission assessment. The Brief Interview for Mental Status was coded as 13 out of 15 indicative of intact cognition. On 04/06/2022 at approximately 4:00 P.M., the administrator was notified of findings. On 04/07/2022 at approximately 10:15 A.M., Resident #20 was observed seated in his wheelchair self-propelling in his room. When asked about accessing the bathroom sink, Resident #20 stated he was now able to access his sink and demonstrated ability to self-propel to the bathroom sink. This surveyor observed the side bar had been removed to widen the space.

Based on staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide treatment and services to one Resident (Resident #27) in a survey sample of 15 Residents. For Resident #27, the facility staff failed to solicit assistance from the facility management and medical director for treatment orders for a Resident with pneumonia on two occasions, when the attending physician was not responsive, which resulted in a delay in treatment. Past non-compliance was achieved on 2/28/22. The findings included: On 4/5/22 and 4/6/22, a closed clinical record review was conducted for Resident #27. This review revealed a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] * On 11/24/21, Resident #27 exhibited abnormal bilateral lung sounds. A chest x-ray was ordered. * On 11/25/21 at 10:35 AM, the results of the chest x-ray were received and showed a left base infiltrate and/or small effusion. Nursing notes showed that the facility staff attempted to reach the attending physician and nurse practitioner throughout the day. However, no attempts were made to notify the medical director that the attending physician was not responding, in an effort to obtain treatment orders for Resident #27's infection. * On 11/26/21 at 4:50 PM, [two days after symptom onset], the facility nursing staff spoke with the attending physician and obtained treatment orders which included an antibiotic and nebulizer treatments. * On 1/12/22, Resident #27 was noted to have abnormal lung sounds and increased congestion. A chest x-ray was ordered. On 1/12/22 at 10:44 PM, the chest x-ray results were received and noted possible bilateral pneumonia. Nursing notes showed that the facility staff attempted to reach the attending physician but were not successful. * On 1/13/22 at 6:34 AM, attempts to reach the attending physician were again unsuccessful. There was no indication that the facility nursing staff notified facility management or medical director in an effort to obtain treatment orders for Resident #27. * On 1/13/22 at 1:15 PM, the facility staff obtained treatment orders for an antibiotic from the attending physician for Resident #27. On 4/6/22 at 12:42 PM, an interview was conducted with LPN B. LPN B confirmed that if a Resident had a change in condition she would continue to call the provider until she got a response. On 4/6/22 at 12:30 PM, and again at 3:17 PM, the attending physician for Resident #27 was attempted to be reached via telephone, but the calls were not successful. On 4/6/22 at 3:44 PM, an interview was conducted with Employee G, an RN. She stated that she tended to get a better response from the nurse practitioner than the attending physician for Resident #27, but neither of them were fantastic, they didn't have an on-call service and there were times they weren't reaching back out timely. It was a challenge. Employee G said if it was an excess of 24 hours, That's when you would reach out to the Administrator, Director of Nursing and Medical Director. On 4/6/22 at 6:11 PM, an interview was conducted with LPN D. LPN D stated that frequently she would attempt to call the attending physician and nurse practitioner and would not have an option to leave a message and would have to call multiple times to get a response. LPN D stated it was pretty common to go an entire shift without a response. A review was performed of the facility policy titled, Prohibition of Abuse. This policy stated, .The facility promotes the Rights of Residents to be free from verbal, sexual, physical, and mental abuse, including involuntary seclusion, neglect, exploitation and misappropriation of property . Neglect - is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review was performed of the facility policy titled, Attending Physician/Provider Responsibilities. This policy read, .Ensuring Adequate Ongoing Coverage: 1. The Attending Physician/Provider will designate an alternate physician or another appropriately licensed practitioner to respond in an appropriate, timely manner in case the Attending Physician is unavailable. The Medical Director will respond to all residents' medical issues if facility is unable to reach Attending Physician/Provider. On 4/6/22, during an end of day meeting, the facility Administrator and Director of Nursing were made aware of the findings. On 4/7/22, during the review of the facility Quality Assurance (QA) Program, the facility Administrator indicated they had identified a concern with the facility staff not reaching out to the Medical Director when the attending physician was not responsive in January 2022. The facility held an ad hoc QA meeting on 1/26/22, and initiated a root cause analysis and plan of correction which was completed 2/28/22. The plan of correction included: Primary MD (medical doctor) not responding to calls, Medical Director to be notified 30 minutes after calling primary MD without response. All Residents have the potential to be affected. The Director of Nursing or designee to educate licensed nurses to notify the Medical Director when Primary Care MD does not respond within 30 minutes. The Director of Nursing/designee to monitor the licensed nurses calling Medical Director when Primary MD does not respond monthly x 2 months. Findings to be reported to QAPI (Quality Assurance and Performance Improvement) committee monthly and updated as indicated. The education of licensed nurses was reviewed. The monthly audits were reviewed. On 4/7/22 at 10:30 AM, an interview was conducted with LPN C, to validate the past non-compliance. LPN C said that if she was not able to reach the doctor or didn't get a return call within 30 minutes, she would call the medical director. LPN C confirmed she was trained on this about a month or two ago. No further information was received/provided.

Based on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide needed care and treatment for one Resident (Resident #22) in a sample size of 15 Residents. Specifically, the facility staff failed to ensure Resident #22's oxygen was humidified on 04/06/2022. The findings included: On 04/06/2022 at approximately 9:55 A.M., this surveyor observed Resident #22 approach Licensed Practical Nurse B in the hall and stated that she had been waiting over 24 hours for someone to fill her water bottle. LPN B apologized and stated she would get her water. Resident #22 then stated that 24 hours is too long to wait for water. At approximately 10:10 A.M., Resident #22 was observed seated in her chair in her room. Resident #22 had oxygen set at 2 liters per minute via nasal cannula (the tubing was dated 04/04/22). The humidified reservoir was empty. When asked about the empty reservoir, Resident #22 indicated that she had [CONDITION(S)] ([CONDITION(S)]) and stated If there's no water in there, it causes my coughing to be worse and makes my throat so dry. Resident #22 went on to explain that About this time yesterday she told one of the aides the bottle needed to be refilled and she said she would tell the nurse. Resident #22 stated around dinnertime she told a different aide and the aide said she would tell my nurse. Then a third person came around and I told them, too. Resident #22 stated that every time she saw an aide she would tell her the bottle needed to be refilled and the aide would say she would tell the nurse. LPN B then entered the room and filled the reservoir with distilled water. Resident #22 continued and stated that I didn't have a good night because I was coughing; my throat was so dry and I felt choked. LPN B then stated I was in here several times yesterday and you didn't say anything to me. Resident #22 then indicated that when her oxygen is not humidified, she finds it is hard to focus. Resident #22 then began to cry. LPN B stepped close to Resident #22 and comforted her. At approximately 10:25 A.M., Resident #22 was no longer crying when LPN B and this surveyor exited the room. LPN B then stated that when [Resident #22] gets angry or frustrated, she will cry. When asked about the humidified reservoir, LPN B stated that she saw water in the reservoir when she came on her shift yesterday [morning of 04/05/2022]. On 04/06/2022 at 10:35 A.M., Certified Nursing Assistant C (CNA C) was interviewed. CNA C verified she worked on the day shift on 04/05/2022. When asked if she had any interaction with (Resident #22), CNA C stated that she was not assigned to care for Resident #22 yesterday and didn't have any interaction with (Resident #22) yesterday. On 04/06/2022 at 10:45 A.M., Certified Nursing Assistant D (CNA D) was interviewed. CNA D confirmed she was assigned to care for Resident #22 on 04/05/2022 and this day 04/06/2022. When asked about Resident #22 CNA D stated that [Resident #22] is not a morning person and I asked her if she wanted breakfast about 10:30 [A.M.]. When asked about the water in her humidifier, CNA D stated it was a little over half full at breakfast time yesterday. When asked if Resident #22 requested the bottle be refilled, CNA D stated that [Resident #22] didn't say anything about her humidifier. When asked if there was water in the humidifier this morning, CNA D indicated that the machine was on but she did not take note if there was water in the humidifier reservoir. On 04/06/2022, Resident #22's clinical record was reviewed. Resident #22's most recent Minimum Data Set with an Assessment Reference Date of 03/17/2022 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of 15 indicative of intact cognition. Resident #22's care plan was reviewed. A focus dated 10/08/2019 entitled, [Resident #22] has oxygen therapy r/t [related to] [CONDITION(S)] included but was not limited to the following intervention with a revision date of 06/21/2021: Administer O2 [oxygen] via nasal prongs/mask at 2L [2 liters per minute] continuously. Humidification of oxygen was not addressed on the care plan. On 04/06/2022 at 4:45 P.M., the administrator and Director of Nursing (DON) were notified of findings. When asked about the expectation of oxygen humidification reservoirs, the DON indicated that the nurses should be checking to make sure the reservoirs remain adequately filled. On 04/07/2022, the facility staff provided a copy of their policy entitled, Oxygen Concentrator/Oxygen Utilization. An excerpt under the section entitled, The facility may perform some functions to maintain adequate flow of oxygen via device to include: In [sic] oxygen device have humidifier application, ensure humidifier bottle has distill [sic] water present at appropriate level. On 04/07/2022, the Director of Nursing provided an updated copy of the care plan. Under the focus dated 10/08/2019 entitled, [Resident #22] has oxygen therapy r/t [related to] [CONDITION(S)] included but was not limited to the following intervention with a revision date of 04/07/2022: Administer O2 [oxygen] via nasal [sic] at 2L [2 liters per minute] continuously with humidification. On 04/07/2022 at approximately 1:00 P.M., the administrator stated there was no further information or documentation to submit.

