Every finding on record at Autumn Care of Suffolk

Facility staff failed to ensure that residents and/or resident representative had the opportunity to develop an Advanced Directive for 19 of 24 residents reviewed. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives. Facility policy does not meet requirement for advance planning, affecting all residents including a number of residents in the survey sample. During record review, surveyors noted difficulty locating documentation concerning advance care planning in resident records. Since the facility had changed clinical record software during calendar year 2024, surveyors asked staff for advance care planning documentation for 24 residents in the survey sample. Surveyors received a policy titled Advance Care Planning Meeting Protocol with revision date 10/1/2023. The policy stated under Purpose: It is the policy of this facility that Advance Care Planning is conducted on each patient's admission to the facility. The patient will meet wit the appropriate member of the healthcare team to ensure their preferences; (Living Wills, Medical [NAME] of Attorney, etc.) are recorded in their medical record and further used in the patient's plan of care. Advance Care Planning assists to ensure that family, friends, and caregivers are all familiar with a patient's wishes regarding the care they wish to receive, especially re;dated to end of life care as each patient will have different preferences based on personal values and beliefs. Under Procedure: 1-[Summary] an appropriate staff member will discuss advance care planning 3-5 days fro admission 2- [verbatim] Information regarding Advance Directives is provided to the resident and family by the facility during the meeting. 3- [verbatim] Resident/representative will be given opportunity to discuss their goals for care including their preference for Advance Care Planning. 4-[summary] legal documents will be obtained and placed in the clinical record 5- [verbatim] Results of the Advanced Care planning will be communicated to the resident's care providers and documented in the clinical record. The surveyor interviewed by phone the Social Service Director, who is responsible for the Advance Care Planning process in the facility. The social service director stated the facility used a form titled Advance Care Planning Tracking form to document resident wishes. 9/17, surveyors requested the tracking forms for 24 residents in the final survey sample. All were admitted to the facility prior to the start of the survey on 9/11/2024 and should have already had an Advance Care Planning meeting. Of the 24, thirteen residents had a tracking form on record, while eleven did not. There was no record of a care planning discussion with the eleven who did not have forms (Residents 18, 22, 24, 28, 30, 32, 48, 77, 87, 90, 100). None of the thirteen tracking forms document written information provided to the resident or resident's representative as required by the regulation. None of the residents is documented to have chosen DNI (do not intubate), DNH (do not hospitalize), Living Will, No artificial feeding, POST(Physician Orders for Life-Sustaining Treatment/MOLST/POST end of life instructions, No artificial feeding, other care limiting orders, or any type of Durable Power of Attorney. The only options documented as chosen by residents were Full Code and Do not Resuscitate. Surveyors determined the facility did not have a procedure that met regulatory requirements for provision of written information about formulating advance care plans and providing a meaningful opportunity to formulate those plans and put them into practice. The administrator and Director of Nursing were notified of the ongoing system failure during a summary meeting on the final day of the survey.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team, and/or failed to involve the resident and/or resident representative in planning care, for 5 of 35 sampled residents. Resident #28, Resident #61, Resident #83, Resident #40, and Resident #206. The findings included: 1. For Resident #28, the facility staff failed to review the plan of care after the resident's comprehensive assessment on 3/21/24 and the facility staff failed to ensure the resident and/or resident representative, was provided the opportunity to participate in planning care at the facility. Resident #28's diagnosis list indicated diagnoses that included, but were not limited to, Emphysema, Hypertension, Glaucoma, Anxiety Disorder, Adult Failure to Thrive, Acute Respiratory Failure, Legal Blindness, Depression, Mild Cognitive Impairment, and Insomnia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/19/2024 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating Resident #28 was cognitively intact. On 9/10/24 at 6:05 PM, surveyor interviewed Resident #28 and the resident informed surveyor he only remembers attending one care plan meeting since admission and could not recall receiving any care plan meeting invitations. A review of the clinical record did not reveal any invitations to care plan meetings for Resident #28 and there was no evidence of a care plan meeting being held for the ARD of 3/21/24. Surveyor requested evidence of resident and/or resident representative being invited to care plan meetings. On 9/13/24 at 9:03 AM, surveyor interviewed the social worker, and she informed surveyor there was no evidence of the resident and/or resident representative being invited to the care plan meeting for the 3/21/24 ARD or any evidence of a care plan meeting being held. On 9/18/24 at 9:33 AM, surveyor interviewed registered nurse #8 and she stated she was not able to locate any evidence of a care plan meeting being held for the 3/21/24 ARD. This concern was discussed at the end of day meeting on 9/17/24 at 5:28 PM, with the administrator, director of nursing, assistant administrator, and assistant director of nursing and again at the pre-exit meeting on 9/18/24 at 1:05 PM with the above-mentioned staff and the regional director of clinical services. Surveyor requested and received a facility policy titled, Comprehensive Care Planning Policy, that read in part, .H. A Facility Resident Care Plan coordinator .is responsible for .the Resident Care Plan Conference .M. The facility designee is responsible for delivering to each resident who is scheduled for conference an invitation to attend the meeting. The letter of requested participation is presented to the resident at least five (5) days prior to the date of the conference .A copy of the letter is maintained for reference .S. The Resident Care Conference meets as scheduled .T. All Resident Care Plan participants sign .on each Plan of Care. The conference date is to be properly logged . Surveyor also requested and received a facility policy titled, Care Plan Invitation Letter Policy, that read in part, .The resident and the resident's Responsible Party or legal representative will be invited to attend each of the Interdisciplinary Care Planning Conferences .1 .will designate a staff member who will be responsible for completing the Care Planning invitations, for delivering the invitation to the resident prior to the conference date .2. Copies of the invitations .will be maintained as verification the invitations were sent .3. Ask the resident to sign a copy of the invitation letter and retain a copy as verification that the invitation was delivered to the resident .5. All attendees at the Care Planning Conference .will sign the Care Plan to verify their attendance. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/18/24. 2. For Resident #61, the facility staff failed to review the plan of care after the resident's comprehensive assessment on 3/11/24 and the facility staff failed to ensure the resident and/or resident representative, was provided the opportunity to participate in planning care at the facility. Resident #61's diagnosis list indicated diagnoses that included, but were not limited to, Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, Tremor, Cellulitis of Left Lower Limb, Peripheral Vascular Disease, Suicidal ideations, and Vascular Dementia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/20/24, assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. On 9/10/24 at 5:50 PM, surveyor interviewed Resident #61 and the resident informed surveyor she could not recall being invited to any care plan meetings. A review of the clinical record did not reveal any invitations to care plan meetings for Resident #61 and there was no evidence of a care plan meeting being held for the ARD of 3/11/24. Surveyor requested evidence of resident and/or resident representative being invited to care plan meetings. On 9/13/24 at 8:25 AM, the assistant administrator verified no care plan meeting invitations could be located for the comprehensive assessment date of 3/11/24. On 9/13/24 at 9:03 AM, surveyor interviewed the social worker, and she informed surveyor there was no evidence of the resident and/or resident representative being invited to the care plan meeting for the 3/21/24 ARD or any evidence of a care plan meeting being held. On 9/18/24 at 9:33 AM, surveyor interviewed registered nurse #8 and she stated she was not able to locate any evidence of a care plan meeting being held for the 3/11/24 ARD. This concern was discussed at the end of day meeting on 9/17/24 at 5:28 PM, with the administrator, director of nursing, assistant administrator, and assistant director of nursing and again at the pre-exit meeting on 9/18/24 at 1:05 PM with the above-mentioned staff and the regional director of clinical services. Surveyor requested and received a facility policy titled, Comprehensive Care Planning Policy, that read in part, .H. A Facility Resident Care Plan coordinator .is responsible for .the Resident Care Plan Conference .M. The facility designee is responsible for delivering to each resident who is scheduled for conference an invitation to attend the meeting. The letter of requested participation is presented to the resident at least five (5) days prior to the date of the conference .A copy of the letter is maintained for reference .S. The Resident Care Conference meets as scheduled .T. All Resident Care Plan participants sign .on each Plan of Care. The conference date is to be properly logged . Surveyor also requested and received a facility policy titled, Care Plan Invitation Letter Policy, that read in part, .The resident and the resident's Responsible Party or legal representative will be invited to attend each of the Interdisciplinary Care Planning Conferences .1 .will designate a staff member who will be responsible for completing the Care Planning invitations, for delivering the invitation to the resident prior to the conference date .2. Copies of the invitations .will be maintained as verification the invitations were sent .3. Ask the resident to sign a copy of the invitation letter and retain a copy as verification that the invitation was delivered to the resident .5. All attendees at the Care Planning Conference .will sign the Care Plan to verify their attendance. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/18/24. 3. For Resident #83, the facility staff failed to reassess the effectiveness of the interventions and review and revise the resident's activity care plan to meet the resident's physical, mental, and psychosocial well-being. Resident #83's diagnosis list indicated diagnoses that included, but were not limited to, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Epilepsy, Personal history of transient ischemic attack (TIA), Unspecified convulsions, and Type 2 (two) diabetes mellitus. Resident #83 is on Hospice Services for end-of-life care. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/18/24 indicated in the review of Section C, Cognitive Patterns, that Resident #83 was severely impaired in cognitive decision-making with short & long-term memory problems and was coded as being rarely/never understood and rarely/never understands. Surveyor could not locate an initial activity assessment or any activity progress notes on the clinical record for Resident #83. On 9/12/24 at 12:52 PM, activity director provided surveyor with an activity care plan with a created date of 9/12/24, that read in part, Problem .has decreased orientation and limited orientation. Activities needed that she may observe and enjoyy [sic] .Goal .will positively respond to sensory thru [sic] next review period .Intervention .will be visited regularly by activity staff and volunteers thru [sic] next review period . Activity director stated she could not locate an initial activity assessment and stated she does not complete quarterly activity progress notes. She stated she was not sure what the activity policy stated about activity progress notes On 9/12/24 at 2:31 PM, activity director informed surveyor that she was on vacation at the time Resident #83 was admitted and was not sure what happened with the resident's initial activity assessment. She informed surveyor she had reviewed the activity policies and agreed she should have completed an activity progress note every ninety days. This concern was discussed at the end of day meeting on 9/17/24 at 5:28 PM, with the administrator, director of nursing, assistant administrator, and assistant director of nursing and again at the pre-exit meeting on 9/18/24 at 1:05 PM with the above-mentioned staff and the regional director of clinical services. Surveyor requested and received a facility policy titled, Life Enrichment Assessment and Documentation Policy, that read in part, .The Life Enrichment Department will complete ongoing assessments and documentation required by the MDS cycle for each resident in order to promote their physical, mental, and psychosocial well-being .5 .The Care Plan will be reviewed, updated, and rewritten quarterly and as needed .7. The completed Life Enrichment Assessment will be part of the resident's medical record .9 .A Life Enrichment progress note needs to be written at minimal every quarter (every ninety days), including any time MDS documentation is completed . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/18/24. 47299 4. For resident # 40, the facility staff failed to inform or include the residents responsible party in the care plan process, and failed to provide evidence that care plan conferences were being held. Resident # 40's care plan states resident has altered cognitive function related to a brief interview for mental status (BIMS) score of 3. This surveyor interviewed resident # 40's responsible party on 9/11/24 at 2:27 PM. They stated they had not been informed or invited to any care conferences lately and that they had only ever been invited to one that they attended via telephone. The clinical record was reviewed. This surveyor was unable to locate care plan invitations, or documentation of care plan conferences for the minimum data set (MDS) assessments dated 3/13/24 for a quarterly review, or 6/11/24 for an annual review. On 9/12/24 at 11:59 AM this surveyor interviewed the Social Worker about inviting the Responsible Party to care plan meetings. They stated that the resident and/or responsible party were sent invitations for each meeting and that meetings are held at least quarterly to coincide with the MDS assessments. They provided a care plan invitation dated 10/3/23 Which was already seen in the record. They stated, That's all I could come up with for resident # 40 except for the one that we are having next week. When asked if invitations are being sent, they stated, They are now, but I've only been here for two months, so I don't know about before. Surveyor asked if they knew whether or not meetings were being held prior to their arrival, I'm not sure. On 9/13/24 the Assistant Administrator provided care plan invitations for October 3, 2023, and June 20, 2023. For 2024 they provided a care plan invitation for 9/17/24. On 9/17/24 this surveyor interviewed the Assistant Administrator and the Social Worker at 09:40 AM. The social worker stated, the care plan invitation letters should have a signature. I take it to the resident, and I get a signature, even if it's just an x, and I scan it into the record. I also send an invitation to the responsible party and scan that in. Care plan meetings are held on Tuesdays every three months, or with a significant change. The meetings are held within 7 days of the ARD (assessment reference date). They stated that the actual meetings should be documented in the record and were able to provide documentation of all the 2023 meetings. This surveyor requested and received the policy entitled, Comprehensive Care Plan Policy with a revised date of 3/2/21. Under the heading Procedure, the policy read in part, I) A resident care plan conference is scheduled at least weekly. J) Residents scheduled for the Resident Care conference include: 1. New admissions who's MDS was completed within the previous 7 days. 2. Residents who have returned from the hospital in the past week. Their previous MDS and care plan must be reviewed and updated. 3. Residents who have had a significant condition change and MDS completed in the past week. 4. Residents who have had 90-day review assessments or an annual full assessment completed with the previous 7 days. M. The facility designee is responsible for delivering to each resident who is scheduled for conference an invitation to attend the meeting. The letter of requested participation (original) is presented to the resident at least five days prior to the date of conference. A designated time of meeting is given to each resident. (Those residents who have been deemed legally incompetent or has documentation in their medical record as medically incompetent by their attending physician would be exempt from this procedure.) A copy of the letter is maintained for reference. N. The facility designee is responsible for mailing an original letter of requested participation to an appropriate family member or legal representative for all residents scheduled for review who have deemed legally incompetent or have been charted as being medically incompetent by their attending physician. The letter is mailed at least seven days prior to the date of conference. A copy of the letter is maintained for reference . O. The facility designees are responsible for proving the Coordinator copies of all said letters on the scheduled day of conference. The coordinator makes notations on the copies addressing the recipient's participating or nonparticipating status. On 9/17/24 at 5:15 PM the survey team met with the Administrator, Director of Nursing, Assistant Director of Nursing and the Assistant Administrator. This concern was discussed. No further information was provided to the survey team prior to the exit conference. 21227 5. The facility staff failed to review and/or revise Resident #206's care plan at the appropriate time intervals. The facility staff failed to include Resident #206's responsible party as part of the interdisciplinary team. Resident #206's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/25/23, was signed as completed on 7/27/23. Resident #206 was assessed as usually able to make self understood and as able to understand others. Resident #206 was assessed as having problems with both short-term memory and long-term memory. Resident #206 was assessed as being dependent on others for transfers, dressing, personal hygiene, and bathing. The following information was found in a facility policy titled Comprehensive Care Planning Policy (with a revision date of 3/2/21): - The Interdisciplinary Care Planning Team may consist of: . The resident, the resident's family and/or the resident's legal representative. - A Resident Care Plan conference is scheduled at least weekly. - Residents scheduled for the Resident Care conference include: . Residents who have had 90-day review assessments or an annual full assessment completed within the previous 7 days. - The facility designee is responsible for delivering to each resident who is scheduled for conference an invitation to attend the meeting. The letter of requested participation (original) is presented to the resident at least five (5) days prior to the date of conference. A designated time of meeting is given to each resident. (Those residents who have been deemed legally incompetent or has documentation in their medical record, as medically incompetent by their attending physician would be exempt from this procedure.) A copy of the letter is maintained for reference. - The facility designee is responsible for mailing an original letter of requested participation to an appropriate family member or legal representative for all residents scheduled for review who have been deemed legally incompetent or have been charted as being medically incompetent by their attending physician. The letter is mailed at least seven (7) days prior to the date of conference. A copy of the letter is maintained for reference. The family may call the facility and request to change their time, and the facility will attempt to accommodate all times to the best of our ability. On 9/17/24 at 9:35 a.m., the Director of Social Services reported that a signature should be obtained on the form provided to the resident about the scheduled care plan meeting; this signed form should be scanned into the electronic clinical record. The Director of Social Services reported that a letter is sent to the responsible party about the scheduled care plan meeting; the Director of Social Services reported a copy of the letter should be scanned into the electronic clinical record. On 9/17/24 at 9:35 a.m., the Assistant Administrator reported the care plan meetings would occur every three (3) months or with a significant change in the resident's condition. Resident #206's clinical record indicated the resident had Minimum Data Set (MDS) assessments completed with the following ARD dates: - A quarterly assessment dated [DATE]; - An annual assessment dated [DATE]; - A quarterly assessment dated [DATE]; - A quarterly assessment dated [DATE]; - A quarterly assessment dated [DATE]; - A quarterly assessment dated [DATE]; - A quarterly assessment dated [DATE]; and - A significant change in condition assessment dated [DATE]. The facility staff provided the surveyor a copy of an invitation letter which indicated a care plan meeting was planned for 8/9/22 at 12:30 p.m. No documentation was provided to indicate who was given this letter. The facility staff provided the surveyor a copy of an invitation letter which indicated a care plan meeting was planned for 12/13/22 at 12:30 p.m. No documentation was provided to indicate who was given this letter. The facility staff provided the surveyor a social services note dated 6/13/23 which indicated the Social Worker had discussed Resident #206's change in condition care planning form with the resident's responsible party. (The change in condition MDS assessment had an assessment reference date of 5/23/23; no evidence was provided to indicate the responsible party had been included in a care plan meeting related to this MDS assessment.) No evidence was found by or provided to the surveyor to indicate Resident 206's responsible party was consistently invited to the resident's care plan meetings. On 9/17/24 at 11:31 a.m., the Assistant Administrator reported there were times when no evidence of Resident #206's responsible party being included in the care plan meeting was found. Resident #206's clinical record included documents titled (company name omitted) Care Plan Conference Summary. The facility staff provided the survey team with two (2) of these forms documented with effective dates of: 12/13/22 at 2:24 p.m. and 3/28/23 at 10:28 a.m.; both of these documents indicated that Resident #206's Resident Representative was invited to the care plan conference but chose not to participate. No care plan conference summaries were provided for Resident #206's following MDS assessments: - A quarterly assessment with an ARD date of 7/30/22; - An annual assessment with an ARD date of 9/2/22; - A quarterly assessment with an ARD date of 10/21/22; - A quarterly assessment with an ARD date of 12/21/22; - A quarterly assessment with an ARD date of 4/21/23; and - A significant change in condition assessment with an ARD date of 5/23/23. Resident #206's care plan failed to address the resident's responsible party's request for morphine not to be administered to the resident. On 9/18/24 at 1:06 p.m., the survey team met with the facility's Administrator, Assistant Administrator, Director of Nursing (DON), Assistant DON, and Regional Director of Clinical Services. During this meeting, the following care plan findings was discussed: (a) the failure to ensure care plan meetings were completed, (b) the failure to ensure the Resident #206's responsible party was consistently included in the care plan meetings, and (c) the failure of Resident #206's care plan to address Resident #206's responsible party's request for the resident not to be administered morphine.