Based on interview, clinical record review and facility documentation the facility staff failed to implement policies and procedures related to abuse and neglect for 3 Residents (#15, #13, and #5), in a survey sample of 17 Residents. Immediate Jeopardy was called on 2/10/21 at 3:26 P.M. related to Residents #15 and #13. It was abated on 2/12/21 at 5:30 P.M. After Immediate Jeopardy was removed, the deficiency was assigned a Scope and Severity of level 2, isolated. The findings included: 1. For Resident #15, the facility did not implement facility policies and procedures by allowing LPN A to continue to work with Resident #15 after being accused of abusing Resident #15 and written up for Intimidating a Resident [#15] Resident #15 an [AGE] year old woman, was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15's most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/21/20, an quarterly assessment, coded Resident #15 as having a BIMS (brief interview of mental status) score of 10 out of a possible 15. This score indicates moderate cognitive impairment. The MDS codes the resident as needing extensive assistance with physical assistance of 1 person for toileting, hygiene, dressing and bed mobility. She requires limited assistance with physical assistance of 1 person for walking in room, and transfers. She requires supervision for eating meals. The Resident uses a walker to aid in mobility. On 2/9/21 approximately 1:00 PM Resident #15 was asked about abuse and neglect in the facility, she stated There was one aide that wasn't nice but I told her to leave. She hasn't been around lately. On 2/10/20 during clinical record review it was discovered that the following entry was made in the progress notes: 1/1/21 at 9:18 PM - At 430 PM [Resident #15 name redacted] came out from her room and was ambulating with her rollator. She passed by the nurse's station and stated 'Someone banged my face and head in the bars this morning.' Writer asked if she can recall the name of the person and she stated 'I don't know.' On 2/10/21 at 11:41 an interview was conducted with the DON and the Administrator who was asked about an incident involving Resident #15 and LPN A. The Administrator stated it happened when she was out sick. She stated that The DON called me at home. When asked what day she was notified she stated she wasn't sure. She also stated 2 CNA's that work night shift reported the incident. When asked who they reported it to she stated They called me at home. I told the DON to do the investigation. The Administrator submitted a Corrective Action Plan for LPN A excerpts are as follows: Employee Name: [redacted] Department: Nursing Date: 1/28/21 Date of Occurrence: 1/1/21 Location: Nursing Time: 11 pm -7 am Action Taken: Written Counseling Description of Issue: [box checked] Policy Violation [box checked] other: Mental Intimidation. Explanation: It was reported to Acting DON by Administrator on 1/6/21 of an incident involving resident # [medical record number redacted] on the morning of 1/1/21. The report stated that Resident was refusing care which was reported to the Charge Nurse, [LPN A name redacted]. At that time, Charge Nurse and CNA both went in to care for Resident. Per report, Resident continued to be resistant to care and Charge Nurse began to pull down Residents clothes while Resident was in bed and was speaking to Resident in a loud and uncalm voice. When Charge Nurse was pulling Resident's clothes off, the bed was unlocked on one side and began to move with the headboard hitting the wall. Charge Nurse locked the bed and continued pulling clothes off, kicking the soiled depends and clothing on the floor at which time she was bumping or hitting the walker and rocking chair with her feet which in turn was hitting the wall and the furniture in the Resident's room. Resident yelled at Charge Nurse to stop and Charge Nurse responded that they were there to help her and she was fighting them and telling them that they were hitting her furniture. Charge Nurse then stated This is how we hit furniture and grabbed the walker or the rocking chair and was hitting it against the wall or the china dresser. CNA approached the Resident and took over washing her up and changing her clothes and Charge Nurse exited the room, however she was still talking to the Resident in a loud and Unocal manner. Per CNA, Resident at this time was reported to be shaking and walked outside of her room and sat in recliner on the unit. Another staff member came to see what all the loud voices was about and to see if everything was okay. The Charge Nurse said everything was Okay. On the night of 1/2/21 staff reported that when they knocked on the Resident's door, Resident jumped, seemed scared and was shaking. She reported to the staff that 'the black woman with the round thing on her head' came into her room and kept hitting her head on the wall. At a later time that same night Resident reported the same thing and also said ' I think it was T, (which is what she calls the Charge Nurse), but why would she do that?' At a later time, a staff member stated that Resident approached her and stated the night nurse [name redacted], who wears that knot on her head, hit her in the arm and the head. The staff member asked when that happened and was told it happened a few nights ago and that the nurse was hitting and kicking her bed and throwing her chair around. Staff also reports that Resident has been telling other people who will listen to her, including her family, that she was hit and kicked by the night nurse, [name redacted], and that she did not want to stay at [facility name redacted] anymore because she might be killed. It was noted that the Corrective Action Plan had not been signed by the DON or the LPN. The DON was asked about why the document had not been signed and she stated The LPN has been out of the facility on Administrative Leave. When asked was that due to this incident she stated, Yes I believe so. On 2/10/21 a review of the time clock punches for LPN A revealed that LPN A continued to work on the very same unit with the Resident until 2/1/21. On this date she was written up for Sleeping on the job. On 2/10/21 at approximately 3:00 PM an interview was conducted with the Administrator and she was asked if the LPN A was still an employee there and she stated that she is supposed to come in on Thursday (2/11/21) to sign the corrective action plan. The Administrator was then asked to provide the survey team with the entire investigation including witness statements. The witness statement from CNA C was reviewed and an excerpt is as follows: 1/14/21 - The incident started when I was cleaning and sanitizing the shower room, when I heard people screaming and yelling, so I immediately ran out and saw the nurse [LPN name redacted] standing at the opening of room [ROOM NUMBER], which is [Resident #15 name redacted] room. The nurse was leaning on the resident's door and the resident was standing inside with her walker extended out in front of the nurse and her aide [CNA name redacted] behind her. I asked them was everything okay and the nurse said yes. When I was emptying my soiled linen cart the resident came to me and said the night nurse, [name redacted], who wear that knot on her head, hit her in the arm and head. I asked her when did this happen she said a few nights ago & the nurse was hitting and kicking her bed and throwing her chair around. I reported this to [Administrator name redacted] and she said she will report it to [DON name redacted] to investigate it, as time went by almost 2 weeks, I heard nothing, so I then called Mother and she stated she had heard something about it and she will look into it better. I wasn't sure if anyone was looking into the matter. [Resident #15 name redacted] was telling anyone including her family, who will listen to her, that she was hit and kicked by the night nurse, and that she didn't want to stay at [facility name redacted] anymore because she might be killed. A review of the Abuse and Neglect Policy read: Page 9 Paragraph F Protection Abuse Policy Requirements: It is the policy of this HOME that the resident(s) will be protected from the alleged offender(s). Procedure: Immediately upon receiving a report of alleged abuse, the Administrator, and / or designee will coordinate delivery of appropriate medical and or psychological care and attention. Ensuring safety and wellbeing for the vulnerable individual are of utmost priority. Safety, security and support of the Resident, their roommate, if applicable and other Residents with the potential to be affected will be provided. This should include as appropriate: 1. Procedures must be in place to provide the Resident with a safe, protected environment during the investigation. a. The alleged perpetrator will immediately be removed and the Resident protected. Employees accused of alleged abuse will be immediately removed from the Home and will remain removed pending the results of a thorough investigation. (Decision of the extent of immediate disciplinary action will be made by the Administrator and/or designee). 2. For Resident #13 LPN B failed to implement facility policies and procedures by not immediately reporting an allegation of abuse. Resident # 13 a [AGE] year old woman, was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #13's most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/4/20, an annual assessment, coded Resident #13 as having a BIMS (brief interview of mental status) score of 14 out of a possible 15. This score indicates no cognitive impairment. The MDS codes the resident as needing extensive assistance with all aspects of ADL care with the exception of eating. Resident #13 is able to feed herself with only supervision. The Resident uses a walker for aid in short distance mobility and a wheelchair for longer distances. On 2/10/21 at approximately 10:00 AM Surveyor C reported the following observation. At 9:20 AM Resident #13 was in wheel chair next to the medication cart. Resident #13 stated Somebody kicked me. LPN C asked Who kicked you? Resident replied I don't know. LPN C assisted the Resident to lift her right pant leg to reveal a dressing on right shin. LPN C then stated to the resident No one kicked you and went on to tell Resident that she had a dressing on her shin from a skin tear. Another staff member then approached Resident and rolled her down the hall in wheel chair. At 10:40 AM, Surveyor B interviewed Resident #13 after she returned from physical therapy. The Resident was asked about the injury to her right shin and she stated Somebody kicked me, I don't remember who. When asked about abuse or neglect she stated I cannot stand that nurse from last night we had a fight. When asked what happened she stated I can't stand her she is rude and she just would not leave me alone, so we got into a fight. She is not a good nurse and she drops stuff and then picks it up off the floor and gives it to you. That's not sanitary or wise these days. She has no patience. I was kicking at her to get her to leave me alone. They know I don't like her and don't want her in my room. On 2/10/21 a review of the clinical record revealed the following progress note: 2/10/21 at 12:59 AM - Resident call bell was on, and staff went to answer the call bell, resident stated she want to go to BR, staff got resident up in the w/c and assisted resident to the bathroom and while assisting resident back to bed she refused to allow staff to apply pillow under her legs and was insisting on keeping her legs outside the bed sa [sic] staff was assisting to put the legs back to bed resident became physically aggressive and started kicking and swinging at staff was verbally aabusive [sic] and told staff she hate her, redirected and assured resident that staff is here to help and to assure her safety. On 2/10/21 at approximately 10:58 AM an interview was conducted with the Administrator who was asked if she was aware of an allegation of abuse by Resident #13. She stated that she had not heard of this but would start an investigation. Immediate Jeopardy was called on 2/10/21 at 3:26 PM, and the Administrator was notified. Immediate Jeopardy Abatement Plan is as follows: All staff on evening shift, 3pm-11pm, for 2/10/21 will be in -serviced on Resident Rights and Abuse and Neglect on 2/10/21. Staff for night shift, 11pm -7 am, will be in serviced before their shift on 2/10/21. Dayshift staff will be in-serviced before their shift on 2/11/21. There will be a mandatory all staff meeting on 2/11/21 at 12 noon for training on Resident's Rights and Abuse and Neglect. All afore-mentioned staff will be provided a copy of the homes policy regarding Resident Rights and Abuse and Neglect at the time of the meeting. All other staff will be trained over the phone or in person before working with residents. LPN B has been removed from schedule and statement requested from this person regarding incident with Resident #13 on 2/10/21. Per policy, LPN B will remain removed pending the results of a thorough investigation and disciplinary action will be made by the Administrator. LPN C has been called for a statement about her conversation with Resident #13 this morning 2/10/21. She has provided documentation of the incident with Resident #13 on 2/10/21. Interviewing every Nursing Resident (24 total) to determine if any abuse, neglect, or resident rights violations have occurred. This has been completed by 2/10/21 by 445 pm. Body checks will be completed by 10 AM on 2/11/21 for cognitively impaired residents. The Abatement Plan will be completed by 4PM on 2/11/21 The survey team verified education in service sheet checks, interviews, and completed skin assessments were reviewed. The Immediate Jeopardy was removed on 2/12/21 at 5:30 PM. 3. For Resident #5, the facility staff failed to implement their abuse policy when an injury of unknown source was identified on 01/12/2021. Resident #5, a [AGE] year old female, was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's most recent Minimum Data Set with an Assessment Reference Date of 01/06/2021 was coded as an annual assessment. The Brief Interview for Mental Status was coded as 99 meaning unable to complete the interview. Cognitive Skills for Daily Decision Making were coded as moderately impaired. Short-term and Long-term memories were coded as memory problem. Functional status for bed mobility and transfers were coded as requiring extensive assistance from staff. On 02/11/2021 at approximately 8:45 A.M., the clinical record was reviewed. A nurse's note dated 01/12/2021 at 6:46 A.M. documented, Note Text: cna reported to writer that she noted discoloration to right hand between 2nd and 3rd fingers, denies pain will continue to monitor the area. The subsequent nurse's notes through 01/18/2021 at 2:26 P.M. were reviewed and the injury of unknown origin to the right hand was not addressed. A nursing skin assessment dated [DATE] at 4:03 P.M. did not document a skin issue on the right hand as indicated in the nurse's note dated 01/12/2021. On 02/12/2021 at approximately 9:20 A.M., a copy of the facility-reported incident and the investigation documentation associated with this injury of unknown origin to the right hand were requested. On 02/12/2021 at approximately 11:15 A.M., an interview with the Director of Nursing was conducted. When asked about a facility-reported incident and the investigation documentation associated with this injury of unknown origin, the Director of Nursing stated that it was not reported investigated or reported to the state agency. The Director of Nursing stated the staff were re-educated and a facility-reported incident will be sent to the state agency. When asked about expectation from staff when an injury of unknown origin is discovered, the Director of Nursing stated the expectation is that the nurse report it as soon as possible so we can send in a FRI [facility-reported incident] and begin the investigation. The Director of Nursing also stated the expectation includes assessing and interviewing residents and staff associated with the injury and notify all the proper people and the doctor. The facility staff provided a copy of their policy entitled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property. In Section E entitled, Investigation under the header Abuse Policy Requirements, it was documented, It is the policy of the Home that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. In Section E, Part 2 and subpart (a), it was documented, Investigation of injuries of Unknown Origin or Suspicious injuries: must be immediately investigated to rule out abuse: (a) Injuries include but are not limited to, bruising of the inner thigh, chest, face, and breast, bruises of an unusual size, multiple unexplained bruises, and/or bruising in an area not typically vulnerable to trauma. In Section G entitled, Reporting and Response under the header, Abuse Policy Requirements, an excerpt documented, It is the policy of this Home that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of Resident property) are reported per Federal and State law. In summary, Resident #5 had an injury of unknown source to her right hand between the 2nd and 3rd fingers (identified on 01/12/2021) and the facility staff failed to implement their abuse policy to report and investigate the matter. On 02/12/2021 at approximately 1:45 P.M., the administrator and Director of Nursing were notified of findings.

3. For Resident #5, the facility staff failed to implement their abuse policy when an injury of unknown source was identified on 01/12/2021. Resident #5, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses for Resident #5 included but were not limited to atherosclerosis and peripheral vascular disease. Resident #5's most recent Minimum Data Set with an Assessment Reference Date of 01/06/2021 was coded as an annual assessment. The Brief Interview for Mental Status was coded as 99 meaning unable to complete the interview. Cognitive Skills for Daily Decision Making were coded as moderately impaired. Short-term and Long-term memories were coded as memory problem. Functional status for bed mobility and transfers were coded as requiring extensive assistance from staff. On 02/11/2021 at approximately 8:45 A.M., the clinical record was reviewed. A nurse's note dated 01/12/2021 at 6:46 A.M. documented, Note Text: cna reported to writer that she noted discoloration to right hand between 2nd and 3rd fingers, denies pain will continue to monitor the area. The subsequent nurse's notes through 01/18/2021 at 2:26 P.M. were reviewed and the injury of unknown origin to the right hand was not addressed. A nursing skin assessment dated [DATE] at 4:03 P.M. did not document a skin issue on the right hand as indicated in the nurse's note dated 01/12/2021. On 02/12/2021 at approximately 9:20 A.M., a copy of the facility-reported incident and the investigation documentation associated with this injury of unknown origin to the right hand were requested. On 02/12/2021 at approximately 11:15 A.M., an interview with the Director of Nursing was conducted. When asked about a facility-reported incident and the investigation documentation associated with this injury of unknown origin, the Director of Nursing stated that it was not reported investigated or reported to the state agency. The Director of Nursing stated the staff were re-educated and a facility-reported incident will be sent to the state agency. When asked about expectation from staff when an injury of unknown origin is discovered, the Director of Nursing stated the expectation is that the nurse report it as soon as possible so we can send in a FRI [facility-reported incident] and begin the investigation. The Director of Nursing also stated the expectation includes assessing and interviewing residents and staff associated with the injury and notify all the proper people and the doctor. The facility staff provided a copy of their policy entitled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property. In Section E entitled, Investigation under the header Abuse Policy Requirements, it was documented, It is the policy of the Home that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. In Section E, Part 2 and subpart (a), it was documented, Investigation of injuries of Unknown Origin or Suspicious injuries: must be immediately investigated to rule out abuse: (a) Injuries include but are not limited to, bruising of the inner thigh, chest, face, and breast, bruises of an unusual size, multiple unexplained bruises, and/or bruising in an area not typically vulnerable to trauma. In Section G entitled, Reporting and Response under the header, Abuse Policy Requirements, an excerpt documented, It is the policy of this Home that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of Resident property) are reported per Federal and State law. In summary, Resident #5 had an injury of unknown source to her right hand between the 2nd and 3rd fingers (identified on 01/12/2021) and the facility staff failed to implement their abuse policy to report and investigate the matter. On 02/12/2021 at approximately 1:45 P.M., the administrator and Director of Nursing were notified of findings. Based on interview, clinical record review and facility documentation the facility staff failed to implement policies and procedures related to abuse and neglect for 3 Residents (#15, #13, and #5), in a survey sample of 17 Residents. Immediate Jeopardy was called on 2/10/21 at 3:26 P.M. related to Residents #15 and #13. It was abated on 2/12/21 at 5:30 P.M. After Immediate Jeopardy was removed, the deficiency was assigned a Scope and Severity of level 2, isolated. The findings included: 1. For Resident #15, the facility did not implement facility policies and procedures by allowing LPN A to continue to work with Resident #15 after being accused of abusing Resident #15 and written up for Intimidating a Resident [#15] Resident #15 an [AGE] year old woman, was admitted to the facility on [DATE] with diagnoses of but not limited to dementia without behavioral disturbance, anemia, chronic kidney disease, anxiety, major depressive disorder, falls, and atherosclerotic heart disease. Resident #15's most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/21/20, an quarterly assessment, coded Resident #15 as having a BIMS (brief interview of mental status) score of 10 out of a possible 15. This score indicates moderate cognitive impairment. The MDS codes the resident as needing extensive assistance with physical assistance of 1 person for toileting, hygiene, dressing and bed mobility. She requires limited assistance with physical assistance of 1 person for walking in room, and transfers. She requires supervision for eating meals. The Resident uses a walker to aid in mobility. On 2/9/21 approximately 1:00 PM Resident #15 was asked about abuse and neglect in the facility, she stated There was one aide that wasn't nice but I told her to leave. She hasn't been around lately. On 2/10/20 during clinical record review it was discovered that the following entry was made in the progress notes: 1/1/21 at 9:18 PM - At 430 PM [Resident #15 name redacted] came out from her room and was ambulating with her rollator. She passed by the nurse's station and stated 'Someone banged my face and head in the bars this morning.' Writer asked if she can recall the name of the person and she stated 'I don't know.' On 2/10/21 at 11:41 an interview was conducted with the DON and the Administrator who was asked about an incident involving