Based on staff interview, clinical record review, and facility document review the facility staff failed to follow physician's orders for the administration of medications for 5 of 35 residents, Resident #33, Resident #207, Resident #100, Resident #357, and Resident #20. The findings included: 1. For Resident #33 the facility staff failed to administer the medication gabapentin per the physician's orders. Resident #33's face sheet listed diagnoses which included but not limited to hypertension and chronic pain syndrome. Resident #33's most recent minimum data set with an assessment reference date of 07/02/24 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive status. This indicates that the resident is moderately cognitively impaired. Resident #33's comprehensive care plan was reviewed and contained a care plan for Pain: Resident has potential for pain r/t (related to) generalized discomfort. Interventions for this care plan include Administer pharmacological interventions as indicated per physician and monitor the effectiveness. Resident #33's clinical record was reviewed and contained a physician's order summary which read in part gabapentin-Schedule V capsule; 100 mg; amt: 1 capsule; oral. Twice a day, and gabapentin-Schedule V capsule; 300 mg; amt: 1 capsule; oral. Special instructions: 1 cap by mouth every day related to chronic pain syndrome. Resident #33's electronic medication administration record for the month of August 2024 was reviewed and contained entries as above. The entry for gabapentin 100 mg was not administered on 08/23, 08/25, or 08/26 for the am dose and not administered on 08/20, 08/21, 08/23, 08/24 or 08/25 for the pm dose. Reasons given for each of these missed doses were documented as drug/item unavailable, on order, and waiting for arrival. Surveyor spoke with the director of nursing (DON) on 09/12/24 regarding resident #33's medications. DON stated that resident has refused medications at times, and that it should be documented, if refused. Surveyor pointed out that medication was documented as not available. Surveyor requested and was provided with a list of medications available in the facility's emergency medications supply. This list contained gabapentin 100 mg and gabapentin 300 mg. Surveyor requested and was provided with a facility policy entitled Medication Shortages/Unavailable Medications which read in part, 1. Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy. 2. If a medication is unavailable during normal pharmacy hours: 2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, Facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. 3. If a medication is unavailable is discovered after normal Pharmacy hours: 3.1 A Facility nurse should obtain the ordered medication from the Emergency Medication Supply. The concern on not administering medications as ordered by the physician was discussed with the administrator, administrator-in-training, DON, and regional director of clinical services on 09/12/24 at 5:25 pm. No further information was provided prior to exit. 28169 2. For Resident #207, facility staff failed to administer Gabapentin per provider orders. Resident #207's admission record listed diagnoses which included but not limited to sepsis and right leg pain. The minimum data set assessment with an assessment reference date of 01/29/24 coded the resident's brief interview for mental status a 15 out of 15 (in Section C - cognitive patterns) which indicated the resident was cognitively intact. The clinical record contained a provider order for gabapentin oral capsule 300mg; give 2 capsules by mouth one time a day for nerve pain and give 3 capsules by mouth at bedtime for nerve pain. Resident #207's medication administration record (MAR) for February 2024 was reviewed. On 02/07/24 for the morning and evening doses, on 02/08/24 for the evening dose, and on 02/11/24 for the evening dose, the MAR documentation indicated the resident's gabapentin was not administered. Staff documented a numerical code for these four (4) doses: 1. 02/07/24 9:00 a.m. dose - Code 19 was documented (19 = other/see nurses notes). The registered nurse documented awaiting pharmacy. That nurse no longer worked at the facility. A registered nurse unit manager (RN-UM) was interviewed on 09/17/24. The RN-UM had written a witness statement about retrieving two (2) Gabapentin 300mg capsules from the facility's Omnicell for Resident #207. The statement was dated 02/09/24 but read the doses were for 02/07/24. During the interview, the RN-UM could not be sure which date she retrieved the medication from the Omnicell. The nurse stated she did not administer the medication; she retrieved the medication for another nurse but could not recall which nurse. The RN-UM stated it takes two (2) nurses to retrieve a narcotic from the Omnicell. 2. 02/07/24 9:00 p.m. dose - Code 19 was documented (19 = other/see nurses notes). The licensed practical nurse (LPN) documented on order. The assistant director of nursing (ADON) provided a statement the LPN gave to the ADON via phone on 09/13/24. The statement read the LPN learned in report the medication was on order therefore did not need to be reordered. The statement read the evening dose had been retrieved from the Omnicell. The surveyor was unable to interview this nurse who worked for an agency company. 3. 02/08/24 9:00 p.m. dose - Code 16 was documented (16 = hold/see note). A different LPN, who no longer worked at the facility according to the ADON, wrote 2/7/2024 2/8/2024 2/8/2024 Reordered GABAPENTIN (C5) 300MG CAPSULE. The ADON acknowledged this dose was not given and no hold order was found. 4. 02/11/24 9:00 p.m. dose - Code 16 was documented (16 = hold/see note). Another LPN, who no longer worked at the facility according to the ADON, wrote Administered last dosage. reordered, called Pharmacy and was informed medication will be delivered 02/12/24. There was no hold order found. The facility's Omni Inventory (medication dispensing system) list of medications was reviewed. The list included Gabapentin 300mg capsules. This surveyor called the facility's pharmacy and spoke with the general manager, who is a pharmacist, on 09/17/24 at 3:30p.m. After reviewing information regarding Resident #207, the pharmacist listed this information: 01/25/24 - Dispensed 60 Gabapentin pills 01/25/24 - Omnicell, 3 pills possibly 02/07/24 - No Omnicell codes given 02/08/24 - No Omnicell codes given 02/09/24 - Omnicell code given for 2 pills 02/11/24 - No Omnicell codes given 02/12/24 - Dispensed 90 Gabapentin pills Regarding the 60 pills dispensed on 01/25/24, if 5 pills/day were administered as ordered, the 60 pills would have been depleted by 02/05/24. The pharmacy did not have evidence of providing Omnicell codes for 02/07/24, 02/08/24, or 02/11/24. The codes are required to obtain Gabapentin from the Omnicell. The surveyor requested Resident #207's Medication Administration Audit Report. For the four doses over 02/07/24, 02/08/24, and 02/11/24, the audit report showed an administration time. After reviewing a different audit report for medications refused by another resident, those medications that were refused showed an administration time. The administration time on the audit report indicated staff had inserted documentation; it did not indicate the medication was administered. On 09/17/24 at 5:00 p.m., this surveyor with another surveyor spoke with the DON and ADON in the ADON's office. The surveyors informed the nurses it was apparent the administration time on the medication administration audit report did not indicate the medication was given and received. It indicated staff inserted documentation for that time/dose which could be any code to include the 12=refused, 16=hold/see note, and 19=other/see nurse's notes or other possible codes. Both the DON and the ADON verbalized understanding and did not provide further information. On 09/17/24 at 5:28 p.m. the administrator, assistant administrator, DON, and ADON were informed of the concern regarding Resident #207 not receiving Gabapentin for 4 doses over 3 days (02/07/24 a.m. & p.m., 02/08/24 p.m., and 02/11/24 p.m.) This surveyor explained the Omnicare pharmacist reported there was no evidence Omnicell codes were provided for retrieval of Gabapentin on 02/07/24, 02/08/24, or 02/11/24. The facility administration denied questions or comments. No further information was provided prior to the exit conference. 22218 3. For Resident #100, staff failed to administer an anti-hypotensive medication as ordered. Resident #100 was admitted to the facility with diagnoses which included end stage renal disease with hemodialysis, diabetes mellitus, anemia, septicemia, peripheral vascular disease, deep vein thrombosis, orthostatic hypotension, and malnutrition. On the most recent Minimum Data Set assessment the resident scored15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. Clinical record review revealed an order for midodrine 5 milligrams 3 tabs oral every 6 hours. A nursing medication note dated 9/10/2024 18:00 indicated Not Administered: Other Comment: held due to BP of 140/71. The surveyor was unable to locate hold parameters for the medication in the clinical record. There was no documentation that the physician or another provider was notified that the medication was held. The surveyor discussed the concern with the Director of Nursing (DON) on 9/17/24. The DON stated that the physician did not want hold parameters for the medication. The nurse should have contacted the physician for instructions. The surveyor spoke with the medical director (MD) by phone on 9/18/2024. The medical director stated that there were no hold parameters on the order because the MD expected the medication to be administered as ordered. The MD expected to be contacted if the resident's condition was of concern to the nurse. The nurse had not contacted the MD about not administering the medication. Further review of the medication administration record revealed the medication was also held at 12:00 on 9/3, 4, 5, 9, and 10 with medication notes indicating resident unavailable. The physician was not notified of those holds. The administrator and DON were notified of the concern during a summary meeting on 9/18/2024. 42353 4. For Resident #20, the facility staff failed to follow the medical provider orders for notification of blood sugar levels less than 100 (one hundred). Resident #20's diagnosis list indicated diagnoses, which included, but not limited to, Type 2 (two) diabetes mellitus, Muscle weakness (generalized), Hyperlipidemia, Encounter for orthopedic aftercare following surgical amputation, Schizophrenia, Schizoaffective disorder, and Phantom limb syndrome with pain. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/30/24, assigned the resident a brief interview for mental status (BIMS) summary score of 10 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A review of Resident #20's medical provider orders included an order dated 6/14/24 for Humulin (insulin pen) that read in part, .Monitor blood sugar via finger stick. Hold and call MD (medical doctor) if BS (blood sugar) less than 100 . Surveyor reviewed Resident #20's August 2024 and September 2024 MAR (medication administration record) and observed documentation of resident's BS being less than 100 and no evidence could be located in the clinical record that the medical provider was notified as indicated in the order on the following dates: 8/7/24-LOW 8/26-24-BS 87 8/27/24-BS 80 8/28/24-BS 65 8/29/24-BS 98 9/2/24-BS 77 9/4/24-BS 94 9/5/24-Low BS 9/7/24-Low BS On 9/13/24 at 8:39 AM, regional director of clinical services informed surveyor that no documentation could be located that the medical provider was notified. The comprehensive care plan read in part, .Problem .Resident is at risk for unstable blood glucose related to diabetes .Goal .Resident will remain free of symptoms and complications of .hypoglycemia (low blood sugar) .Approach .Call MD for BS equal to or less than 100 . These concerns were discussed at the end of day meeting on 9/17/24 at 5:28 PM with the administrator, director of nursing, assistant administrator, and assistant director of nursing and again at the pre-exit meeting on 9/18/24 at 1:05 PM with the above-mentioned staff and the regional director of clinical services. Surveyor requested and received a facility policy titled, Physician/Provider Orders, that read in part, .3. The nurse shall document .the orders were confirmed . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/18/24. 49622 5. For Resident #20, the facility staff failed to follow the medical provider orders for notification of blood sugar levels less than 100 (one hundred). Resident #20's diagnosis list indicated diagnoses, which included, but not limited to, Type 2 (two) diabetes mellitus, Muscle weakness (generalized), Hyperlipidemia, Encounter for orthopedic aftercare following surgical amputation, Schizophrenia, Schizoaffective disorder, and Phantom limb syndrome with pain. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/30/24, assigned the resident a brief interview for mental status (BIMS) summary score of 10 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A review of Resident #20's medical provider orders included an order dated 6/14/24 for Humulin (insulin pen) that read in part, .Monitor blood sugar via finger stick. Hold and call MD (medical doctor) if BS (blood sugar) less than 100 . Surveyor reviewed Resident #20's August 2024 and September 2024 MAR (medication administration record) and observed documentation of resident's BS being less than 100 and no evidence could be located in the clinical record that the medical provider was notified as indicated in the order on the following dates: 8/7/24-LOW 8/26-24-BS 87 8/27/24-BS 80 8/28/24-BS 65 8/29/24-BS 98 9/2/24-BS 77 9/4/24-BS 94 9/5/24-Low BS 9/7/24-Low BS On 9/13/24 at 8:39 AM, regional director of clinical services informed surveyor that no documentation could be located that the medical provider was notified. The comprehensive care plan read in part, .Problem .Resident is at risk for unstable blood glucose related to diabetes .Goal .Resident will remain free of symptoms and complications of .hypoglycemia (low blood sugar) .Approach .Call MD for BS equal to or less than 100 . These concerns were discussed at the end of day meeting on 9/17/24 at 5:28 PM with the administrator, director of nursing, assistant administrator, and assistant director of nursing and again at the pre-exit meeting on 9/18/24 at 1:05 PM with the above-mentioned staff and the regional director of clinical services. Surveyor requested and received a facility policy titled, Physician/Provider Orders, that read in part, .3. The nurse shall document .the orders were confirmed . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/18/24.

Based on staff interview, clinical record review, and facility document review the facility staff failed to obtain lab testing as ordered by the medical provider for 2 of 35 sampled residents. (Resident #51 and #357). The findings included: 1. For resident # 51 the facility failed to obtain a hemoglobin A1C (HgbA1c) ordered by the primary care provider. Resident # 51's diagnoses included type II diabetes mellitus. During a review of the clinical record on 9/12/24, an order to obtain a HgbA1c on 9/2/24 was noted. This surveyor was not able to locate results in the clinical record. The Medication Administration Record (MAR) was reviewed. The order was on the MAR and scheduled for 9/2/24, the order had not been signed off as done. On 09/12/24 04:04 PM this surveyor interviewed Registered Nurse (RN) # 2. They stated, the lab was not done. The physician has been notified and it is scheduled to be done tomorrow. They stated they did not know how the order was missed, I don't know, it was just missed. HgbA1c is a blood test that measures average blood sugar levels over the past two to three months. It is used to diagnose diabetes and to monitor how well people with diabetes are managing their blood sugar levels. On 9/17/24 Surveyor requested to see the results of the HgbA1c done on 9/13/24. The results were provided, along with an updated order to obtain the lab that was entered on 9/12/24, and were within normal limits at 4.4. On 09/17/24 05:14 PM The survey team met with the Administrator, Director of Nursing, Assistant Director of Nursing, Assistant Administrator and Regional Director of Clinical Services. This concern was reviewed with them at that time. No further information was provided to the survey team prior to the exit conference. 42353 2. For Resident #357, the facility staff failed to obtain a complete blood count (CBC) with differential blood test as ordered by the medical provider. Resident #357's diagnosis list indicated diagnoses, which included, but not limited to Acute on Chronic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Anemia, and Type 2 Diabetes Mellitus. The minimum data set (MDS) with an assessment reference date (ARD) of 4/29/24 assigned the resident a brief interview for mental status (BIMS) summary score of 7 out of 15 indicating the resident was severely cognitively impaired. A review of Resident #357's clinical record revealed a medical provider order dated 5/07/24 to obtain a CBC with differential on 5/08/24. Resident #357 was seen by the nurse practitioner (NP) on 5/07/24, the progress note read in part .Given h/o [history of] recurrent falls will obtain .CBC . Surveyor reviewed Resident #357's clinical record and was unable to locate CBC results for 5/08/24. On 9/17/24 at 5:27 PM, surveyor informed the Administrator, Assistant Administrator, Director of Nursing, and Assistant Director of Nursing that Resident #357's clinical record failed to show evidence of a CBC being obtained as ordered on 5/08/24. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/18/24.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to develop and/or implement a person-centered, comprehensive, activity care plan for 1 of 24 sampled residents, Resident #83. The findings included: For Resident #83 the facility staff failed to develop and implement a comprehensive person-centered activity care plan to include measurable objectives and timeframes to meet the resident's mental and psychosocial needs and include the resident's goals, desired outcomes, and preferences for activities. Resident #83's diagnosis list indicated diagnoses that included, but were not limited to, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Epilepsy, Personal history of transient ischemic attack (TIA), Unspecified convulsions, and Type 2 (two) diabetes mellitus. Resident #83 is on Hospice Services for end-of-life care. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/18/24 indicated in the review of Section C-Cognitive Patterns, that Resident #83 was severely impaired in cognitive decision-making with short & long-term memory problems and was coded as being rarely/never understood and rarely/never understands. A review of the clinical record and comprehensive care plan on 9/11/24, produced no evidence of a person-centered, activity care plan for Resident #83. On 9/12/24 at 11:50 AM, during an interview with the activity director, surveyor requested evidence of an activity care plan for Resident #83. On 9/12/24 at 12:52 PM, activity director provided surveyor with an activity care plan with a created date of 9/12/24, that read in part, Problem .has decreased orientation and limited orientation. Activities needed that she may observe and enjoyy [sic] .Goal .will positively respond to sensory thru [sic] next review period .Intervention .will be visited regularly by activity staff and volunteers thru [sic] next review period . This concern was discussed at the end of day meeting on 9/17/24 at 5:28 PM, with the administrator, director of nursing, assistant administrator, and assistant director of nursing and again at the pre-exit meeting on 9/18/24 at 1:05 PM with the above-mentioned staff and the regional director of clinical services Surveyor requested and received a facility policy titled, Life Enrichment Assessment and Documentation Policy, that read in part, .5. Each resident's Life Enrichment Care Plan .should reflect his/her individual needs .6 .Life Enrichment Care Plan will identify if a resident is capable of pursuing leisure without intervention from the community . Surveyor requested and received the facility policy titled Comprehensive Care Planning Policy, which read in part, .An interdisciplinary plan of care will be established for every resident .A. The facility must develop a comprehensive Person Centered Care Plan for each resident that includes measurable objectives and timetables to meet the resident's .mental and psychosocial needs . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/18/24.

Based on staff interview, clinical record review and facility document review the facility staff failed to ensure one of 24 residents was clinically appropriate for self-administration of medications, Resident #87. The findings included: For Resident #87 the facility staff failed to complete a self-administration of medications assessment. Resident #87's face sheet listed diagnoses which included but not limited to stiff-man syndrome, other pulmonary embolism without cor pulmonale, and chronic obstructive pulmonary disease. Resident #87's most recent minimum data set with an assessment reference date of 07/27/24 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #87's clinical record was reviewed and contained a physician's order summary which read in part, albuterol sulfate HFA aerosol inhaler; 90 mcg/actuation; amt: 2 puffs; inhalation. Special instructions: May keep at bedside. Twice a day 9:00, 21:00. This order listed a start date of 07/30/24. Resident #87's clinical record was reviewed, and surveyor could not locate a self-administration of medications assessment. Surveyor spoke with the director of nursing (DON) on 09/12/24 at 2:30 pm regarding Resident #87's self-administration of medications assessment. DON provided surveyor with a copy of a Self-administration of medications form dated 09/12/24 and stated to surveyor that the order for medications at bedside was just entered on 09/11/24. Surveyor pointed out the albuterol order, and that it was dated 07/30/34. Surveyor requested and was provided with a facility policy entitled Self-Administration of Medications which read in part, 2. Facility, in conjunction with the interdisciplinary care team, should assess and determine, with respect to each resident, whether self-administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition. The concern of not completing the self-administration of medications assessment was discussed with the administrator, administrator-in-training, DON, and regional director of clinical services on 09/12/24 at 5:25 pm. No further information was provided prior to exit.

Based on interviews, document review, and clinical record review facility staff failed to notify the medical provider and/or a responsible party for related to residents' medication regime for 2 of 35 sampled residents (Resident #100 & #206). 1. For Resident #100, facility staff failed to notify the physician when an anti-hypotensive medication was held. Resident #100 was admitted to the facility with diagnoses which included end stage renal disease with hemodialysis, diabetes mellitus, anemia, septicemia, peripheral vascular disease, deep vein thrombosis, orthostatic hypotension, and malnutrition. On the most recent Minimum Data Set assessment the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. Clinical record review revealed an order for Midodrine 5 milligrams 3 tabs oral every 6 hours. A nursing medication note dated 9/10/2024 18:00 indicated Not Administered: Other Comment: held due to BP of 140/71. The surveyor was unable to locate hold parameters for the medication in the clinical record. There was no documentation that the physician or another provider was notified that the medication was held. The surveyor discussed the concern with the Director of Nursing (DON) on 9/17/24. The DON stated that the physician did not want hold parameters for the medication. The nurse should have contacted the physician for instructions. The surveyor spoke with the medical director (MD) by phone on 9/18/2024. The medical director stated that there were no hold parameters on the order because the MD expected the medication to be administered as ordered. The MD expected to be contacted if the resident's condition was of concern to the nurse. The nurse had not contacted the MD about not administering the medication. Further review of the medication administration record revealed the medication was also held at 12:00 on 9/3, 4, 5, 9, and 10 with medication notes indicating resident unavailable. The physician was not notified of those holds. The administrator and DON were notified of the concern during a summary meeting on 9/18/2024. 21227 2. Resident #206's clinical documentation failed to contain evidence of the resident's responsible party being notified of changes in the resident's medications. Resident #206's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/25/23, was signed as completed on 7/27/23. Resident #206 was assessed as usually able to make self understood and as able to understand others. Resident #206 was assessed as having problems with both short-term memory and long-term memory. Resident #206 was assessed as being dependent on others for transfers, dressing, personal hygiene, and bathing. Resident #206's clinical record included evidence of multiple medications being discontinued on 7/18/23. These discontinued medications included, but were not limited to: potassium, multivitamin, metoprolol, Norvasc, ergocalciferol, iron, and cyanocobalamin. No documentation was found to explicitly indicate Resident #206's responsible party was notified of these medications being discontinued. On 9/17/24 at 4:11 p.m., Licensed Practical Nurse (LPN) #2 reported they found no documentation of Resident #206's responsible party being notified of the aforementioned discontinued medications. LPN #2 reported the hospice initiated the discontinuation of the medications therefore they would expect the hospice staff to have notified the resident's responsible party. LPN #2 confirmed a facility staff member would have had to enter the discontinue orders. The following information was found in a nursing note dated 7/18/23 at 5:15 p.m.: Call placed to Hospice spoke with (hospice nurse practitioner name omitted) orders obtained to discontinues [sic] scheduled medications, (due to) patient's inability to swallow at this time. Also discontinue weekly and monthly weights. No evidence of Resident #206's responsible party being notified of these medication discontinuation orders was included in this note. On 9/18/24 at 11:40 a.m., the facility's Regional Director of Clinical Services (RDCS) stated they would have expected the hospice staff to communicate these medication discontinuations with the resident's responsible party. The RDCS provided the surveyor with a hospice nursing note dated 7/19/23 at 11:26 a.m. This note included the following information: Upon arrival of RN, check in with facility nurse (name omitted) stating pt (patient) has continued to have shallow, increased respirations. Pt sleeping upon arrival and pt opens eyes when forehead is stroked. Closes eyes again. Pt on 2 (liters of oxygen) via (nasal cannula) continuously. Oral care provided with glycerin swabs. Pt HOH (hard of hearing) bilateral/ eyes do not track this RN voice when opened. (Vital signs) charted in (the electronic medical record). Facial grimacing with movement. Returns to baseline when peri care completed. (Last bowel movement) per staff was 7/18/23. Pt has not eaten more than a few bites since Sunday. Pt consumed nothing in past 24 hours per staff. Oral Medication [sic] reviewed and (discontinue) order received from (medical provider name omitted) 07/18/23 evening. Pt appears to be in no distress with eyes closed when visit ends. (Resident #206's adult child's identifying information deleted) contacted. This note does not detail what information was provided to Resident #206's adult child / responsible party. Resident #206's clinical record included an order, dated 7/25/23, for morphine 5 mg to be administered orally for shortness of breath. This medication was documented as being administered on 7/25/23 at 3:31 p.m. No nursing assessment documentation was found to detail the resident's clinical condition resulting in the need for the 7/25/23 morphine order. No documentation was found to indicate Resident #206's responsible party had been notified of the need to obtain a new order for morphine. On 9/17/24 at 2:06 p.m., LPN #2 stated that the resident's responsible party would be notified of a new medication order. LPN #2 reported the notification is usually found as a nursing progress note. LPN #2 reported they did not find documentation of Resident #206's responsible party being notified of the 7/25/23 provider order for morphine to be administered for shortness of breath. On 9/18/24 at 9:56 a.m., LPN #3 reported Resident #206's adult child was present when the 7/25/23 morphine order was obtained. LPN #3 stated the adult child was okay with the administration of the morphine. Resident #206's clinical record did not include documentation of a resident assessment related to the need to obtain the 7/25/23 morphine order; Resident #206's clinical record did not include documentation to indicate the Resident's responsible party was at the bedside and aware of the new morphine order. The following information was found in a facility policy titled Resident Change in Condition Policy (with a revised date of 6/27/24): The Physician / Provider and Resident / Family / Responsible Party will be notified when there has been: . A need to alter the resident's medical treatment, including a change in provider orders . On 9/18/24 at 1:06 p.m., the survey team met with the facility's Administrator, Assistant Administrator, Director of Nursing (DON), Assistant DON, and Regional Director of Clinical Services. During this meeting, the absence of documentation to indicate Resident #206's responsible party had been notified of the aforementioned medication orders being either discontinued or initiated was discussed.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to screen for a mental disorder and/or intellectual disability prior to admission for 2 of 24 sampled residents. Resident #20 and Resident #61. The findings include: 1. For Resident #20, the facility staff failed to obtain a Level I Screening for Mental Illness, Intellectual Disability (ID), or Related Conditions, to determine if the resident had or may have had a MD (Mental Disorder), ID, or related condition prior to admission. Resident #20's diagnosis list indicated diagnoses, which included, but not limited to, Type 2 (two) diabetes mellitus, Muscle weakness (generalized), Hyperlipidemia, Encounter for orthopedic aftercare following surgical amputation, Schizophrenia, Schizoaffective disorder, and Phantom limb syndrome with pain. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/30/24, assigned the resident a brief interview for mental status (BIMS) summary score of 10 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. On 9/11/24, during review of the clinical record, surveyor could not locate a PASARR (Preadmission Screening and Resident Review) on Resident #20's clinical record. Surveyor requested evidence of a completed PASARR on 9/11/24 at 5:16 PM at the end of day meeting with the administrator, director of nursing, regional director of clinical services and assistant administrator. On 9/12/24 at 10:46 AM, surveyor was provided with a PASARR form dated 9/11/24 for Resident #20. On 9/12/24 at 11:00 AM, surveyor interviewed the social worker-other staff #2 (OS#2), who informed surveyor the PASARR was completed on 9/11/24, as she had only been employed at the facility for two months and she was unable to locate a PASARR for Resident #20's admission several months ago, so she completed the PASARR yesterday (9/11/2024). This concern was discussed at the end of day meeting on 9/12/24 at 5:23 PM with the administrator, director of nursing, and regional director of clinical services and again at the end of day meeting on 9/17/24 with the above-mentioned facility staff and the assistant director of nursing, and assistant administrator. This concern was also discussed at the pre-exit meeting on 9/18/24 at 1:05 PM with the administrator, director of nursing, assistant administrator, assistant director of nursing, and regional director of clinical services. Surveyor requested a facility policy for PASARR, but was informed a facility policy could not be located and was provided with a document titled, Preadmission Screening and Resident Review (PASRR) Technical Assistance for States, that read in part, .Federal law mandates that Medicaid-certified nursing facilities (NF) may not admit an applicant with serious mental illness (MI), mental retardation (MR), or a related condition, unless the individual is properly screened .States are required to have a PASRR program in order to screen all NF applicants .The state uses the evaluation to determine, prior to admission, whether NF placement is appropriate .screens generally consist of forms completed by hospital discharge planners, community health nurses, or others . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/18/24. 2. For Resident #61, the facility staff failed to obtain a Level I Screening for Mental Illness, Intellectual Disability (ID), or Related Conditions, to determine if the resident had or may have had a MD (Mental Disorder), ID, or related condition prior to admission. Resident #61's diagnosis list indicated diagnoses, which included, but not limited to, Metabolic encephalopathy, Chronic obstructive pulmonary disease, Personal history of transient ischemic attack (TIA), and cerebral infarction, Tremor, Cellulitis of left lower limb, Peripheral vascular disease, Suicidal ideations, and Vascular Dementia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/20/24, assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. On 9/11/24, during review of the clinical record, surveyor could not locate a PASARR (Preadmission Screening and Resident Review) on Resident #61's clinical record. Surveyor requested evidence of a completed PASARR on 9/12/24 at 5:23 PM at the end of day meeting with the administrator, director of nursing, and regional director of clinical services. On 9/13/24 at 8:20 AM, surveyor was informed by the assistant administrator that a PASARR could not be located for Resident #61. This concern was discussed at the end of day meeting on 9/17/24 at 5:28 PM with the administrator, director of nursing, assistant administrator, and assistant director of nursing and again with the above-mentioned facility staff and the regional director of clinical services at the pre-exit meeting on 9/18/24 at 1:05 PM. Surveyor requested a facility policy for PASARR, but was informed a facility policy could not be located and was provided with a document titled, Preadmission Screening and Resident Review (PASRR) Technical Assistance for States, that read in part, .Federal law mandates that Medicaid-certified nursing facilities (NF) may not admit an applicant with serious mental illness (MI), mental retardation (MR), or a related condition, unless the individual is properly screened .States are required to have a PASRR program in order to screen all NF applicants .The state uses the evaluation to determine, prior to admission, whether NF placement is appropriate .screens generally consist of forms completed by hospital discharge planners, community health nurses, or others . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/18/24.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide an ongoing, person-centered activity program to support resident choice, interests and physical, mental, and psychosocial well-being for 1 of 24 sampled residents, Resident #83. The findings included: For Resident #83, the facility staff failed to provide an ongoing, person-centered, activity program to support resident choice, interests, and physical, mental, and psychosocial well-being. Resident #83's diagnosis list indicated diagnoses that included, but were not limited to, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Epilepsy, Personal history of transient ischemic attack (TIA), Unspecified convulsions, and Type 2 (two) diabetes mellitus. Resident #83 is on Hospice Services for end-of-life care. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/18/24 indicated in the review of Section C-Cognitive Patterns, that Resident #83 was severely impaired in cognitive decision-making with short & long-term memory problems and was coded as being rarely/never understood and rarely/never understands. A review of the clinical record and comprehensive care plan on 9/11/24, produced no evidence of a person-centered, activity care plan, initial activity assessment, or any evidence of activity progress notes for Resident #83. On 9/12/24 at 11:50 AM, during an interview with the activity director, surveyor inquired what activities were being provided for Resident #83 and she responded that resident is provided with in-room activities with activity staff and volunteers. She stated she did not have a schedule of one-to-one visits, but activity staff take the activity cart around three times per week. Surveyor requested the activity care plan, activity participation records for July, August, September 2024, activity assessments, and activity progress notes for Resident #83. On 9/12/24 at 12:52 PM, activity director provided surveyor with hand-written activity participation records and an activity care plan with a created date of 9/12/24, that read in part, Problem .has decreased orientation and limited orientation. Activities needed that she may observe and enjoyy [sic] .Goal .will positively respond to sensory thru [sic] next review period .Intervention .will be visited regularly by activity staff and volunteers thru [sic] next review period . Activity director stated she could not locate an initial activity assessment and stated she does not complete quarterly activity progress notes. A review of the hand-written activity participation records indicated resident was visited for Cozy Corner activity on the following dates: 7/23/24 8/4/24 8/13/24 8/20/24 9/3/24 The activity director stated this was the only activity participation documentation that she could find, but they (activity staff) visit resident every day. On 9/12/24 at 2:31 PM, activity director informed surveyor that she was on vacation at the time Resident #83 was admitted and was not sure what happened with the resident's initial activity assessment. She also stated that, Cozy Cart is a sensory program, and the activity staff play music for that program. This concern was discussed at the end of day meeting on 9/12/24 at 5:23 PM, and at the end of day meeting on 9/17/24 at 5:28 PM, with the regional director of clinical services, administrator, director of nursing, assistant director of nursing, and assistant administrator. Surveyor requested and received a facility policy titled, Life Enrichment Programming Policy, that read in part, .An ongoing resident-centered Life Enrichment Program, based on comprehensive assessments and care plans, will be provided .This program will be designed to meet the interests .and abilities of each resident including as their physical; mental; emotional; social; spiritual; psychosocial and leisure needs . No further information was presented to the survey team prior to exit on 9/18/24.