Resident #15 and LPN A. The Administrator stated it happened when she was out sick. She stated that The DON called me at home. When asked what day she was notified she stated she wasn't sure. She also stated 2 CNA's that work night shift reported the incident. When asked who they reported it to she stated They called me at home. I told the DON to do the investigation. The Administrator submitted a Corrective Action Plan for LPN A excerpts are as follows: Employee Name: [redacted] Department: Nursing Date: 1/28/21 Date of Occurrence: 1/1/21 Location: Nursing Time: 11 pm -7 am Action Taken: Written Counseling Description of Issue: [box checked] Policy Violation [box checked] other: Mental Intimidation. Explanation: It was reported to Acting DON by Administrator on 1/6/21 of an incident involving resident # [medical record number redacted] on the morning of 1/1/21. The report stated that Resident was refusing care which was reported to the Charge Nurse, [LPN A name redacted]. At that time, Charge Nurse and CNA both went in to care for Resident. Per report, Resident continued to be resistant to care and Charge Nurse began to pull down Residents clothes while Resident was in bed and was speaking to Resident in a loud and uncalm voice. When Charge Nurse was pulling Resident's clothes off, the bed was unlocked on one side and began to move with the headboard hitting the wall. Charge Nurse locked the bed and continued pulling clothes off, kicking the soiled depends and clothing on the floor at which time she was bumping or hitting the walker and rocking chair with her feet which in turn was hitting the wall and the furniture in the Resident's room. Resident yelled at Charge Nurse to stop and Charge Nurse responded that they were there to help her and she was fighting them and telling them that they were hitting her furniture. Charge Nurse then stated This is how we hit furniture and grabbed the walker or the rocking chair and was hitting it against the wall or the china dresser. CNA approached the Resident and took over washing her up and changing her clothes and Charge Nurse exited the room, however she was still talking to the Resident in a loud and Unocal manner. Per CNA, Resident at this time was reported to be shaking and walked outside of her room and sat in recliner on the unit. Another staff member came to see what all the loud voices was about and to see if everything was okay. The Charge Nurse said everything was Okay. On the night of 1/2/21 staff reported that when they knocked on the Resident's door, Resident jumped, seemed scared and was shaking. She reported to the staff that 'the black woman with the round thing on her head' came into her room and kept hitting her head on the wall. At a later time that same night Resident reported the same thing and also said ' I think it was T, (which is what she calls the Charge Nurse), but why would she do that?' At a later time, a staff member stated that Resident approached her and stated the night nurse [name redacted], who wears that knot on her head, hit her in the arm and the head. The staff member asked when that happened and was told it happened a few nights ago and that the nurse was hitting and kicking her bed and throwing her chair around. Staff also reports that Resident has been telling other people who will listen to her, including her family, that she was hit and kicked by the night nurse, [name redacted], and that she did not want to stay at [facility name redacted] anymore because she might be killed. It was noted that the Corrective Action Plan had not been signed by the DON or the LPN. The DON was asked about why the document had not been signed and she stated The LPN has been out of the facility on Administrative Leave. When asked was that due to this incident she stated, Yes I believe so. On 2/10/21 a review of the time clock punches for LPN A revealed that LPN A continued to work on the very same unit with the Resident until 2/1/21. On this date she was written up for Sleeping on the job. On 2/10/21 at approximately 3:00 PM an interview was conducted with the Administrator and she was asked if the LPN A was still an employee there and she stated that she is supposed to come in on Thursday (2/11/21) to sign the corrective action plan. The Administrator was then asked to provide the survey team with the entire investigation including witness statements. The witness statement from CNA C was reviewed and an excerpt is as follows: 1/14/21 - The incident started when I was cleaning and sanitizing the shower room, when I heard people screaming and yelling, so I immediately ran out and saw the nurse [LPN name redacted] standing at the opening of room [ROOM NUMBER], which is [Resident #15 name redacted] room. The nurse was leaning on the resident's door and the resident was standing inside with her walker extended out in front of the nurse and her aide [CNA name redacted] behind her. I asked them was everything okay and the nurse said yes. When I was emptying my soiled linen cart the resident came to me and said the night nurse, [name redacted], who wear that knot on her head, hit her in the arm and head. I asked her when did this happen she said a few nights ago & the nurse was hitting and kicking her bed and throwing her chair around. I reported this to [Administrator name redacted] and she said she will report it to [DON name redacted] to investigate it, as time went by almost 2 weeks, I heard nothing, so I then called Mother and she stated she had heard something about it and she will look into it better. I wasn't sure if anyone was looking into the matter. [Resident #15 name redacted] was telling anyone including her family, who will listen to her, that she was hit and kicked by the night nurse, and that she didn't want to stay at [facility name redacted] anymore because she might be killed. A review of the Abuse and Neglect Policy read: Page 9 Paragraph F Protection Abuse Policy Requirements: It is the policy of this HOME that the resident(s) will be protected from the alleged offender(s). Procedure: Immediately upon receiving a report of alleged abuse, the Administrator, and / or designee will coordinate delivery of appropriate medical and or psychological care and attention. Ensuring safety and wellbeing for the vulnerable individual are of utmost priority. Safety, security and support of the Resident, their roommate, if applicable and other Residents with the potential to be affected will be provided. This should include as appropriate: 1. Procedures must be in place to provide the Resident with a safe, protected environment during the investigation. a. The alleged perpetrator will immediately be removed and the Resident protected. Employees accused of alleged abuse will be immediately removed from the Home and will remain removed pending the results of a thorough investigation. (Decision of the extent of immediate disciplinary action will be made by the Administrator and/or designee). 2. For Resident #13 LPN B failed to implement facility policies and procedures by not immediately reporting an allegation of abuse. Resident # 13 a [AGE] year old woman, was admitted to the facility on [DATE], with diagnoses of but not limited to hypertension, malignant neoplasm of pancreas, diabetes, UTI, prosthetic heart valve, and age related macular degeneration. Resident #13's most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/4/20, an annual assessment, coded Resident #13 as having a BIMS (brief interview of mental status) score of 14 out of a possible 15. This score indicates no cognitive impairment. The MDS codes the resident as needing extensive assistance with all aspects of ADL care with the exception of eating. Resident #13 is able to feed herself with only supervision. The Resident uses a walker for aid in short distance mobility and a wheelchair for longer distances. On 2/10/21 at approximately 10:00 AM Surveyor C reported the following observation. At 9:20 AM Resident #13 was in wheel chair next to the medication cart. Resident #13 stated Somebody kicked me. LPN C asked Who kicked you? Resident replied I don't know. LPN C assisted the Resident to lift her right pant leg to reveal a dressing on right shin. LPN C then stated to the resident No one kicked you and went on to tell Resident that she had a dressing on her shin from a skin tear. Another staff member then approached Resident and rolled her down the hall in wheel chair. At 10:40 AM, Surveyor B interviewed Resident #13 after she returned from physical therapy. The Resident was asked about the injury to her right shin and she stated Somebody kicked me, I don't remember who. When asked about abuse or neglect she stated I cannot stand that nurse from last night we had a fight. When asked what happened she stated I can't stand her she is rude and she just would not leave me alone, so we got into a fight. She is not a good nurse and she drops stuff and then picks it up off the floor and gives it to you. That's not sanitary or wise these days. She has no patience. I was kicking at her to get her to leave me alone. They know I don't like her and don't want her in my room. On 2/10/21 a review of the clinical record revealed the following progress note: 2/10/21 at 12:59 AM - Resident call bell was on, and staff went to answer the call bell, resident stated she want to go to BR, staff got resident up in the w/c and assisted resident to the bathroom and while assisting resident back to bed she refused to allow staff to apply pillow under her legs and was insisting on keeping her legs outside the bed sa [sic] staff was assisting to put the legs back to bed resident became physically aggressive and started kicking and swinging at staff was verbally aabusive [sic] and told staff she hate her, redirected and assured resident that staff is here to help and to assure her safety. On 2/10/21 at approximately 10:58 AM an interview was conducted with the Administrator who was asked if she was aware of an allegation of abuse by Resident #13. She stated that she had not heard of this but would start an investigation. Immediate Jeopardy was called on 2/10/21 at 3:26 PM, and the Administrator was notified. Immediate Jeopardy Abatement Plan is as follows: All staff on evening shift, 3pm-11pm, for 2/10/21 will be in -serviced on Resident Rights and Abuse and Neglect on 2/10/21. Staff for night shift, 11pm -7 am, will be in serviced before their shift on 2/10/21. Dayshift staff will be in-serviced before their shift on 2/11/21. There will be a mandatory all staff meeting on 2/11/21 at 12 noon for training on Resident's Rights and Abuse and Neglect. All afore-mentioned staff will be provided a copy of the homes policy regarding Resident Rights and Abuse and Neglect at the time of the meeting. All other staff will be trained over the phone or in person before working with residents. LPN B has been removed from schedule and statement requested from this person regarding incident with Resident #13 on 2/10/21. Per policy, LPN B will remain removed pending the results of a thorough investigation and disciplinary action will be made by the Administrator. LPN C has been called for a statement about her conversation with Resident #13 this morning 2/10/21. She has provided documentation of the incident with Resident #13 on 2/10/21. Interviewing every Nursing Resident (24 total) to determine if any abuse, neglect, or resident rights violations have occurred. This has been completed by 2/10/21 by 445 pm. Body checks will be completed by 10 AM on 2/11/21 for cognitively impaired residents. The Abatement Plan will be completed by 4PM on 2/11/21 The survey team verified education in service sheet checks, interviews, and completed skin assessments were reviewed. The Immediate Jeopardy was removed on 2/12/21 at 5:30 PM.