Based on staff interview, clinical record review and facility document review the facility staff failed to maintain an accurate accounting of narcotics for one of 24 residents, Resident #18. The findings included: For Resident #18 the facility staff failed to report and/or account for missing doses of the medication morphine sulfate. Resident #18's face sheet listed diagnoses which included but not limited to Alzheimer's disease and pain. Resident #18's most recent minimum data set with an assessment reference date of 06/29/24 coded the resident as having both short- and long-term memory problems. Resident #18's clinical record was reviewed and contained a physician's order summary which read in part, morphine concentrate-Schedule II solution; 100 mg/5 ml (20 mg/ml); amt: 0.25 ml; oral. Special Instructions: Take 0.25 ml (5mg) by mouth every hour as needed for mild pain or shortness of breath. This order was discontinued on 04/22/24. Resident #18's electronic medication administration records for the months of July-December 2023 and January-April 2024 were reviewed and contained an entry as above. This entry was last initialed as being administered on 07/13/23. Resident #18's clinical record was reviewed and contained a Controlled Medication Utilization Record dated 07/09/23 indicating 30 ml of the medication, morphine sulfate, was received on this date. The record indicated the resident received five 0.25 ml doses between 07/10/23 and 07/13/23 for a total of 1.25 ml administered. This left a total of 28.75 ml on 07/13/23. The next entry on the control utilization form was dated 11/19/23, and read actual count and indicated an amount of 25.75 ml, a discrepancy of 3 ml. The next entry on the control form was dated 01/02/24 and read actual count and indicated an amount of 24.25 ml, a discrepancy of 1.5 ml from the previous amount. The control form contained entries dated 01/11/24, 01/19/24, 02/09/24, 02/23/24, 03/29/24, 04/03/24 and 04/17/24. Each entry indicated a corrected count and stated either spillage or leaking. The corrected counts ranged from 0.25 ml to 3 ml each count. The final count on the control utilization form indicated 16 ml remaining, for a total of 12.75 ml unaccounted for. Surveyor spoke with the director of nursing (DON) on 09/11/24 at 9:30 am regarding the discrepancies on Resident #18's Controlled Medication Utilization Record. DON stated this form is not the narcotics count sheet, but an administration record. Surveyor asked DON how often narcotics should be counted, and DON responded, They should be counting morphine every day. Surveyor asked DON what should be done if the count is not correct, and DON stated they should be notified of incorrect narcotics counts. Surveyor asked the DON if anyone had notified them of the incorrect counts for Resident #18, and DON stated they had not. Surveyor spoke with the DON again on 09/11/24 at 12 pm regarding the discrepancies in the controlled medications count. Surveyor asked DON if nurses' work 8- or 12-hour shifts, and DON stated they work 12 hours shifts. Surveyor again asked DON how often narcotics should be counted, and DON stated, they should count narcs every shift. Surveyor requested and was provided with a facility policy entitled Inventory Control of Controlled Substances which read in part, 1. With respect to Schedule II controlled substances: 1.1 Facility should maintain separate individual controlled substance records on all Schedule II medications and any medication with a potential for abuse or diversion in the form of declining inventory using the 'Controlled Substances Declining Inventory Record' .1.3 Facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily and document results on a 'Controlled Substance Count Verification/Shift Count Sheet.' 4. Facility staff should ensure that its staff IMMEDIATELY reports suspected theft or loss of controlled substances to their supervisor/manager for appropriate documentation, investigation, and timely follow-up in accordance with Facility policy and Applicable Law. Surveyor requested and was provided with a facility policy entitled Missing Medication Policy which read in part, Any medication[s] identified as missing will be promptly investigated. 1. When a medication is identified as missing the issue is to be immediately communicated to the supervisor on duty, who will notify the Director of Nursing. 4. If, after the efforts above, a missing medication cannot be accounted for, the following steps should occur: Notify the Regional Director of Clinical Services for guidance. If the medication missing is a controlled substance, the local law enforcement is to be notified and the community must follow the steps of the state's regulations for long-term care and pharmacy regarding missing/diverted medications (discuss with your consulting pharmacist). If the medication missing is a controlled substance, work with both law enforcement and your consulting pharmacist to determine further investigational steps which might be necessary. Surveyor spoke with unit manager on 09/12/24 at 1:15 pm regarding narcotics counts, Unit manager stated the staff counts narcotics between shifts, and anytime another nurse takes over a cart. Surveyor asked unit manager what happens if they find a discrepancy in the count, and unit manager stated, they immediately do a re-count, and if it's still off, they notify the DON. Surveyor requested the Controlled Substance Count Verification/Shift Count Sheets for Resident #18's morphine sulfate from July 2023 until medication was discontinued in April 2024 on 09/11/24. DON stated they would look for them, but as of 11:00 am on 09/13/24, they had not been provided. The concern on not maintaining an accurate accounting of narcotics was discussed with the administrator, administrator-in-training, DON, and regional director of clinical services on 09/12/24 at 5:25 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, the facility staff failed to review and/or act upon pharmacist recommendations for 3 of 24 residents, Resident #4, #51, #48. The findings included: 1. For resident # 4, the facility staff failed to review and act upon a pharmacy recommendation to complete an AIMS (abnormal involuntary movement scale) assessment for two months. Resident # 4's diagnoses included but were not limited to major depressive disorder, anxiety, bipolar disorder, and dementia with behavior disturbance. The minimum data set (MDS) assessment with an assessment reference date of 8/12/24 assigned the resident a brief interview for mental status (BIMS) score of 6 indicating they had a moderate cognitive impairment. The Medication Administration Record (MAR) for resident # 4 was reviewed. Resident had an order for Quetiapine ( an antipsychotic) 25 mg every 12 hours for bipolar disorder. The clinical record was reviewed. A pharmacy consultation report dated 9/13/23 read in part, .receives Quetiapine 25 mg q (every) 12 hours for bipolar disorder, which may cause involuntary movements including tardive dyskenisia (TD), but and Abnormal Involuntary Movement scale (AIMS), dyskinesia identification system: condensed user scale (Discus), or other appropriate assessment was not documented in the medical record within the previous 6 months. The most recent AIMS is from 11/15/22 and was 3. Please monitor for involuntary movements now and at least every 6 months per facility protocol. It is recommended that monitoring frequency increase following dose adjustments adjustments. If voluntary movements are present, it is recommended that a risk/benefit assessment be completed and Quetiapine Fumarate be considered for discontinuation. This surveyor was unable to find the AIMS assessment in the clinical record. On 9/13/24 9:00 AM the Regional Director of Clinical Services was interviewed. They provided an AIMS for resident # 4 that was dated 11/8/23. They were unable to state why the AIMS was done nearly 2 months after the recommendation. The policy entitled, Medication Regimen Review with a revision date of 6/1/24 was requested and reviewed. The facility read in part, 9. Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. On 9/18/24 this surveyor interviewed the Director of Nursing. When asked what the expectation would be for a recommendation that read now and every six months they stated, I would expect it to be done now, not two months later. 2. For resident # 51 the facility staff failed to review and act upon a pharmacy recommendation dated 10/18/23. which read in part, .receives clopidogrel and a CYP2C19 inhibitor (a liver enzyme that metabolizes many medications), Omeprazole which may significantly reduce the effectiveness of clopidogrel (prevents blood clots). Please discontinue Omeprazole and, if appropriate, initiate alternative therapy with or Famotidine. A second pharmacy recommendation dated 2/14/24 read under the heading Comment: ***CLINICAL PRIORITY RECOMMENDATION: PROMPT RESPONSE REQUESTED.*** .has received a PPI Omeprazole 40 mg twice daily since 2-23-23 for GERD Recommendation: in the absence of an indication requiring twice daily PPI therapy (e.g., nocturnal symptoms, [NAME]-[NAME] syndrome), please change to pantoprazole 20 mg once daily since also taking clopidogrel. Omeprazole which may significantly reduce the effectiveness of clopidogrel. The Regional Director of Clinical Services provided an order that was dated 3/2/24 which indicated the Omeprazole was discontinued at that time. This surveyor requested and reviewed the policy entitled, 9.1 Medication Regimen Review with a revision date of 6/1/24. The policy read in part, 9. Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. 11. When the consultant pharmacist identifies an time-sensitive medication related concern during the MRR that requires immediate action, the consultant pharmacist will notify the nurse and request the facility contact the attending physician/prescriber to communicate the issue and obtain direction or new orders. 13. The attending physician/prescriber should address the consultant pharmacists recommendation no later that their next scheduled visit to the facility to assess the resident per facility policy and state or federal regulations. The survey team met with the Administrator, Assistant Administrator, Director of Nursing Regional Nurse Consultant and the Assistant Director of Nursing on 9/18/24 at 1:06 PM and this concern was reviewed at that time. No further information was provided to the survey team prior to the exit conference. 28169 3. For Resident #48, facility staff failed to ensure pharmacy recommendations for AIMS (Abnormal Involuntary Movement Scale) assessments were completed every six (6) months. Resident #48's facesheet listed diagnoses to include but not limited to, schizoaffective disorder, anxiety disorder, dementia psychotic disturbance, mood disturbance, anxiety and bipolar disorder. The minimum data set assessment with an assessment reference date of 07/19/24 coded the resident's brief interview for mental status score a 03 out of 15 (in Section C - cognitive patterns) which indicated a severe cognitive impairment. A pharmacy recommendation dated 07/11/24 read Resident #48 received Risperidone which may cause involuntary movements including tardive dyskinesia (TD), but an AIMS was last completed 10/13/23 and was 0 (zero). The pharmacist's recommendation read to monitor for involuntary movements now and at least every 6 months or per facility protocol. The rationale for the recommendation read that early detection of involuntary movements can allow for discontinuation of medication and prevent potentially irreversible TD. Resident #48's provider orders included but were not limited to: Risperdal (risperidone) solution 1mg/ml; 1mg at bedtime and Risperdal (risperidone) solution 1mg/ml; 0.5mg in the morning. Risperdal is an antipsychotic medication. On 09/12/24, this surveyor requested Resident #48's pharmacy recommendations (medication regimen review - MRR) for the four (4) months out of the last 12 months of pharmacy reviews. On 09/16/24 the director of nursing provided an AIMS document dated 01/13/24 and 09/14/24. There was no AIMS provided for six (6) months after the 01/13/24 document which would have been in July 2024, the month of the pharmacy recommendation. The AIMS completed on 09/14/24 was eight (8) months from the previous AIMS and completed after this surveyor asked about the AIMS documentation. The director of nursing (DON) was interviewed on 09/17/24 and stated she did not know why the AIMS was not completed in July but that would have been her expectation. The DON did not report facility policy indicated a different AIMS time-period. On 09/17/24 at 5:28 p.m., the administrator, assistant administrator, DON and assistant director of nursing were informed of the AIMS completion not being every six (6) months as recommended by the pharmacist's review. No further information was provided prior to the exit conference.