Based on observation, interview, clinical record review and facility documentation the faintly staff failed to ensure Residents were free from abuse for 1 Resident (# 15) in a survey sample of 17 Residents. This is harm. The findings included: 1. For Resident #15 the facility failed to prevent abuse. This is harm. Resident #15 an [AGE] year old woman, was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15's most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/21/20, an quarterly assessment, coded Resident #15 as having a BIMS (brief interview of mental status) score of 10 out of a possible 15. This score indicates moderate cognitive impairment. The MDS codes the resident as needing extensive assistance with physical assistance of 1 person for toileting, hygiene, dressing and bed mobility. She requires limited assistance with physical assistance of 1 person for walking in room, and transfers. She requires supervision for eating meals. The Resident uses a walker to aid in mobility. On 2/9/21 approximately 1:00 PM Resident #15 was asked about abuse and neglect in the facility, she stated There was one aide that wasn't nice but I told her to leave. She hasn't been around lately. On 2/10/20 during clinical record review it was discovered that the following entry was made in the progress notes: 1/1/21 at 9:18 PM - At 430 PM [Resident #15 name redacted] came out from her room and was ambulating with her rollator. She passed by the nurse's station and stated 'Someone banged my face and head in the bars this morning.' Writer asked if she can recall the name of the person and she stated 'I don't know.' On 2/10/21 at 11:41 an interview was conducted with the DON and the Administrator who was asked about an incident involving Resident #15 and LPN A. The Administrator stated it happened when she was out sick with Covid. The DON called me at home. She stated 2 CNA's that work night shift reported the incident. When asked who they reported it, to her she stated They called me at home and I told the DON to do the investigation. The Administrator submitted a Corrective Action Plan for LPN A, excerpts are as follows: Employee Name: [redacted] Department: Nursing Date: 1/28/21 Date of Occurrence: 1/1/21 Location: Nursing Time: 11 pm -7 am Action Taken: Written Counseling Description of Issue: [box checked] Policy Violation [box checked] other: Mental Intimidation. Explanation: It was reported to Acting DON by Administrator on 1/6/21 of an incident involving resident # [medical record number redacted] on the morning of 1/1/21. The report stated that Resident was refusing care which was reported to the Charge Nurse, [LPN A name redacted]. At that time, Charge Nurse and CNA both went in to care for Resident. Per report, Resident continued to be resistant to care and Charge Nurse began to pull down Residents clothes while Resident was in bed and was speaking to Resident in a loud and uncalm voice. When Charge Nurse was pulling Resident's clothes off, the bed was unlocked on one side and began to move with the headboard hitting the wall. Charge Nurse locked the bed and continued pulling clothes off, kicking the soiled depends and clothing on the floor at which time she was bumping or hitting the walker and rocking chair with her feet which in turn was hitting the wall and the furniture in the Resident's room. Resident yelled at Charge Nurse to stop and Charge Nurse responded that they were there to help her and she was fighting them and telling them that they were hitting her furniture. Charge Nurse then stated This is how we hit furniture and grabbed the walker or the rocking chair and was hitting it against the wall or the china dresser. CNA approached the Resident and took over washing her up and changing her clothes and Charge Nurse exited the room, however she was still talking to the Resident in a loud and Unocal manner. Per CNA, Resident at this time was reported to be shaking and walked outside of her room and sat in recliner on the unit. Another staff member came to see what all the loud voices was about and to see if everything was okay. The Charge Nurse said everything was Okay. On the night of 1/2/21 staff reported that when they knocked on the Resident's door, Resident jumped, seemed scared and was shaking. She reported to the staff that 'the black woman with the round thing on her head' came into her room and kept hitting her head on the wall. At a later time that same night Resident reported the same thing and also said ' I think it was [name redacted], (which is what she calls the Charge Nurse), but why would she do that?' At a later time, a staff member stated that Resident approached her and stated the night nurse T, who wears that knot on her head, hit her in the arm and the head. The staff member asked when that happened and was told it happened a few nights ago and that the nurse was hitting and kicking her bed and throwing her chair around. Staff also reports that Resident has been telling other people who will listen to her, including her family, that she was hit and kicked by the night nurse, [name redacted], and that she did not want to stay at [facility name redacted] anymore because she might be killed. It was noted that the Corrective Action Plan had not been signed by the DON or the LPN. The DON was asked about why the document had not been signed and she stated The LPN has been out of the facility on Administrative Leave. When asked was that due to this incident she stated, Yes I believe so. On 2/10/21 a review of the time clock punches for LPN A revealed that LPN A continued to work on the very same unit with the Resident until 2/1/21 when she was written up for Sleeping on the job. On 2/10/21 at approximately 3:00 PM an interview was conducted with the Administrator and she was asked if the LPN A was still an employee there and she stated that she is supposed to come in on Thursday (2/11/21) to sign the corrective action plan. Excerpts from CNA D's statement is as follows: I was disappointed by the actions of my supervisor [LPN A name redacted]. Normally if a resident refuses care (especially at this time early in the morning or during the night) I would leave give them time and come back to them. This morning [LPN A name redacted] said she'll go in there with me and get [resident name redacted] up. [LPN A] began to pull [resident #15's name redacted] clothes down while she was still in bed. As [LPN A] was yanking on her pajama pants she was also speaking in a loud, uncalm voice. I could tell that [resident name redacted] was frightened as she tried to hold on to her pajama pants. I couldn't look [LPN A's name redacted] way and all I could think was to get between [LPN A] and [Resident #13]. By then [Resident #13 name redacted] was on the side of the bed looking scared and confused as [LPN A name redacted] kept talking loudly and kicking the ripped pull-up that fell to the floor. I heard [Resident #13] telling [LPN A] stop hitting my furniture. When [LPN A] was kicking the stuff (pull up and pants) on the floor out of the way, she was bumping or hitting the walker and rocking chair with her feet which then were hitting the wall. At this time I was standing there looking for an opening to get between LPN A and what she was doing, and in front of [resident #13] So I got to [Resident #13] and washed and changed her right there at her bedside. LPN A still talking loudly and inappropriately to [Resident #13] at this time she was shaking. The next night I went to work and when I knocked on her door she jumped. I went to her to calm her down and she was shaking and seemed scared. She told me that she black woman with the round thing on her head wet into her room and kept hitting her head on the wall. On 2/11/21 the Administrator showed surveyor second Corrective Action Plan for LPN A dated 2/2/21 excerpts are as follows: Employee name: [redacted] Department: Nursing Date 2/2/21 Date of Occurrence: 2/2/21 Action Taken: [box checked] Discharge from Employment Description of Issue: [box checked] Unsatisfactory Work Quality [box checked] Policy Violation Explanation: Employees are subject to appropriate diciplinary [sic] action up to and including dismissal for violations of the Home's policies including but not limited to the following : Negligent or poor performance of duties; Sleeping on Duty. pg. 74 employee handbook. NOTE: The LPN A was subsequently terminated on Thurs 2/11/21 for Sleeping on Duty. A review of the Abuse and Neglect Policy read: Page 7 of 13 Paragraph E Investigation Abuse Policy Requirements: It is the policy of this Home that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. Page 9 Paragraph F Protection Abuse Policy Requirements: It is the policy of this HOME that the resident(s) will be protected from the alleged offender(s). Procedure: Immediately upon receiving a report of alleged abuse, the Administrator, and / or designee will coordinate delivery of appropriate medical and or psychological care and attention. Ensuring safety and wellbeing for the vulnerable individual are of utmost priority. Safety, security and support of the Resident, their roommate, if applicable and other Residents with the potential to be affected will be provided. This should include as appropriate: 1. Procedures must be in place to provide the Resident with a safe, protected environment during the investigation. a. The alleged perpetrator will immediately be removed and the Resident protected. Employees accused of alleged abuse will be immediately removed from the Home and will remain removed pending the results of a thorough investigation. (Decision of the extent of immediate disciplinary action will be made by the Administrator and/or designee). On 2/11/21 during the end of day conference the Administrator was made aware of the concerns and no further information was provided. The Administrator was made aware of the concerns during the end of day meeting on 2/10/21, and no further information was provided.