Based on staff interview, clinical record review and facility document review the facility staff failed to ensure 3 of 35 residents was free of significant medication errors, Resident #33, Resident #87, and Resident #206. The findings included: 1. For Resident #33 the facility staff held the blood pressure medication amlodipine without a hold order. Resident #33's face sheet listed diagnoses which included but not limited to hypertension and chronic pain syndrome. Resident #33's most recent minimum data set with an assessment reference date of 07/02/24 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive status. This indicates that the resident is moderately cognitively impaired. Resident #33's clinical record was reviewed and contained a physician's order summary which read in part, amlodipine tablet; 2.5 mg; amt: 1 tab; Oral. Special Instructions: Give 2.5 mg by mouth one time a day related to essential hypertension. Resident #33's electronic medication administration record for month of August 2024 was reviewed and contained an entry as above. This entry was not initialed as administered on 08/04/24, 08/17/24 and 08/19/24. Reasons for not administering were given as bp (blood pressure) 101/58, held for hypotension; BP 97/65, and d/t (due to) low BP. Surveyor spoke with the director of nursing on 09/12/24 at 11:40 am regarding Resident #33's amlodipine. DON stated the order did not contain parameters. Surveyor requested and was provided with a facility policy entitled General Dose Preparation and Medication Administration which read in part, 3. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 3.1 Verify each time a medication is administered that its is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. 3.2 Confirm that the MAR (medication administration record) reflects the most recent order. The concern of holding the resident's medications without a physician's order was discussed with the administrator, administrator-in-training, DON, and regional director of clinical services on 09/12/24 at 5:25 pm. No further information was provided prior to exit. 2. For Resident #87 the facility staff failed to administer the medications Xarelto and Lasix (furosemide) per the physician's orders. Resident #87's face sheet listed diagnoses which included but not limited to stiff-man syndrome, other pulmonary embolism without cor pulmonale, and localized edema. Resident #87's most recent minimum data set with an assessment reference date of 07/27/24 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #87's comprehensive care plan was reviewed and contained care plans for Resident is prescribed anticoagulant therapy and Resident receives diuretic medication R/T (related to) pedal edema. Interventions for these care plans included Administer anticoagulant and Administer diuretic. Resident #87's clinical record was reviewed and contained a physician's order summary which read in part, furosemide tablet; 40 mg; amt: 40 mg; oral. Once a day and Xarelto tablet; 20 mg; amt: 1 tablet; oral. Special Instructions: Give 1 tablet by mouth one time a day related to personal history of pulmonary embolism. Resident #87's electronic medication administration record for the month of July 2024 was reviewed and contained entries as above. The entry for furosemide was marked as not administered on 07/03/24 and 07/05/24, with a reason of not available. The entry for Xarelto was marked as not administered on 07/03/24, with a reason of not available. Surveyor requested and was provided with a list of medications available in the facility's emergency medication supply. This list included furosemide 20 mg tablets, and Xarelto 10 mg tablets. The concern on not administering Resident #87's medications was discussed with the administrator, administrator-in-training, DON, and regional director of clinical services on 09/12/24 at 5:25 pm. No further information was provided prior to exit. 21227 3. The facility staff failed to act on a medical provider's order to discontinue Resident #206's morphine (this medication was ordered on an as needed bases). This resulted in the resident continuing to receive the morphine after the medical provider gave the discontinue order. Resident #206's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/25/23, was signed as completed on 7/27/23. Resident #206 was assessed as usually able to make self understood and as able to understand others. Resident #206 was assessed as having problems with both short-term memory and long-term memory. Resident #206 was assessed as being dependent on others for transfers, dressing, personal hygiene, and bathing. The following VERBAL ORDER was found in Resident #206's clinical record (dated 7/7/23 at 2:14 p.m.): Discontinue: effective 7/7/23 - morphine 20 mg/ml oral concentrate; Administer 0.25 milliliter(s) orally every 4 hours as needed for severe pain; Prn - read back and confirmed . Resident #206's Medication Administration Record (MAR) for July 2023 indicated the aforementioned 'discontinue' order was not implemented. Resident #206 continued to receive doses of morphine on the following dates and times: (1) 7/15/23 at 7:00 p.m., (2) 7/17/23 at 8:20 p.m., (3) 7/18/23 at 5:32 a.m., (4) 7/19/23 at 8:17 a.m., and (5) 7/19/23 at 1:31 p.m. On 9/17/24, the Director of Nursing (DON) and Assistant DON (ADON), reported the aforementioned 7/7/23 order to discontinue the morphine had not been implemented. On 9/18/24 at 11:54 a.m., the Regional Director of Clinical Services (RDCS) reported that it is not known when the 7/7/23 order to discontinue Resident #206's morphine was provided to the facility; the RDCS reported the form was uploaded into the electronic record on 7/18/23. On 9/18/24 at 1:06 p.m., the survey team met with the facility's Administrator, Assistant Administrator, Director of Nursing (DON), Assistant DON, and Regional Director of Clinical Services. During this meeting, the surveyor discussed the failure of facility staff to implement Resident #206's morphine discontinue order.

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to ensure communication with hospice staff allowed for the timely implementation of resident orders for one (1) of 35 sampled residents (Resident #206). The findings include: The facility staff failed to ensure communication with hospice allowed for the prompt implementation of an order to discontinue Resident #206's oral morphine. Resident #206's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/25/23, was signed as completed on 7/27/23. Resident #206 was assessed as usually able to make self understood and as able to understand others. Resident #206 was assessed as having problems with both short-term memory and long-term memory. Resident #206 was assessed as being dependent on others for transfers, dressing, personal hygiene, and bathing. The following VERBAL ORDER was found in Resident #206's clinical record (dated 7/7/23 at 2:14 p.m.): Discontinue: effective 7/7/23 - morphine 20 mg/ml oral concentrate; Administer 0.25 milliliter(s) orally every 4 hours as needed for severe pain; Prn - read back and confirmed . This order was given by the hospice provider. Resident #206's Medication Administration Record (MAR) for July 2023 indicated the aforementioned 'discontinue' order was not implemented. Resident #206 continued to receive doses of morphine on the following dates and times: (1) 7/15/23 at 7:00 p.m., (2) 7/17/23 at 8:20 p.m., (3) 7/18/23 at 5:32 a.m., (4) 7/19/23 at 8:17 a.m., and (5) 7/19/23 at 1:31 p.m. On 9/17/24, the Director of Nursing (DON) and Assistant DON (ADON), reported the aforementioned 7/7/23 order to discontinue the morphine had not been implemented. On 9/18/24 at 11:54 a.m., the Regional Director of Clinical Services (RDCS) reported that it is not known when the 7/7/23 order to discontinue Resident #206's morphine was provided to the facility; the RDCS reported the form was uploaded into the electronic record on 7/18/23. The following information was found in a facility policy titled Hospice Care Policy (with a revision date of 5/24/23): - This community provides hospice services through collaboration with a Medicare certified hospice agency when ordered by the resident's physician. - The hospice services and those providing them will meet professional standards and be provided timely. - The community will designate a team member with a clinical background to work with the hospice representative[s] to coordinate the care provided to the community's residents by the hospice staff and the community staff. This coordinator must practice within their scope of practice and be able to assess the resident or have access to someone that has the skills and capabilities to assess the resident. The coordinator will be responsible for the following: . Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. The following information was found in a hospice Medical Social Worker Visit Note dated 7/7/23 at 12:00 noon: Spoke with (resident's adult child's name omitted) who reports (they) went to see (Resident #206) and was not able to talk with (them). (Adult child) reports (they) told the nurse 2 weeks ago to stop giving (the resident) the morphine and only use the tramadol. MSW encouraged (adult child's name omitted) to call and speak with the Hospice nurse to find out what happened to (their) request to stop the morphine. On 9/18/24 at 1:06 p.m., the survey team met with the facility's Administrator, Assistant Administrator, Director of Nursing (DON), Assistant DON, and Regional Director of Clinical Services. During this meeting, the surveyor discussed the failure of the facility staff and hospice staff to communicate in a manner that ensured Resident #206's medical provider order to discontinue morphine was implemented.

Based on observations, clinical record reviews, staff, resident and family interviews, the facility staff failed to ensure two residents were free from abuse; one resident (R#185) who was intentionally restricted from movement by a tucked in top bed sheet on each side with the two top corners tied at the junction of the side rail and bed frame, and the bottom two corners of the top sheet tied to the bedframe; and, a second resident (R#47) to be free of mental and verbal abuse as evidenced by threatening a 30 day notice of discharge. The treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The findings included: 1. Resident #185 was admitted to the nursing facility on [DATE] for skilled services with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She was discharged home on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] coded the resident as having no problems with short and long term memory and moderately impaired (cues and supervision required) in the skills needed for daily decision making. The resident was not coded with having signs and symptoms of [CONDITION(S)] or any mood and behavioral problems. Resident #185 was assessed unable to speak, rarely or never understood. The resident was coded to require extensive assistance of two staff for bed mobility, dressing, toilet use. She was coded on this assessment as requiring one staff for locomotion on and off the unit which occurred two times or fewer. The resident required extensive assistance of one staff for eating and also coded with a feeding tube. She was coded totally dependent on two staff for bathing. The MDS assessment continued to indicate that the resident had no impairments of upper and lower extremity and used the wheelchair as her primary mode of transportation. She was assessed always incontinent of bowel and bladder. This assessment did not code the resident as receiving antipsychotic, antianxiety, antidepressant, hypnotic or opioid medications. The resident was coded as receiving restorative nursing services. The resident was assessed not requiring physical restraints (manual, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body). The assessment indicated the family or significant other participated in the assessment. The nursing restorative program dated [DATE] indicated that some of the goals were that the resident would be able to stand and pivot and transfer to the wheelchair, and to and from the bed and chair with one assist. The resident also had a range of motion restorative program dated [DATE] for all extremities with active participation from the resident ,d+[DATE] repetitions per session. There was no documentation to indicated that the resident did not tolerate the program. The care plan dated as initiated on [DATE] identified that the resident met the goal for transfers to be able to stand pivot transfer and wheelchair transfer with functional (active participation) tier. The care plan revised on [DATE] identified a potential for anxiety or feeling of fear. The goal set for the resident was that she would not display nonverbal indications of fear or anxiety related to care by the next review. The approaches the staff would implement to accomplish this goal included communication with the resident using yes/no questions and allow her time to respond and communicate needs, and monitor resident for non-verbal cues or indications of fear or anxiety. The care plan dated [DATE] also identified the resident met the goal for range of motion that included turning head from side to side, tilt head back, chin up, raise arms above head, raise arms straight out from shoulders, touch top of head, rotate feet in and out, up and down and rotate legs inward/outward. The care plan dated as initiated [DATE] identified Resident #185 was at risk for falls as characterized by history of falls/injury, multiple risk factors related to stoke, gait and balance problems. The goal set by the staff for the resident was that there would be no fall related injuries through the next review. Some of the approaches to accomplish this goal included apply concave sleeve to the air mattress, assist with mobility as needed, reinforce need to call for assistance and therapy to screen and treat as necessary per physician order. The care plan dated as initiated on [DATE] identified the resident required tube feeding related to stroke with difficulty swallowing. A speech therapy referral dated [DATE] was initiated related to a request for a swallowing study to inquire if resident could swallow. After speech evaluation, Resident #185 was able to take medication crushed in applesauce on [DATE] and fortified foods diet with pureed texture and nectar consistency. Enteral feedings, ordered on [DATE], in the evening for difficulty swallowing. [MEDICATION(S)] 1.5 Cal 50ml/hr continuous x 12 hours AND in the morning for to stop tube feeding. The bed rail assessment dated [DATE] indicated that the resident had bed rails and the medical need listed for the side rails was to promote independence. There were no physician orders or signed consent to authorize the use of physician restraints. On [DATE] at 4:00 p.m., a phone interview was conducted with the medical power of attorney (POA) of Resident #185 who was also the resident's daughter. She stated that the resident had 6 strokes and on the 6th one she was left unable to speak, but was able to understand what was said to her and responded appropriately by nodding her head, raising her shoulders, gesturing with her hands and facial expressions. She stated the resident was able to move all extremities with some weakness in the right arm and was working with restorative for transfers and range of motion. She stated the resident lived with her for [AGE] years and when she was admitted to the nursing facility, she came in every day and stayed long hours. During the above interview, the POA stated that [DATE] was a day she would never forget when she came into the Resident #185's room to find the resident with the top sheet tucked in tight on each side and the top corners of the top sheet knotted and tied at the base of the side rails to the bed frame. She stated, at the foot of the bed, each corner of the top sheet was knotted and tied to the foot of the bed frame. According to the PO, because the resident was not able to talk, she could see she was agitated and exhibited fear based on her facial expressions, eyes and head movements. She said the resident was trying to reach out to her, but she could not lift her hands or arms from under the top sheet. She stated, she asked the charge nurse, Licensed Practical Nurse (LPN) #4 was the resident okay because she found her tied to the bed to which the charge nurse told her she knew nothing about the incident and did not see the resident in that position when she gave medications. She said she located the Unit Manager, LPN #3 who literally ran down the hallway entering the resident's room in disbelief. The POA stated, the Unit Manager, LPN #3 called all Certified Nursing Assistants (CNA) into the resident's room to question and identify who tied each corner of the top sheet to the bed frame, but could not get a clear story. The POA stated, It was at that time she immediately untied my mother and we both had a few choice words to say. You cannot fake that kind of surprise on (name of Unit Manager #3). She stated once the resident was untied at the top corners, she immediately placed her hands on top of the sheets at her sides in a way to prevent the occurrence from happening again. The POA said, My mother is not a fighter. Yes, she would throw her covers off and try to get up and I would tell her she couldn't, but see what she wanted. It was mainly to go to the bathroom. Just because she could not tell you how she felt did not mean she was not bothered by being tied and restrained in the bed. I had to keep telling her she would be okay. I hated to leave her that day, but I was told by the current DON and Administrator, the CNA involved would no longer be working at the nursing home. As the interview continued, the POA stated the Director of Nursing (DON) at the time and the Administrator at the time took her to the office and shared that they identified the CNA (#5) who tied the sheets at each end and tucked the sides and that CNA #5 stated, I instructed and gave permission to secure my mother in bed that way to keep her from trying to get up. That was crazy that they would think I gave any such instruction and I told them I would never want my mother tied down. A phone interview was conducted with one of the CNA's (#4) that worked with the resident on [DATE] at 3:15 p.m. She stated she no longer worked there, but remembered the incident and the CNA (#5) who remained in the resident's room after she left to finish changing the resident and she did not return to the resident's room before she left for her shift. CNA #4 said, I heard the resident was tied tight like that by (CNA #5) to make sure she did not get out of bed and to be able to finish up for the shift without her (Resident #185) getting out of bed. She stated she would have never tied anything to or across a resident because, It is just not done like that and I think if she was able to talk she would have told them not to fix her sheets that way. I had nothing to do with that, (CNA #5's name) did it so she could finish her work with the other residents without having to deal with her trying to get out of bed. A phone interview was conducted with the previous Unit Manager, LPN #3 on [DATE] at 4:35 p.m. who not longer worked at the facility. She stated although the resident had gait disturbances and a fall history, she was able to move her arms and legs and was doing well enough with restorative in house. She stated one of the aides had left and did not stay employed because of an incident of restraining the resident with tying the top sheet corners. Unit Manager, LPN #3 stated the resident's daughter came to the nurse's station to tell her when she came in her room, she found her top sheet tied and tucked in over her. She continued to say, When I came into the room, I could see fear in her eyes. I released her and spoke to all CNA's. I found out who tied her sheet down and told her that we never do that! (CNA #5's name) said she tucked and tied her top sheet so the resident would not try to get up. I told her that we never do anything like that even if you think residents will try to get up. I told her we take residents to the nurse's station, find an activity for them or assist them to an activity session. I also told her you never do that because too many things could go wrong like getting entangled in the top sheet, choking from the tied part of the top sheet as she wiggled to set herself free. It technically was abuse! Unit Manager, LPN #3 said she went straight to the previous Administrator and informed her of the incident and she wrote a statement about how she found the resident and released the restraints. On [DATE] at approximately 4:00 p.m., the previous Administrator had arrived at the facility. She stated she sent an initial Facility Reported Incident (FRI) to the State survey and certification office on the date of the incident and also the 5 day follow-up report with all the details from a full and complete investigation was in the specific FRI folder for Resident #185. The FRI was reviewed by this surveyor which indicated on [DATE], Resident (name of R#185) was noted in bed with her sheets tied in such way that could prevent her from getting out of bed. Full investigation was started immediately. Resident is currently safe with no injury. Education on abuse policy, including use of restraints has begun. The FRI investigative folder indicated that in the charge nurse's, LPN #4 she flushed Resident #185's feeding tube at 2:00 p.m. and there were No difficulties at the time. This was the only statement that was written by LPN #4. The investigative folder did not include the written statement of the Unit Manager, LPN #3 as was indicated she wrote during the telephone interview above. On the back of the abuse and neglect tool that was used to complete the investigation was a written timeline, undated and not signed. The time line indicated that it was about 3:00 p.m. when Resident #185's daughter reported to Charge Nurse, LPN #4 informed Unit Manager, LPN #3. Both LPN #4 and #3 along with the daughter go into the resident's room and undo the tied sheet. At 3:15 p.m. the incident was reported to the Director of Nursing (DON) and the physician was made aware who was in the facility at the time. The timeline indicated the Administrator and DON initiated a FRI. The five-day follow up report to the FRI, dated [DATE], typed and submitted by the previous Administrator indicated that written statements were obtained from all, but CNA #5 who was the last person to care for the resident. The FRI indicated that numerous unsuccessful attempts were made by the facility to have the CNA come in and give a statement. The FRI further noted that the following day on [DATE], CNA #5 did not come back to work and on [DATE], the CNA was a no call, no show for her shift. The follow-up depicted that CNA #4's statement indicated that she and CNA #5 provided care to the resident at approximately 2:00 p.m. and that CNA #5 was left alone with the resident to straighten the bed while CNA #4 emptied the trash. The follow-up inaccurately indicated that both CNA #4 and #5 returned to the room and the two of them left together. This depiction was not recorded in CNA #4's written statement, nor was it verbally stated during the phone interview with this CNA conducted by this surveyor. The FRI also indicated they could not identify who was responsible for the incident, but due to the fact that CNA #5 refused to cooperate with the facility's investigation and failure to report to work as scheduled led to her termination of employment. CNA #5 was hired on [DATE] and completed abuse training during general staff orientation on [DATE] in accordance with the facility's policy. On the abuse and neglect quiz the CNA answered that the improper use of bedrails or other restraints was considered emotional abuse. The nurse's notes dated [DATE] at 3:35 p.m. indicated that the incident occurred, assessment was completed and inaccurately recorded Residents family/responsible party was notified of occurrence (Resident #185 daughter's name listed). As indicated above, it was the daughter who notified the charge nurse and the Unit Manager that the resident was tied to the bed. All nurse's notes indicated the resident was unable to verbally make her needs known, but was alert and oriented and understood without difficulty. The Adult Protective Services indicated in their letter to the previous Administrator dated [DATE] that a report was sent to them on [DATE] alleging that Resident #185 was a victim of abuse. The APS social worker indicated that the investigation was completed and their was a preponderance of evidence that Resident #185 was a victim of abuse while a resident at the nursing facility. On [DATE] at approximately 3:00 p.m., a phone interview was conducted with the Interim Administrator. She stated, It looks like this was a problem that she was tied in such a way to prevent movement. This was before my time here. I wish they would have never did that. She also stated that the facility staff is trained on abuse and use of restraints based on the facility's established policies. The facility's Abuse policy and procedure dated as effective on ,d+[DATE] and last revised on [DATE] indicated that the facility would not tolerate abuse of a resident by anyone and that willful actions facilitated or enabled through the use of physical restraints was considered abuse without a physician's order, assessment and compliance with regulations and guidelines of the facility's restraint policy and procedures. Specific assessments are required along with a physician's order and if the device restricts The facility's Restraint policy and procedures dated ,d+[DATE], ,d+[DATE], ,d+[DATE] and last revised on ,d+[DATE] indicated a physical restraint was any manual method or physical or mechanical device, material, or equipment attached adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The policy identified specific assessments are required along with a physician's order and if the device restricts freedom of movement, it is a restraint. 2. For Resident #47, the facility staff failed to ensure the resident was free of mental and verbal abuse as evidenced by being threatened with a 30 day notice of discharge. Resident #47 was initially admitted to the facility on [DATE]. Resident #47 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #47's Quarterly Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of [DATE] coded Resident #47 with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #47 as independent with setup help only with eating, requiring extensive assistance of 1 with dressing and toilet use, extensive assistance of 2 with bed mobility and personal hygiene and total dependence of 2 with bathing. On [DATE] at approximately 7:00 p.m., the surveyor entered into Resident #47's room. Resident #47 observed lying in bed awake. When asked how was he doing, Resident #47 stated, I'm not getting the care I think I should get. The resident stated that the facility is understaffed and he thinks that 12 to 15 residents are too many residents for a CNA (Certified Nursing Assistant) to have assigned to them to care for. Resident #47 then stated, The Administrator, (Name) or whatever his name is, told me if you keep this stuff up I will give you a 30 day notice and get you out of here. When asked why did he say that, Resident #47 stated, My wife died in April and I have been rude and abusive to the staff but I have changed. Resident #47 asked, Do I have to take therapy? Resident #47 stated, The Administrator told me I will write in the letter that you are abusive to the staff and refused to do therapy. Resident #47 stated, I'm working with a organization to get me out of here. (Name of Ombudsman) is suppose to visit me in the morning. I want to leave. On [DATE] at approximately 11:58 a.m., requested that Regional Director of Clinical Services come to the conference room. On [DATE] at 12:00 p.m., Regional Director of Clinical Services was notified of the Resident #47's statement made on [DATE]. Regional Director of Clinical Services stated, The first thing I have to do is get him out of here. On [DATE] at approximately 1:00 p.m., review of Resident #47's clinical record was reviewed and revealed a Behavior Contract. Review of Behavior Contract revealed and is documented in part, as follows: BEHAVIOR CONTRACT Inappropriate Behaviors I, (Resident Name), spoke with the administrative staff at (Facility Name) on this date to discuss my recent behaviors. As a result of this conversation, I understand that effective immediately, and permanently I can no longer do the following. I am not permitted to curse, yell at, or treat staff with disrespect. If I have a problem with a staff member, I know I can speak with either the social worker or administrator about this issue. I understand that I have rights in my home. However, if my behavior infringes on any other resident's rights, it may be necessary for my rights to be altered or modified for the safety of others. I agree to stop all of these behaviors immediately. If any of these behaviors continue, I understand that Facility Name will issue a 30 Day Notice of Transfer and Discharge and I will be discharged from this facility. I also understand that I have rights to contact the state Ombudsman to assist with this matter. Resident #47 signature and wife's signature Date [DATE]. Review of Resident #47's clinical record on [DATE] revealed that the Behavior Contract was signed by the resident and his wife 3 months ago. The residents clinical record has documented behaviors towards staff but no documentation of danger to self or other residents. Received copy of Facility Reported Incident (FRI) on [DATE] from the Regional Director of Clinical Services along with copy of fax confirmation to OLC (Office Of Licensure and Certification) and the Ombudsman. On [DATE] received copy of Relias Learning Behavior Education Training Course and Accident Prevention and Management Course. On [DATE] received a copy of the FRI investigation for Resident #47 dated [DATE]. Review of FRI investigation revealed and is documented in part, as follows: Actions: On [DATE], (Name of Administrator) was suspended pending investigation for allegation of verbal abuse. (Name of Administrator) was asked to write a statement with (Regional Nurse Name), and not to return to premises until directed by RVPO (Regional Vice President of Operations) or RCDS. Education for abuse was started immediately with employees of the facility, and interviews of residents, staff and (Resident Name) were initiated. Facility also provided copies of Nurse Progress Notes with resident behaviors highlighted and Psychological Services Progress Notes. On [DATE] at approximately 7:25 p.m., the Vice President of Operations and Regional Director of Clinical Services was made aware of finding at the pre-exit meeting. When asked is cursing a reason to give a 30 day notice of discharge, Vice President of Operations stated, Yes because of the Behavior Contract. The contract was written up in March and the 30 day notice is in the Behavior Contract. No further information was provided. Policy: Virginia Resident Abuse Policy Section: Abuse, Neglect and Exploitation Effective Date: [DATE] Last Revision Date: [DATE] Policy: This facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone.

Based on interview, clinical record review and facility document review, it was determined that facility staff failed to provide evidence that the written bed hold policy was sent upon transfer to the hospital for three of 35 residents in the survey sample, Resident #38, #85 and #76. The findings included: 1. Resident #38 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #38's most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 4/24/21. Resident #38 was coded as being severely impaired in cognitive function on the Staff Assessment for Mental Status. Review of Resident #38's clinical record revealed that she was sent out to the hospital on 1/10/21. The following change of condition note was documented: The Change in Condition/s reported on this evaluation are/were: Abnormal vital signs .At the time of evaluation resident /patient vital signs, weight .were: - Blood Pressure: BP 184/120 (Lying l/arm) (left) .Pulse 77 pulse type: Regular .RR (Respiratory Rate) R: 20 .Temp: (Temperature): 96.2 .Weight: 155.2 lb (pounds) . Pulse oximetry: O2 (oxygen) percent room air .Recommendatons: Send to ER (emergency room ) for evaluation. Review of the next note dated 1/10/21 documented in part, the following: .Patient was admitted to (Name of hospital) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence that written bed hold notification was sent with the resident at the time of hospital transfer. On 6/17/21 at 1:32 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #6. When asked what documents were sent with a resident upon transfer to the hospital, LPN #6 stated that the nurses use envelopes that all transfer paperwork goes into. LPN #6 stated that the front of the envelope list several documents; a checklist with items such as the face sheet, bed hold, care plan, transfer summary, and SBAR (Situation, Background, Assessment, and Recommendation) that reminds staff what documents to send with the resident. When asked if it was the nurses who send the written bed hold notification with the resident, LPN #6 stated that it was. When asked if nurses should be documenting what items were sent with the resident at the time of transfer, as the envelope physically goes with the resident to the hospital; LPN #6 stated that they should. LPN #6 stated that the checklist in the front of the envelope also had a copy that could be ripped off and uploaded into the computer system. When asked how she would know what documents were sent with a resident if there is no evidence of a documented note; or a copy of the checklist on the clinical record; LPN #6 stated, I guess we wouldn't know. On 6/21/21 at 7:23 p.m., Administrative Staff Member (ASM) #4, the interim Administrator and ASM #2, the Regional Director of Clinical Services were made aware of the above concerns. Facility policy titled, Bed Hold Letter Policy, did not address the above concerns. 2. The facility staff failed to provide Resident #85 with a bed-hold policy prior to transferring to a hospital. Resident #85 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility staff failed to provide Resident #85 with a bed-hold policy prior to transferring to a hospital. A 3/3/21 Quarterly Minimum Data Set (MDS) assessed this resident in the area of Cognitive Patterns - Brief Interview for Mental Status as a (10). In the area of Daily Living this resident was coded as requiring minimum assist with supervision in the areas of dressing, toileting, and eating. Resident #85 was continent of bowel and bladder. A 3/18/21 Care Plan indicated: Resident #85 receives [CONDITION(S)] and refuses to go to appointments on multiple occasions. Resident have behaviors of cursing, throwing items in room, also noted to make self vomit when not getting what he wants. Resident is combative and resistive to care: refuses med's and care at times. A review of the clinical records indicated Resident #85 was transferred to the hospital on the following dates with out a bed-hold notice policy: 6/1/21- transported to ER for [CONDITION(S)], 4/23/21 transported to ER for [CONDITION(S)], 3/5/21- transported to ER for [CONDITION(S)], 2/5/21- transferred to the hospital due to elevated blood pressure and pulse, 1/28/21 transported to ER for [CONDITION(S)], 1/7/21 transported to ER for [CONDITION(S)], and 12/31/21 transported to ER for [CONDITION(S)]. During an interview on 6/21/21 at :10:14 a.m. with the Regional Social Worker, she stated, the facility staff did not provide or send a bed hold policy for Resident #85 prior to transferring him to the hospital. The facility staff failed to provide a bed-hold policy prior to transferring a resident to a hospital. 3. The facility staff failed to provide Resident #76 or the resident's representative a copy of the bed hold policy upon discharge/transfer to the hospital on 03/13/21. Resident #76 was originally admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #76's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 03/19/21 coded Resident #76 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. The Discharge MDS assessments was dated for 03/13/21 - discharge return anticipated. Resident #76 was readmitted to the nursing facility on 03/16/21. On 03/13/21, according to the facility's documentation, Resident #76 was observed lying on the floor beside the bed, face down with some blood on the floor. Resident #76 was assessed and noted to be bleeding from her nose. Further assessment reveals no other s/s of injuries. The physician was notified of fall with a new order to send to (local hospital) for evaluation and treatment. A pre-exit conference was conducted with the Vice President of Operations and Regional Director of Clinical Services on 06/21/21 at approximately 9:30 a.m. The Vice President said, Resident #76 should have been given a copy of the bed hold policy when transferred to the hospital on 03/13/21. When asked, What is the purpose of giving the bed hold policy the Regional Director stated, The resident will know there will bed is available if they chose to return to the facility. The facility's policy titled: Discharge Planning Policy (revision date: 09/24/20.) Part 5: Documentation requirements for involuntary and unplanned discharges. When (facility) transfers or discharges a resident for any circumstance, the discharge/transfer must meet the regulatory requirements for transfer/discharge. The facility will take steps to ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.