Based on observation, interview, clinical record review and facility documentation the faintly staff failed to ensure Residents were free from abuse for 1 Resident (# 15) in a survey sample of 17 Residents. This is harm. The findings included: 1. For Resident #15 the facility failed to prevent abuse. This is harm. Resident #15 an [AGE] year old woman, was admitted to the facility on [DATE] with diagnoses of but not limited to dementia without behavioral disturbance, anemia, chronic kidney disease, anxiety, major depressive disorder, falls, and atherosclerotic heart disease. Resident #15's most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/21/20, an quarterly assessment, coded Resident #15 as having a BIMS (brief interview of mental status) score of 10 out of a possible 15. This score indicates moderate cognitive impairment. The MDS codes the resident as needing extensive assistance with physical assistance of 1 person for toileting, hygiene, dressing and bed mobility. She requires limited assistance with physical assistance of 1 person for walking in room, and transfers. She requires supervision for eating meals. The Resident uses a walker to aid in mobility. On 2/9/21 approximately 1:00 PM Resident #15 was asked about abuse and neglect in the facility, she stated There was one aide that wasn't nice but I told her to leave. She hasn't been around lately. On 2/10/20 during clinical record review it was discovered that the following entry was made in the progress notes: 1/1/21 at 9:18 PM - At 430 PM [Resident #15 name redacted] came out from her room and was ambulating with her rollator. She passed by the nurse's station and stated 'Someone banged my face and head in the bars this morning.' Writer asked if she can recall the name of the person and she stated 'I don't know.' On 2/10/21 at 11:41 an interview was conducted with the DON and the Administrator who was asked about an incident involving Resident #15 and LPN A. The Administrator stated it happened when she was out sick with Covid. The DON called me at home. She stated 2 CNA's that work night shift reported the incident. When asked who they reported it, to her she stated They called me at home and I told the DON to do the investigation. The Administrator submitted a Corrective Action Plan for LPN A, excerpts are as follows: Employee Name: [redacted] Department: Nursing Date: 1/28/21 Date of Occurrence: 1/1/21 Location: Nursing Time: 11 pm -7 am Action Taken: Written Counseling Description of Issue: [box checked] Policy Violation [box checked] other: Mental Intimidation. Explanation: It was reported to Acting DON by Administrator on 1/6/21 of an incident involving resident # [medical record number redacted] on the morning of 1/1/21. The report stated that Resident was refusing care which was reported to the Charge Nurse, [LPN A name redacted]. At that time, Charge Nurse and CNA both went in to care for Resident. Per report, Resident continued to be resistant to care and Charge Nurse began to pull down Residents clothes while Resident was in bed and was speaking to Resident in a loud and uncalm voice. When Charge Nurse was pulling Resident's clothes off, the bed was unlocked on one side and began to move with the headboard hitting the wall. Charge Nurse locked the bed and continued pulling clothes off, kicking the soiled depends and clothing on the floor at which time she was bumping or hitting the walker and rocking chair with her feet which in turn was hitting the wall and the furniture in the Resident's room. Resident yelled at Charge Nurse to stop and Charge Nurse responded that they were there to help her and she was fighting them and telling them that they were hitting her furniture. Charge Nurse then stated This is how we hit furniture and grabbed the walker or the rocking chair and was hitting it against the wall or the china dresser. CNA approached the Resident and took over washing her up and changing her clothes and Charge Nurse exited the room, however she was still talking to the Resident in a loud and Unocal manner. Per CNA, Resident at this time was reported to be shaking and walked outside of her room and sat in recliner on the unit. Another staff member came to see what all the loud voices was about and to see if everything was okay. The Charge Nurse said everything was Okay. On the night of 1/2/21 staff reported that when they knocked on the Resident's door, Resident jumped, seemed scared and was shaking. She reported to the staff that 'the black woman with the round thing on her head' came into her room and kept hitting her head on the wall. At a later time that same night Resident reported the same thing and also said ' I think it was [name redacted], (which is what she calls the Charge Nurse), but why would she do that?' At a later time, a staff member stated that Resident approached her and stated the night nurse T, who wears that knot on her head, hit her in the arm and the head. The staff member asked when that happened and was told it happened a few nights ago and that the nurse was hitting and kicking her bed and throwing her chair around. Staff also reports that Resident has been telling other people who will listen to her, including her family, that she was hit and kicked by the night nurse, [name redacted], and that she did not want to stay at [facility name redacted] anymore because she might be killed. It was noted that the Corrective Action Plan had not been signed by the DON or the LPN. The DON was asked about why the document had not been signed and she stated The LPN has been out of the facility on Administrative Leave. When asked was that due to this incident she stated, Yes I believe so. On 2/10/21 a review of the time clock punches for LPN A revealed that LPN A continued to work on the very same unit with the Resident until 2/1/21 when she was written up for Sleeping on the job. On 2/10/21 at approximately 3:00 PM an interview was conducted with the Administrator and she was asked if the LPN A was still an employee there and she stated that she is supposed to come in on Thursday (2/11/21) to sign the corrective action plan. Excerpts from CNA D's statement is as follows: I was disappointed by the actions of my supervisor [LPN A name redacted]. Normally if a resident refuses care (especially at this time early in the morning or during the night) I would leave give them time and come back to them. This morning [LPN A name redacted] said she'll go in there with me and get [resident name redacted] up. [LPN A] began to pull [resident #15's name redacted] clothes down while she was still in bed. As [LPN A] was yanking on her pajama pants she was also speaking in a loud, uncalm voice. I could tell that [resident name redacted] was frightened as she tried to hold on to her pajama pants. I couldn't look [LPN A's name redacted] way and all I could think was to get between [LPN A] and [Resident #13]. By then [Resident #13 name redacted] was on the side of the bed looking scared and confused as [LPN A name redacted] kept talking loudly and kicking the ripped pull-up that fell to the floor. I heard [Resident #13] telling [LPN A] stop hitting my furniture. When [LPN A] was kicking the stuff (pull up and pants) on the floor out of the way, she was bumping or hitting the walker and rocking chair with her feet which then were hitting the wall. At this time I was standing there looking for an opening to get between LPN A and what she was doing, and in front of [resident #13] So I got to [Resident #13] and washed and changed her right there at her bedside. LPN A still talking loudly and inappropriately to [Resident #13] at this time she was shaking. The next night I went to work and when I knocked on her door she jumped. I went to her to calm her down and she was shaking and seemed scared. She told me that she black woman with the round thing on her head wet into her room and kept hitting her head on the wall. On 2/11/21 the Administrator showed surveyor second Corrective Action Plan for LPN A dated 2/2/21 excerpts are as follows: Employee name: [redacted] Department: Nursing Date 2/2/21 Date of Occurrence: 2/2/21 Action Taken: [box checked] Discharge from Employment Description of Issue: [box checked] Unsatisfactory Work Quality [box checked] Policy Violation Explanation: Employees are subject to appropriate diciplinary [sic] action up to and including dismissal for violations of the Home's policies including but not limited to the following : Negligent or poor performance of duties; Sleeping on Duty. pg. 74 employee handbook. NOTE: The LPN A was subsequently terminated on Thurs 2/11/21 for Sleeping on Duty. A review of the Abuse and Neglect Policy read: Page 7 of 13 Paragraph E Investigation Abuse Policy Requirements: It is the policy of this Home that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. Page 9 Paragraph F Protection Abuse Policy Requirements: It is the policy of this HOME that the resident(s) will be protected from the alleged offender(s). Procedure: Immediately upon receiving a report of alleged abuse, the Administrator, and / or designee will coordinate delivery of appropriate medical and or psychological care and attention. Ensuring safety and wellbeing for the vulnerable individual are of utmost priority. Safety, security and support of the Resident, their roommate, if applicable and other Residents with the potential to be affected will be provided. This should include as appropriate: 1. Procedures must be in place to provide the Resident with a safe, protected environment during the investigation. a. The alleged perpetrator will immediately be removed and the Resident protected. Employees accused of alleged abuse will be immediately removed from the Home and will remain removed pending the results of a thorough investigation. (Decision of the extent of immediate disciplinary action will be made by the Administrator and/or designee). On 2/11/21 during the end of day conference the Administrator was made aware of the concerns and no further information was provided. The Administrator was made aware of the concerns during the end of day meeting on 2/10/21, and no further information was provided.

Based on observation, staff interview, and clinical record review, the facility staff failed to identify and treat a Stage 3 sacral pressure wound for 1 Resident (Resident #18) in a sample size of 17 residents. This is harm. The findings included: Resident #18, a [AGE] year old male, was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #18's Minimum Data Set with an Assessment Reference Date of 12/21/2020 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 11 out of possible 15 indicative of moderate cognitive impairment. Functional status for bed mobility was coded as requiring extensive assistance from staff. Urinary continence was coded as frequently incontinent. Bowel continence was coded as occasionally incontinent. On 02/09/2021 at approximately 2:47 P.M., Resident #18 was observed sleeping in bed lying supine and leaning to the right with the head of the bed elevated approximately 30 degrees. Resident #18 had a wedge under his head and pillows on each side of the bed. On 02/09/2021 through 02/11/2021, Resident #18's clinical record was reviewed. An excerpt of a nursing skin assessment dated [DATE] at 9:45 A.M. under the header Skin Evaluation and sub-header site documented, Coccyx. Beside this site under the sub-header Description, it was documented, 2x2x1 stage 3 open area per wound doctor. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/11/21 at approximately 2:05 P.M., this surveyor and Licensed Practical Nurse D (LPN D) entered Resident #18's room to perform a skin assessment. LPN D stated that [Resident #18] had a healed stage 3 sacral wound. LPN D asked Employee J, a physical therapist, to assist with positioning. LPN D and Employee J assisted Resident #18 to reposition to his left side to assess sacral region. When the facility staff removed the brief, it was noted Resident #18 had a bowel movement in the brief but it did not obstruct the view of the sacral region. There was no dressing and no evidence of paste or cream on the buttocks or sacral region. The skin in the sacral region was reddened with an open area and slough at the center of the wound. When asked about assessment findings, LPN D stated that the wound physician saw [Resident #18] a few days ago and that [Resident #18] had a healed stage 3 sacral pressure wound. LPN D also stated that now it looks like [Resident #18] needs a treatment plan. LPN D also stated she would notify the wound doctor. On 02/11/2021 at approximately 4:05 P.M., LPN D provided wound physician notes and nursing notes associated with the finding. When asked how often skin assessments are performed, LPN D stated the nurses perform skin assessments once a month and document them in the electronic health record. LPN D also stated that the CNA's [certified nursing assistants] do skin checks with baths and document them in a book on the unit. A wound physician note dated 02/03/2021 under the header Stage 3 Pressure Wound Sacrum and sub-header Wound Progress, it was documented, Resolved. Anatomic location of previously existing wound examined today: epithelialized and resolved. Follow up only as needed. On 02/11/2021 at approximately 5:15 P.M., the facility staff provided a copy of the CNA skin check sheets for Resident #18. A document filled in by Certified Nursing Assistant A (CNA A) dated 02/10/2021 at 8:45 P.M. entitled, Pressure Ulcer Identification Pocket Pad documented the following header: CNA please complete for your unit, Check areas during your rounds, dressing and bathing, You are the first set of eyes that sees the skin, be sure to check feet, heels, buttocks and all other areas especially pressure areas, Please feel free to write on this sheet and use descriptions and circle or mark site on the image below and turn in to your nurse so they can follow-up, thanks. Place the patient's/resident's name on the top of the pad, date it, and place an X on the area of concern. Give this to the nurse and ask him or her to check the patient/resident. They will follow-up as needed. There was an X marked on the sacral region with the word Discoloration written beside it. On the bottom right side of the page, it was documented, Noted RN [registered nurse] 02/10/2021. A nurse's note written by LPN D dated 02/11/2021 at 2:31 P.M. (approximately 30 minutes after the wound observation with this surveyor) documented, Upon checking residents [sic] buttocks, noticed sacrum wound stage 3 pressure area appeared reopened formally resolved on 02/03/2021 with [wound physician company name] wound specialist [physician name] in person, sacrum wound area red, 1.0 x 1.0cm [centimeter], partial thickness skin loss noted but no bone, tendon or muscle tissues are exposed, area is without drainage or slough, resident stated he had no pain, PT [physical therapist name] assisted in turning and repositioning of resident, contacted [wound doctor name] to complete telemed visit for re-opened pressure wound to sacrum. An excerpt of a nurse's note written by LPN D dated 02/11/2021 at 3:01 P.M. documented, Resident evaluated by [wound doctor name and company] wound specialist via telemed for re-opened stage 3 pressure wound to sacrum, per forms 2 x 2 x 0.1 cm, 'Patient with a re-opened stage 3 wound, when healed used [MEDICATION(S)] paste as prevenative [sic] measure, please resume q day [every day] alginate dressing with foam which has worked in the past, [sic]' A nurses note written by LPN D dated 02/11/2021 at 3:25 P.M. documented, Stage 3 pressure sacrum wound claened [sic] and dry, no drainage no signs of infection noted, calcium alginate with foam dressing applied to scarum [sic], no pain noted during dressing change, eveing [sic] nurse present and notified of new orders. A nurse's note written by LPN D dated 02/11/2021 at 3:32 PM documented, Resident on pressure relieving mattress, wedge placed under resident buttocks, reisdent [sic] currently facing the window, notified cna [certified nursing assistant] to continue to turn the resident and reposition q 2hr [every two hours] and as needed, contniue [sic] back to bed after meals. A wound physician note dated 02/11/2021 under the header Focused Wound Exam (Site 4) Stage 3 Pressure Wound Sacrum included but not limited to the following sub-headers and input: Etiology: Pressure MDS 3.0 Stage: 3 Duration: > [greater than] 1 days [sic] Wound size (L x W x D)[length x width x depth]: 2 x 2 x 2 x 0.1 cm [centimeters]. Surface area: 4.00 cm² Exudate: Moderate Serous Slough: 20% Granulation tissue: 60% Other viable tissue: 20% (dermis). Additional Wound Detail: Patient with reopened stage 3 wound. When healed a prevention order was put in place using [MEDICATION(S)] paste. Please resume algiante [sic] and foam which has worked well in the past. Dressing Treatment Plan Primary Dressing: Alginate calcium apply once daily for 30 days Secondary Dressing: Foam Silicone bdr [border] & faced apply three times per week for 30 days Reason for No Debridement: Telemedicine. On 02/12/2021 at approximately 11:15 A.M., an interview with the Director of Nursing was conducted. In reference to another Resident, the Director of Nursing stated that a skin assessment by a CNA was completed. When questioned about CNA's doing skin assessments, the Director of Nursing stated, Well, it's not a skin assessment, the CNA's are just looking to see if they see discolorations and then they report it to the nurse. When asked about policy for the frequency of skin assessments, the Director of Nursing stated that nurses complete skin assessments once a month and the CNA's fill out the sheet once a week or when giving [residents] a bath. When informed of discovering a stage 3 sacral pressure wound during a skin assessment with this surveyor on 02/11/2021, the Director of Nursing stated [Resident #18] was up in his chair longer than usual on the previous day (02/10/2021) due to a doctor's appointment so the re-opening of the stage 3 sacral wound may be due to that. On 02/12/2021 at approximately 1:45 P.M., the administrator was notified of the wound observation (discovery of a stage 3 sacral pressure wound with slough in the wound bed) with this surveyor and facility staff on 02/11/2021. On 02/16/2021 at approximately 8:15 A.M., the facility staff provided further documents which included the following: A handwritten statement entitled, Statement from CNA that had [Resident #18] on 2/11/21 from 6AM - 2PM documented, I got [Resident #18's name] down and up 4 times yesterday 02/11/21 and I applied cream on his bottom each time. He ate, was cleaned up from bowel movements and urinations several times. The statement was signed by CNA E and dated 2/12/21. Below that handwritten statement, there was another handwritten statement dated 2/15/21 and documented, [CNA E's name] stated that she changed him again after lunch he was dry. That statement was signed by Registered Nurse A (RN A). A handwritten statement written by CNA A dated 2/12/21 but not timed documented, On 2/11/2021 (no time included) while helping a resident to the bathroom, the nurse told me that [Resident #18's name] needed to be changed. When I finished helping the resident I went to change [Resident #18's last name]. He was incontinent of stool and urine I wash him up [sic] an [sic] put calmosptine [sic] on his bottom and around his wounds. The dressing was still in place. A typewritten statement dated 2/15/21 signed by Employee J, Physical Therapist, documented, On Thursday, February 11, 2021 Physical Therapist was asked to assist the wound care nurse in turning a patient in bed so his skin could be assessed. Therapist observed the patient sacral region had white epithelial scar tissue with blanchable pink borders/periwound & appeared to be healing wound. The skin surrounding the wound area, wound borders and the wound itself appeared clean. The skin on patient's buttocks was clean and intact, as there were no other observable wounds noted. Physical therapist also observed that the patient had just begun to have a bowel movement when the nurse remove the diaper for the patient's skin to be assessed. Upon initially removing the diaper it appeared to be clean, dry and free of stool. Therapist was unable to observe the perianal scan due to patient having just begun to have a bowel movement. This statement contradicts what LPN D and the wound physician documented in the clinical record. In summary, the facility staff failed to identify and treat a stage 3 sacral pressure wound until it was discovered during a skin assessment with the wound nurse and this surveyor on 02/11/2021. According to the CNA sheet completed by CNA A on 02/10/2021 at 8:45 P.M., there was discoloration in the sacral region and a registered nurse (unnamed) was made aware on 02/10/2021. There was no evidence in the clinical record the sacral region was then assessed by a nurse or findings documented.

Based on observation, staff interview, and clinical record review, the facility staff failed to identify and treat a Stage 3 sacral pressure wound for 1 Resident (Resident #18) in a sample size of 17 residents. This is harm. The findings included: Resident #18, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but were not limited to type 2 diabetes mellitus and dementia. Resident #18's Minimum Data Set with an Assessment Reference Date of 12/21/2020 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 11 out of possible 15 indicative of moderate cognitive impairment. Functional status for bed mobility was coded as requiring extensive assistance from staff. Urinary continence was coded as frequently incontinent. Bowel continence was coded as occasionally incontinent. On 02/09/2021 at approximately 2:47 P.M., Resident #18 was observed sleeping in bed lying supine and leaning to the right with the head of the bed elevated approximately 30 degrees. Resident #18 had a wedge under his head and pillows on each side of the bed. On 02/09/2021 through 02/11/2021, Resident #18's clinical record was reviewed. An excerpt of a nursing skin assessment dated [DATE] at 9:45 A.M. under the header Skin Evaluation and sub-header site documented, Coccyx. Beside this site under the sub-header Description, it was documented, 2x2x1 stage 3 open area per wound doctor. A physician's order for zinc oxide paste to apply to sacrum topically had a start date of 12/18/2020 and an end date of 12/23/2020. A physician's order for calcium alginate to apply to sacrum topically had a start date of 12/24/2020 and an end date 02/05/2021. On 02/11/21 at approximately 2:05 P.M., this surveyor and Licensed Practical Nurse D (LPN D) entered Resident #18's room to perform a skin assessment. LPN D stated that [Resident #18] had a healed stage 3 sacral wound. LPN D asked Employee J, a physical therapist, to assist with positioning. LPN D and Employee J assisted Resident #18 to reposition to his left side to assess sacral region. When the facility staff removed the brief, it was noted Resident #18 had a bowel movement in the brief but it did not obstruct the view of the sacral region. There was no dressing and no evidence of paste or cream on the buttocks or sacral region. The skin in the sacral region was reddened with an open area and slough at the center of the wound. When asked about assessment findings, LPN D stated that the wound