Based on observation, resident and staff interviews and clinical record review the facility staff failed to ensure 1 of 35 residents (Resident #24) in the survey sample who were unable to carry out activities of daily living (ADL) receives the necessary services. The findings included: The facility staff failed to ensure that Resident #24 had his hair washed and fingernail care was provided. Resident #24 was admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #24's Minimum Data Set (MDS-an assessment protocol) a significant changes with an Assessment Reference Date of 04/06/21 coded Resident #24 total dependence of one with bathing, extensive assistance of two with bed mobility and transfer, extensive assistance of one with dressing, eating, toilet use and personal hygiene. Resident #24's comprehensive care plan with a revision date 01/19/20 documented the resident frequently refuses showers (agrees to bed baths) and resistive to ADL care. The goal set by the staff: resident will not have any negative outcomes related to noncompliance. Some of the approaches to manage goal is to document educational attempts made with resident in relation to (r/t) compliance, educate resident, family and/or responsible party on negative outcomes r/t noncompliance and to notify MD of non-compliance per routine and prn. Review of the Care Plan History (Task) included the following information: offer shower Monday and Thursday (3-11) shift and as needed or resident request. Resident prefers bed bath over shower. During the initial tour on 06/15/21 at approximately 2:30 p.m., Resident #24 was observed lying in bed with his hair full of flakes and greasy, and with really long fingernails. A phone interview was conducted with License Practical Nurse (LPN #7) on 06/15/21 at approximately 4:04 p.m. The LPN assessed Resident #24 then stated, His hair is oily/greasy and large flakes which looks like dandruff and his fingernails are extremely long. She said Resident #24 really need a shower, to have his hair wash and his fingernails need to be cut. On the same day at approximately 7:30 p.m., a phone call was received from LPN #7. She said, Resident #24 was given a shower by the Certified Nursing Assistant (CNA) and the Director of Nursing (DON.) He was Hoyer lifted to a shower bed, given a shower, hair washed and fingernails cut and trimmed. On 06/17/21 at approximately 8:05 a.m., the Administrator was asked to provide the CNA who gave Resident #24 a shower on 06/15/21 (3-11 shift) which was not his scheduled shower/complete bed bath day. The Administrator was also asked for a list of all CNA's in the last 2 weeks who was assigned to provide Resident #24 with his twice a week scheduled shower/bed bath. This information was never provided. An onsite interview was conducted with Resident #24 on 06/16/21 at approximately 3:00 p.m. Resident #24 stated, I haven't had a shower since admission until last night which was very interesting. Resident #24 said last night (06/15/21), I got a shower on a shower bed and they washed my hair and cut my fingernails. A phone interview was conducted with LPN #5 on 06/16/21 at approximately 1:15 p.m. She said Resident #24 received a shower last night; got his hair washed and fingernails cut and trimmed. The LPN stated, Resident #24 should have received a shower or bed bath at least twice a week. She said even if Resident #24 did not get a shower, he should have gotten his fingernails cut and trimmed and his hair shampooed with the no rinse shampoo caps which we have in stock. On the same day at approximately 1:30 p.m., a phone interview was conducted with Resident #24. He said, I got a shower last night for the first time since I've been here. They put me on a shower bed, gave me a shower, washed my hair and cut my fingernails. Resident #24 stated, I feel so much cleaner now, I hope my showers will continue. A pre-exit conference was conducted with the Vice President of Operations and Regional Director of Clinical Services on 06/21/21 at approximately 9:30 a.m. The facility did not present any further information about the findings. The facility titled: Resident Bath/Showering/Scheduling Policy (revision date: 02/01/21.) Policy: Residents will be bathed or showered according to their preferences in order to maintain healthy hygiene and skin condition.

Based on information gleamed during a complaint investigation, resident, family and staff interviews, and clinical record review, the facility's staff failed to ensure a resident's emotional well being was managed to attain the highest practicable mental and psychosocial well-being for a resident with an anxiety disorder and a major depressive disorders for 1 of 35 residents (Resident #80), in the survey sample. The findings included: Resident #80 was originally admitted to the facility 11/19/20, and had never been discharged from the facility. Resident #80's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly discharge Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/28/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #80's cognitive abilities for daily decision making were intact. Section D (Mood) stated the resident wasn't assessed and Section E (Behavior) for coded for no behaviors. Section G was coded for supervision after set-up with eating, supervision of one person with bed mobility, transfers, walking, locomotion, limited assistance with personal hygiene, dressing and toileting and total care with bathing. During an interview with Resident #80 on 6/15/21 at approximately 3:00 p.m., the resident stated she cries frequently because she doesn't want to continue to live in the facility for its like living with 100 people and you have to wait for everything. The resident also stated she prefers to live in a group home for there are only 4-5 people, like a normal household. She repetitively stated I would rather take my chances in the streets than stay here. Resident #80 stated she dislikes living in the facility so much that most days she cries and repetitively ask staff how the search for her placement is looking. The resident further stated in April 2021 she was so desperate to discharge from the facility that she opted to go to the local hospital because she was told they would locate her another place to live. The resident stated to get to the hospital the facility's staff didn't inform her she wouldn't be going by ambulance but by police escort and being removed from the facility handcuffed with the police was demeaning. She stated the police took her to the hospital, handcuffed her to the hospital's bed and she spoke with someone on a television screen and they declared her not suicidal or homicidal and recommended a discharge back to the facility. Resident #80 stated once again she was disappointed because the local hospital discharged her back to the facility and upon return to the facility she had a plastic device placed on her ankle to prevent her from exiting doors and a chair sat outside of her door in which someone sat in on the night shift to watch her in case she attempted to harm herself. The resident further stated she thought she had placement in April and May 2021 in a group home but something unknown to her occurred and the discharge didn't take place. As a result of another disappointment of not leaving the facility the resident stated she is ready to leave against medical advise and has requested to many times. Review of the clinical record revealed a nurse's note dated 4/13/21 at 11:48 a.m., stating the resident demanded to leave the facility against medical advice and stated she wanted it all over. The 4/13/21 nurse's note also stated the resident stated she could achieve ending it with pills and ropes or just keep walking until she falls out. The note stated the resident was displaying flight of ideas, disturbances of thought process and manic behaviors as well as paranoia (saying people were laughing at her, being selective about which CNA renders her care. Another nurse's note on 4/13/21 stated the resident was exhibiting increased anxiety, restlessness, demonstrating manic episodes, threatening to harm herself, pointing out objects she could use to harm herself and kill herself such as banging her head on the window, walk out in traffic and be hit by a car and die and threatened if she had to stay in the facility she would stop eating and starve herself to death or drink so much fluids that she would go into fluid overload. The nurses's note also stated the resident was manipulative, continued to make negative statements and retract the statements later. Review of the hospital discharge summary dated 4/14/21 stated the resident presented to the hospital with manic behavior that could not be managed by the nursing facility. The hospital discharge summary also stated the resident was anxious, crying and stated she wasn't satisfied with the care she was receiving at the nursing facility. The discharge summary further stated the resident was nervous and anxious, positive for a hyperactive behaviors, the speech was rapid, pressured but her thought content didn't include homicidal or suicidal ideation. The discharge summary revealed no new medication orders but that the resident schedule an appointment as soon as possible with her physician. On 6/16/21 at approximately 2:00 p.m., the resident came to the facility's conference room to speak with the surveyors. She stated all the facility's personnel that were working with her to obtain a discharge from the facility were no longer employed by the facility and she feared she would never get discharged . The resident also stated Administrator #1 stated she was using too much of the staff's time working on finding her placement outside the facility. The resident began to become very anxious, couldn't be redirected , began crying while stating I needed someone to help me, they are going to mistreat me when they see me leave this room. The resident further stated keep everything I tell you confidential for I want the new Social Worker to continue to work towards my discharge for I'll die if I have to continue to live here. The resident also stated Administrator #1 was often rude to her and The West Unit Manager yells at her. A interview was conducted with the former Social Worker (SW) for the facility on 6/21/21 at approximately 3:00 p.m. The former SW stated she met with the resident on a regular basis when she worked at the facility. he stated the resident required a great deal of reassurance therefore she constantly expressed they cared for her and were there to listen to her. She also stated the resident worried daily about what direct care staff would work with her and often negotiated to have specific staff be her caregiver for the shift. The former SW also stated they requested a consult with a local psychological practice to aid the resident with coping and managing her anxiety but the consult was never provided and she didn't know why but she felt the resident wouldn't be receptive to the services. The former SW stated no other practices were contacted to render psychological services to Resident #80 that she was aware of. The following medication orders were noted on the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was dated 11/19/20, and another order dated 3/15/21 read Lorazepam 2 milligrams by mouth two times a day for anxiety. No medication was prescribed for the major depressive disorder and neither was she receiving psychological services for the major depressive disorder. The active care plan had a problem dated 3/1/21, which read; resident has obsessive and paranoid thoughts and accuses staff of lying and/or laughing at her. The goal read the resident will have an improved mood state (less anxiety) through the next review date. The interventions included; Administer medications as ordered. encourage the resident to express her feelings and allow her time to talk as needed. observe for signs/symptoms of [CONDITION(S)], hypomania, racing thoughts, or euphoria, increased irritability, frequent mood changes, pressured speech, flight of ideas, marked change in need for sleep, agitation or [CONDITION(S)]. Psychiatric consult as needed. At the time of this survey the facility's staff hadn't obtained the 4/13/21 hospital's discharge summary for Resident #80 to determine if orders or recommendations had been made or if after care was necessary. The Nurse Practitioner's 6/8/21 progress note stated the resident had no ER visits since last recertification and there were no practitioner notes addressing the resident's indicators of distress and inability to cope in the current environment as well as the fragility of the resident's emotional and psychosocial state. On 6/17/21 at approximately 10:45 a.m. an interview was conducted with the West Unit Manager. The West Unit Manager stated the resident had become increasingly anxious and restless with the change in staff, mainly the Admission Director and the former Social Worker. She stated the resident frequently asked her who would help her now that the others have left and she reassures her they all will. The West Unit Manager stated the resident hadn't received psychological services since her admission to the facility but there was orders for a consult if needed. The West Unit Manager stated the resident had demanded the leave against medical advice paper several times and talks about taking her chances in the streets rather than living in the facility. The West Unit Manager also stated the resident has family dynamics with her sister and often she doesn't want information disclosed to her sister as well as dynamics with certain staff members therefore; she requests almost daily to know who will be working so she can select the staff she desires to work with her. On 6/21/21 at approximately 8:15 p.m., the above findings were shared with the Interim Administrator, and Director of Nursing. The Interim Administrator stated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Interim Administrator also stated that the facility's staff has continued to provide emotional support to the resident and no psychological or psychiatry services had provided services to Resident #80. The Interim Administrator further stated the resident didn't have to disclose her psychological status or emergency room discharge summary with the facility upon her return from the emergency department in April 2021, for her psychological status is her own private matter. COMPLAINT DEFICIENCY