physician saw [Resident #18] a few days ago and that [Resident #18] had a healed stage 3 sacral pressure wound. LPN D also stated that now it looks like [Resident #18] needs a treatment plan. LPN D also stated she would notify the wound doctor. On 02/11/2021 at approximately 4:05 P.M., LPN D provided wound physician notes and nursing notes associated with the finding. When asked how often skin assessments are performed, LPN D stated the nurses perform skin assessments once a month and document them in the electronic health record. LPN D also stated that the CNA's [certified nursing assistants] do skin checks with baths and document them in a book on the unit. A wound physician note dated 02/03/2021 under the header Stage 3 Pressure Wound Sacrum and sub-header Wound Progress, it was documented, Resolved. Anatomic location of previously existing wound examined today: epithelialized and resolved. Follow up only as needed. On 02/11/2021 at approximately 5:15 P.M., the facility staff provided a copy of the CNA skin check sheets for Resident #18. A document filled in by Certified Nursing Assistant A (CNA A) dated 02/10/2021 at 8:45 P.M. entitled, Pressure Ulcer Identification Pocket Pad documented the following header: CNA please complete for your unit, Check areas during your rounds, dressing and bathing, You are the first set of eyes that sees the skin, be sure to check feet, heels, buttocks and all other areas especially pressure areas, Please feel free to write on this sheet and use descriptions and circle or mark site on the image below and turn in to your nurse so they can follow-up, thanks. Place the patient's/resident's name on the top of the pad, date it, and place an X on the area of concern. Give this to the nurse and ask him or her to check the patient/resident. They will follow-up as needed. There was an X marked on the sacral region with the word Discoloration written beside it. On the bottom right side of the page, it was documented, Noted RN [registered nurse] 02/10/2021. A nurse's note written by LPN D dated 02/11/2021 at 2:31 P.M. (approximately 30 minutes after the wound observation with this surveyor) documented, Upon checking residents [sic] buttocks, noticed sacrum wound stage 3 pressure area appeared reopened formally resolved on 02/03/2021 with [wound physician company name] wound specialist [physician name] in person, sacrum wound area red, 1.0 x 1.0cm [centimeter], partial thickness skin loss noted but no bone, tendon or muscle tissues are exposed, area is without drainage or slough, resident stated he had no pain, PT [physical therapist name] assisted in turning and repositioning of resident, contacted [wound doctor name] to complete telemed visit for re-opened pressure wound to sacrum. An excerpt of a nurse's note written by LPN D dated 02/11/2021 at 3:01 P.M. documented, Resident evaluated by [wound doctor name and company] wound specialist via telemed for re-opened stage 3 pressure wound to sacrum, per forms 2 x 2 x 0.1 cm, 'Patient with a re-opened stage 3 wound, when healed used zinc paste as prevenative [sic] measure, please resume q day [every day] alginate dressing with foam which has worked in the past, [sic]' A nurses note written by LPN D dated 02/11/2021 at 3:25 P.M. documented, Stage 3 pressure sacrum wound claened [sic] and dry, no drainage no signs of infection noted, calcium alginate with foam dressing applied to scarum [sic], no pain noted during dressing change, eveing [sic] nurse present and notified of new orders. A nurse's note written by LPN D dated 02/11/2021 at 3:32 PM documented, Resident on pressure relieving mattress, wedge placed under resident buttocks, reisdent [sic] currently facing the window, notified cna [certified nursing assistant] to continue to turn the resident and reposition q 2hr [every two hours] and as needed, contniue [sic] back to bed after meals. A wound physician note dated 02/11/2021 under the header Focused Wound Exam (Site 4) Stage 3 Pressure Wound Sacrum included but not limited to the following sub-headers and input: Etiology: Pressure MDS 3.0 Stage: 3 Duration: > [greater than] 1 days [sic] Wound size (L x W x D)[length x width x depth]: 2 x 2 x 2 x 0.1 cm [centimeters]. Surface area: 4.00 cm² Exudate: Moderate Serous Slough: 20% Granulation tissue: 60% Other viable tissue: 20% (dermis). Additional Wound Detail: Patient with reopened stage 3 wound. When healed a prevention order was put in place using zinc paste. Please resume algiante [sic] and foam which has worked well in the past. Dressing Treatment Plan Primary Dressing: Alginate calcium apply once daily for 30 days Secondary Dressing: Foam Silicone bdr [border] & faced apply three times per week for 30 days Reason for No Debridement: Telemedicine. On 02/12/2021 at approximately 11:15 A.M., an interview with the Director of Nursing was conducted. In reference to another Resident, the Director of Nursing stated that a skin assessment by a CNA was completed. When questioned about CNA's doing skin assessments, the Director of Nursing stated, Well, it's not a skin assessment, the CNA's are just looking to see if they see discolorations and then they report it to the nurse. When asked about policy for the frequency of skin assessments, the Director of Nursing stated that nurses complete skin assessments once a month and the CNA's fill out the sheet once a week or when giving [residents] a bath. When informed of discovering a stage 3 sacral pressure wound during a skin assessment with this surveyor on 02/11/2021, the Director of Nursing stated [Resident #18] was up in his chair longer than usual on the previous day (02/10/2021) due to a doctor's appointment so the re-opening of the stage 3 sacral wound may be due to that. On 02/12/2021 at approximately 1:45 P.M., the administrator was notified of the wound observation (discovery of a stage 3 sacral pressure wound with slough in the wound bed) with this surveyor and facility staff on 02/11/2021. On 02/16/2021 at approximately 8:15 A.M., the facility staff provided further documents which included the following: A handwritten statement entitled, Statement from CNA that had [Resident #18] on 2/11/21 from 6AM - 2PM documented, I got [Resident #18's name] down and up 4 times yesterday 02/11/21 and I applied cream on his bottom each time. He ate, was cleaned up from bowel movements and urinations several times. The statement was signed by CNA E and dated 2/12/21. Below that handwritten statement, there was another handwritten statement dated 2/15/21 and documented, [CNA E's name] stated that she changed him again after lunch he was dry. That statement was signed by Registered Nurse A (RN A). A handwritten statement written by CNA A dated 2/12/21 but not timed documented, On 2/11/2021 (no time included) while helping a resident to the bathroom, the nurse told me that [Resident #18's name] needed to be changed. When I finished helping the resident I went to change [Resident #18's last name]. He was incontinent of stool and urine I wash him up [sic] an [sic] put calmosptine [sic] on his bottom and around his wounds. The dressing was still in place. A typewritten statement dated 2/15/21 signed by Employee J, Physical Therapist, documented, On Thursday, February 11, 2021 Physical Therapist was asked to assist the wound care nurse in turning a patient in bed so his skin could be assessed. Therapist observed the patient sacral region had white epithelial scar tissue with blanchable pink borders/periwound & appeared to be healing wound. The skin surrounding the wound area, wound borders and the wound itself appeared clean. The skin on patient's buttocks was clean and intact, as there were no other observable wounds noted. Physical therapist also observed that the patient had just begun to have a bowel movement when the nurse remove the diaper for the patient's skin to be assessed. Upon initially removing the diaper it appeared to be clean, dry and free of stool. Therapist was unable to observe the perianal scan due to patient having just begun to have a bowel movement. This statement contradicts what LPN D and the wound physician documented in the clinical record. In summary, the facility staff failed to identify and treat a stage 3 sacral pressure wound until it was discovered during a skin assessment with the wound nurse and this surveyor on 02/11/2021. According to the CNA sheet completed by CNA A on 02/10/2021 at 8:45 P.M., there was discoloration in the sacral region and a registered nurse (unnamed) was made aware on 02/10/2021. There was no evidence in the clinical record the sacral region was then assessed by a nurse or findings documented.

Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare, and serve foods in accordance with professional standards for food service safety. The facility staff failed to monitor temperatures on 02/04/21 for the dairy walk-in cooler, the walk-in freezer, the bread walk-in cooler, the produce walk-in cooler, and the misc. walk-in cooler.; failed to monitor a sanitation sink on 02/07/2021 and 02/08/21; and failed to monitor dishwater temperatures on 02/03/21, 02/04/21, 02/07/21, and 02/08/21; On 02/09/2021 at approximately 12:25 P.M., Surveyor A and Surveyor C toured the kitchen with head cook, Employee C. This surveyor and Surveyor A observed the Refrigerator Temperature Checklist for the month of February 2021. There were temperature values for 4 refrigerators (dairy walk-in cooler, bread walk-in cooler, produce walk-in cooler, and the misc. walk-in cooler) and one freezer recorded for each day with the exception of 02/04/2021. For 02/04/2021, there were no temperature values recorded, the input for each column was marked with an X. When asked about the expectation for monitoring refrigerator temperatures, Employee C stated that the temperatures should be written in. On 02/09/2021 at approximately 12:40 P.M., this surveyor and Surveyor A observed the sanitation sink PPM [parts per million] log for the week beginning 02/07/2021. The PPM values were recorded daily at 6:30 A.M., 10:30 A.M., 2:30 P.M., and 4:00 P.M. with the exception of 02/07/2021 at 2:30 P.M., 02/07/2021 at 4:00 P.M., and 02/08/2021 at 6:30 A.M. When asked about the expectation for checking the sanitation sink, Employee C stated that they probably just forgot to sign it. On 02/09/2021 at approximately 12:45 P.M., this surveyor and Surveyor A observed the dishwasher wash/rinse temperature log for the month of February 2021. There were wash and rinse temperature values recorded daily at 7:00 A.M., 1:00 P.M., and 7:00 P.M. with the exception of 02/03/2021 at 7:00 A.M., 02/04/2021 at 7:00 A.M., 02/07/2021 at 7:00 A.M., and 02/08/2021 at 7:00 A.M. On 02/10/2021 at approximately 8:45 A.M., Employee D, the Dietary Manager, was notified of finding. When asked about the expectation for monitoring temperatures of the refrigerators and the dishwasher cycles, Employee D stated that the temperatures should be checked so we know what they are. On 02/10/2021 at approximately 9:00 A.M., the administrator was notified of findings and a copy of their related kitchen policies were requested. The facility staff provided a copy of their policy entitled, Dish Machine Temperature Log. Under the header Policy it was documented, Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. The facility staff provided a copy of their policy entitled, Cleaning Dishes/Dish Machine. Under the header, Policy, it was documented, All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. The facility staff provided a copy of their policy entitled, Food Safety and Sanitation. In Section 4 entitled, Food Storage subpart (a), it was documented, Refrigerated food is stored at or below 41 degrees F [Fahrenheit].