Based on resident interview, staff interviews, facility documentation review and clinical record review the facility staff failed to ensure 2 of 35 residents in the survey sample (Resident #67 and #16) received physician ordered medications. The findings included: 1. The facility staff failed to ensure Resident #67 received physician ordered medication ([MEDICATION(S)] vixcous [MEDICATION(S)], [MEDICATION(S)] 1:1:1: max sign 10 ml) on 06/11, 06/12, 06/13, 06/14, 06/15, and 06/16/21. Resident #67 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #67's Admission Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 05/19/2021 was not coded with a BIMS (Brief Interview for Mental Status) score. In addition, the Minimum Data Set coded Resident #67 as requiring limited assistance of 1 with dressing and personal hygiene, extensive assistance of 1 with bed mobility and toilet use and total dependence of 1 with eating and bathing. On 06/15/2021 at approximately 4:00 p.m., entered Resident #67's room during initial tour of facility. When asked how was everything going for him at the facility, Resident #67 stated, I have throat cancer and I'm getting laser treatments. I have a feeding tube and I get tube feedings at night. When asked if he received a meal tray, Resident #67 stated, I'm still able to eat food. Resident #67 stated, The doctors told me that I will probably have throat soreness but I'm ok right now. Resident #67 stated, The doctor ordered a new medication, [MEDICATION(S)] or something, to help with my throat. It's to help prevent soreness, pain. I'm suppose to get it 3 times a day but I have only got it a couple times. On 06/16/2021 Resident #67's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/17/2021 at approximately 11:00 a.m., review of Resident #67's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Start Date - 06/10/2021 2300. Review of Hours column revealed - PRN. Review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no evidence on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The facility staff failed to ensure Resident #16 received the correct dosage of [MEDICATION(S)] per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #16 was originally admitted to the facility on [DATE]. The resident has never been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The significant change, annual quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/24/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #16 cognitive abilities for daily decision making were severely impaired. In section G(Physical functioning) the resident was coded as requiring extensive assistance of two people with bed mobility and transfers. Requires extensive assistance of one person for locomotion on and off the unit. Requires extensive assistance of one person with dressing and requires supervision of one person with eating. The Care Plan dated 4/07/21 reads: FOCUS: HOSPICE SERVICES: Resident #16 is on Hospice services for cerebral infarction with Compassionate Care Hospice. Date Initiated: 03/05/2021. Created by: MDS Coordinator. Revision on: 3/25/2021. Goals: o Resident will receive palliative measures to provide comfort care and emotional support for pain, N/V, shortness of breath and diarrhea, etc. until next review. Date Initiated: 03/05/2021. Created by: MDS Coordinator. Revision on: 03/21/2021. Target Date: 05/06/2021. Interventions: Hospice services as ordered. Assist with grieving process by allowing resident to express concerns/fears offer supportive but realistic feedback. Provide emotional support and comfort measures. Date Initiated: 03/05/2021. Created by: (MDS Coordinator). Revision on: 03/21/2021. o PAIN: Resident #16 has chronic pain r/t chronic pain syndrome and receives scheduled and prn pain medications. Date Initiated: 08/06/2018. Created by: (MDS Coordinator). Revision on: 06/20/2020. Goal: o Resident #16 will not have discomfort related to side effects of [MEDICATION(S)] through the review date. Date Initiated: 08/06/2018. Created by: (MDS Coordinator). Revision on: 05/28/2020. Target Date: 05/06/2021. o Resident #16 will display a decrease in behaviors of inadequate pain control through the review date. Date Initiated: 08/06/2018.Created by: (MDS Coordinator). Revision on: 05/28/2020. Interventions: o Administer [MEDICATION(S)]/medications per orders. Date Initiated: 08/06/2018. Created by: (MDS Coordinator). Nursing to assess/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report to MD if occurs. Date Initiated: 08/06/2018. Created by: (MDS Coordinator). Nursing to Implement no pharmacological interventions to release the pain like Distraction techniques, Relaxation and Breathing exercises, music therapy, Re-position. Date Initiated: 08/19/2019. Created by: (MDS Coordinator). A review of nursing notes dated 6/14/21 reads: DON (Director of Nursing) notified of medication error related to [MEDICATION(S)]. [MEDICATION(S)] 100 mg three times a day ordered was linked incorrectly to a previous order for [MEDICATION(S)] 300 mg which had been discontinued in March 2021. The Nurse administered [MEDICATION(S)] 300 mg as it was the supply on hand. The nurse reports that she wasted the other two as she questioned the link supply order. Physician notified, daughter notified and hospice was notified. The resident was assessed and increased monitoring implemented. Her order was corrected. A review of her medications were completed to ensure that orders linked were correct. The nurse received education via phone call on wasting medications with a second nurse and on the rights of medication administration. According to the order detail report Resident #16 should have received [MEDICATION(S)] ([MEDICATION(S)]) Capsule 100 mg by mouth three times a day for pain. Dated 4/22/21. A review of Administrative orders show that the physician discontinued [MEDICATION(S)] 300 mg capsule give 3 capsules by mouth twice daily due to order entered incorrectly. A review of the controlled medication utilization record reads: [MEDICATION(S)] 300 mg (900 mg) tabs 3 caps by mouth twice daily. According to the controlled medication record Resident #16 received 3 [MEDICATION(S)] capsules 300mg by mouth at 9:00 AM. Amount remaining 57 capsules. Resident #16 received 4 [MEDICATION(S)] capsules 300mg at 9:00 PM. Amount remaining 53 capsules. Amount wasted is 1 capsule. The above medications were given and wasted by RN (Registered Nurse) #1. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order date 4/22/21. Start Date 4/22/21. According to the order detail report Resident #16 should have received [MEDICATION(S)] Capsule 100 mg by mouth three times a day for pain. Dated 4/22/21. According to the MAR (Medication Administration Record) Resident #16 received [MEDICATION(S)] ([MEDICATION(S)]) 100 mg one capsule three times a day for pain at 9:00 AM, 4:00 PM and 9:00 PM. Start date: 4/22/21 at 9:00 PM and discontinued on 6/14/21 at 2:16 AM. According to the MAR (Medication Administration Record) Resident #16 received [MEDICATION(S)] ([MEDICATION(S)]) 100 mg one capsule three times a day for pain at 9:00 AM, 4:00 PM and 9:00 PM. Start date: 6/14/21 at 9:00 AM. A review of the controlled medication utilization record reads: [MEDICATION(S)] 300 mg (900 mg) tabs 3 caps by mouth twice daily. According to the controlled medication record Resident #16 received 3 [MEDICATION(S)] capsules 300mg by mouth at 9:00 AM. With the amount of capsules remaining to 57 capsules. According to the controlled medication record Resident #16 received 4 [MEDICATION(S)] capsules 300 mg at 9:00 PM. Amount remaining 53 capsules. Amount wasted is 1 capsule. An interview was conducted with ASM (Administrative Staff) #2 concerning the medication error involving Resident #16. She stated, The risk management note dated 6/14/21 shows the nurse reported (RN #1) that she wasted 1 300 mg tablet of [MEDICATION(S)]. I still need the nurse written account of the error she made. She is out of town at the moment. She administered 1 300 mg tablet of [MEDICATION(S)]. She ran the report to make sure the drugs linked properly on Resident #16 and the whole building. We have educated the nursing staff. The DON said that the nurse on duty contacted pharmacy to implement the process. The orders were unlinked on 6/14/21. An interview was conducted on 6/16/21 at approximately 6:24 PM with LPN (Licensed Practical Nurse) #1. She stated, The nurse that relieved me gave Resident #16 too much [MEDICATION(S)] (The new RN Supervisor) she thought it was a new order. She should have been getting [MEDICATION(S)] 100mg three times a day. The pharmacy sent in the wrong dosage. Where it says dispense was written wrong. They called the doctor and he said call hospice. This happened on June 11th or the 12th. The medication error is documented in the computer. The resident's daughter knows about it. RN #1 only works weekends, Friday, Saturday and Sunday. The daughter don't like me. She reports me for every little thing. On 6/16/21 at approximately, 7:55 PM an interview was conducted with the DON (Director of Nursing) concerning Resident #16. She stated, The [MEDICATION(S)] capsule 100mg give 1 cap by mouth tid (Three time a day) for pain. [MEDICATION(S)] 300 mg capsule 3 caps by mouth twice daily for pain. The nurse states she only gave 1 capsule which was 300mg of [MEDICATION(S)]. The surveyor asked if another nurse wasted the medication with the nurse. She stated, We started an investigation. This happened at night time. I didn't get the information until the next shift nurse told me about it. LPN #1 is out of town. She was then asked by the surveyor if the discrepancy come from pharmacy? She stated, Yes. We corrected the order called doctor and notified hospice. I personally called the family. We went through all of the MARS (Medication Administration Records) and back tracked. Pharmacy sent the wrong dosage. I had the nurse (RN #4) call she's the nurse that came behind LPN #1. ASM (Administrative Staff) #2 Stated, Some of the medications were linked to the wrong meds in the system. If they ordered 100 mg [MEDICATION(S)] it would come up 300 mg. I had to reach out to the point click care. We can check the system. On 6/17/21 at approximately 10:50 AM, an interview was conducted with OSM (Other Staff Member/Pharmacy Tech.) Concerning Resident #16's [MEDICATION(S)]/[MEDICATION(S)]. She stated, I haven't reviewed them (the monthly Medication Regimen Review) for June yet. The in house pharmacy actually does the review. New orders sent in are reviewed at the in house pharmacy. I don't see those orders. In-house Pharmacy will actually fill the orders. I'm responsible for the clinical part of the medication review. They entered one on 6/14/21 into the system for Neurontin100 mg TID (Three Times a Day). I don't see anything entered on the 6/11/21. I see [MEDICATION(S)] 100 mg TID on 6/14/21. On 7/27/18-3/31/21, the resident was on [MEDICATION(S)] 300 mg capsules 3 twice a day, 900 mg. That's within the dosing you can go up to 3600 mg in one day. Then on 04/ 22/2021 they restarted at [MEDICATION(S)] 100 mg TID. Stopped on June 14th and entered same dosage. I don't have an order entered as [MEDICATION(S)] only under brand name [MEDICATION(S)]. The glitch in PCC would be between the facility and the IT (Information Technology) department not us. [MEDICATION(S)] 100 mg order they stopped on 6/14/21 and re-entered it. I don't know why. The nursing staff RN #4 entered the order at 2:15 AM. I don't see an error on the EMAR (Electronic Medication Administration Record). On 6/17/21 at approximately 1:16 PM an interview was conducted with OSM #22. She stated, We dispense the generic. This patient has [MEDICATION(S)] 100mg TID and [MEDICATION(S)] 300 mg order 3 capsules twice a day. 1t was filled on the 6/12/21 and the other on the 6/14/21. It was written by the NP (Nurse Practitioner). It won't cross reference because it's not the same strength. An electronic order came across by NP and MD (Medical Doctor). Two people are writing for the patient. They should contact the primary care doctor. They may not be aware. [MEDICATION(S)] 900 mg twice daily is from March. They are not sending in the discharged orders when the dosage is filled. It's been filled 3 times, [MEDICATION(S)] 100mg TID since April. The [MEDICATION(S)] 300 mg was filled twice in March and June. Until we get a discharge order we can't cancel them. They need to send us a discharge order on them ([MEDICATION(S)]). On 6/17/21 at approximately 3:31 PM an interview was conducted with NP/ASM (Nurse Practitioner/Administrative Staff Member #3) Concerning Resident #16. She stated, I'm not aware of a medication error involving [MEDICATION(S)]. Generally you have to write a script for that they didn't get one from me. The facility doctor was on call last week. On 6/17/21 at approximately 6:07 PM., an interview was conducted with RN (Registered Nurse) #1. Concerning Resident #16. She stated, She was supposed to get [MEDICATION(S)]. She only got one 300 mg capsule. I wasted the other 5 capsules. I went by what the computer said. My balance was off so I wasted the other tabs. I wasted them by myself. They don't have any nurses in the unit. They put me on the floor with 36 cases (Residents) by myself. On paper it looks like I gave her three pills I only gave her 1 pill. It will show. It will show I only gave her 1 tab. I reported it to the DON that same night. I didn't write the report up yet. I only work Friday, Saturday and Sunday. I was new to the facility. I worked 7:00 AM-7:00 PM. The computer has two different orders. She was supposed to get [MEDICATION(S)] 100 mg dated 6/12/2021. I didn't realize an error was made until they called me. When I counted off with another nurse at the end of the shift. The other nurse is RN #4. The resident was ok. I had no problems with the daughter. A lot of their orders have errors in the computer. The nurse managers are inputting errors. On 6/21/21 at approximately 2:25 PM, an interview was conducted with OSM #10 (Hospice RN/Clinical Manager) Concerning Resident #16. She stated,We were informed on 6/13/21 about the [MEDICATION(S)] medication error. We had our nurse come out that day to see resident. The nurse came out at 3:53 AM in the morning. We (Hospice) prescribed [MEDICATION(S)] 100 mg TID since March 2021 She was on [MEDICATION(S)] 300 mg TID in the beginning but it was changed on 4/22/21 to Gabapentin100 mg TID. [MEDICATION(S)] ([MEDICATION(S)], [MEDICATION(S)]) is a medication used to help manage certain epileptic seizures and relieve pain for some conditions. Dizziness and drowsiness are common [MEDICATION(S)] side effects. https://www.mayoclinic.org/diseases-conditions/[CONDITION(S)]/expert-answers/[MEDICATION(S)]-side-effects/faq- 893 On 6/21/21 at approximately 5:31 PM., the above findings were shared with ASM (Administrative Staff Member/Regional Director of Clinical Services) #2 and with ASM #4 concerning the above issues. An opportunity was offered to the facility's staff to present additional information but no additional information was provided. On 06/21/2021 a copy of facility policy and procedure titled 6.0 General Dose Preparation and Medication Administration was received. On 06/21/2021 at approximately 7:25 p.m., the Vice President of Operations and the Regional Director of Clinical Services was informed of the findindings at the pre-exit meeting. No further information was provided. Policy #/ Title 6.0 General Dose Preparation and Medication Administration Effective Date 12/01/07 Revision Date 05/01/10; 01/01/13 Applicability This Policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to facility policy regarding medication administration and should comply with applicable law and the State Operations Manual when administering medications. Procedure 4. Facility staff should: 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in Appendix 17: Facility Medication Administration Times Schedule.

Based on record review and staff interviews the facility staff failed to provide one resident (Resident #85) in the survey sample of 35 residents with a notice of transfer to the office of the state Long-Term Care Ombudsman. The findings included: Resident #85 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility staff failed to provide a notice of transfer to the Office of the State Long-Term Care Ombudsman while being discharged to the hospital. A 3/3/21 Quarterly Minimum Data Set (MDS) assessed this resident in the area of Cognitive Patterns - Brief Interview for Mental Status as a (10). In the area of Daily Living this resident was coded as requiring minimum assist with supervision in the areas of dressing, toileting, and eating. Resident #85 was continent of bowel and bladder. A 3/18/21 Care Plan indicated: Resident #85 receives [CONDITION(S)] and refuses to go to appointments on multiple occasions. Resident have behaviors of cursing, throwing items in room, also noted to make self vomit when not getting what he wants. Resident is combative and resistive to care: refuses med's and care at times. A review of the clinical records indicated Resident #85 was transferred to the hospital on the following dates: 6/1/21- transported to ER for [CONDITION(S)], 5/3/21 - transported to ER for [CONDITION(S)], 4/23/21 transported to ER for [CONDITION(S)], 3/5/21- transported to ER for [CONDITION(S)], 2/5/21- elevated blood pressure and pulse, 1/28/21 transported to ER for [CONDITION(S)], 1/7/21 transported to ER for [CONDITION(S)], and 12/31/21 transported to ER for [CONDITION(S)]. During an interview on 6/21/21 at :10:14 a.m. with the Regional Social Worker, she stated, the facility staff did not provide or send a notice of transfer to the Long Term Care Ombudsman regarding Resident #85 transfer to the hospital.

Based on observation, resident interview and staff interviews the facility staff to ensure reasonable accommodation of need for 1 of 35 residents (Resident #24) in the survey sample. The findings included: The facility staff failed to ensure Resident #24 was assessed for the correct call light device. Resident #24 was admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #24's Minimum Data Set (MDS-an assessment protocol) a significant changes with an Assessment Reference Date of 04/06/21 coded Resident #24's Brief Interview for Mental Status (BIMS) scored a 10 out of a possible score of 15 indicating moderate cognitive impairment. In addition, the MDS coded Resident #24 total dependence of one with bathing, extensive assistance of two with bed mobility and transfer, extensive assistance of one with dressing, eating, toilet use and personal hygiene. Resident #24's comprehensive care plan with a revision date 06/16/21 documented the resident with ADL self-care deficit, requires assistance related to bilateral upper extremity contractures. The goal set by the staff: needs will be met with regard to ADL's. One approach to manage goal is to have a touch pad call light within reach (date initiated 06/23/21.) During the initial tour on 06/15/21 at approximately 2:30 p.m., Resident #24 was observed lying in bed. Resident observed with severe contractures to both hands and can't manage a regular call light. Resident's call bell was on the floor. Resident #24 said, he's not able to use the current call bell because my hands are contracted. A phone interview was conducted with License Practical Nurse (LPN) #5 on 06/16/21 at approximately 1:15 p.m. LPN #5 said she observed Resident #24 trying to use the regular call bell, but it was hard and awkward for him to hold because of his hand contractures. She said, she spoke with maintenance who provided a pancake call bell. She said the pancake bell was installed and Resident #24 can use without difficulty. On the same day at approximately 1:30 p.m., a phone interview was conducted with Resident #24. He stated, The nurse gave me a new call bell, it's flat and all I have to do is touch it. I love this one, the other light was hard for me to use, I couldn't tell if I had cut my light or not. He said, when I put my light on now, the nurse came right away, that's something that never happen before. A pre-exit conference was conducted with the Vice President of Operations and Regional Director of Clinical Services on 06/21/21 at approximately 9:30 a.m. The Regional Director stated, Any staff member caring for Resident #24 should have been able to identify the need for a different call light and should have proceeded in getting the right call system for Resident #24. The facility's policy titled: Resident Communication System and Call Light Policy (revision date: 06/30/17.) Policy read in part: It is the policy of the facility to provide residents with a means of communication with staff. Answering call lights: General guidelines: ask the resident to return the demonstration so that understanding and ability can be verified that the resident can operate the call light.

The facility staff failed to provide adequate supervision and failed to ensure heated beverage was served in a manner to prevent an avoidable accident for 1 of 59 residents in the survey sample (Resident #83), with known behaviors of throwing objects, food and beverages resulting in harm, a second degree burn, to Resident #74. The staff served Resident #83 a cup of hot coffee without a lid. Resident #83 threw the hot coffee onto Resident #74 resulting in a second degree burn to the resident's left upper thigh requiring physician intervention, medication and treatment. A second degree burn involves the first two layers of the skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. Referenced from http://www.bt.cdc.gov/masscasualties/burns.asp The findings include: A Facility Reportable Incident (FRI), incident type Unusual Occurrence, was received at the State Agency on 1/23/19. The FRI evidenced that on 1/22/19, Resident #74 while in her wheelchair bumped into the wheelchair of Resident #83. This resulted in Resident #83 throwing her coffee at Resident #74. The hot coffee caused a second degree burn to Resident #74's left upper thigh. 1a. Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) prior to the unusual occurrence incident was a quarterly with an Assessment Reference Date of 11/21/18. The resident scored a 2 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had severely impaired decision making skills. Resident #74 was wheelchair bound. The Nursing Noted dated 1/22/19 written by the nurse who heated the hot water in the microwave to make the coffee and served it without a lid to Resident #83 read as follows: Patient sitting at nurses station at 1830 (6:30 p.m.) with a cup of hot coffee and another resident (Resident #74) in a W/C (wheelchair) was passing by and bumped into her and (Resident #83) threw her cup of coffee at the resident and it landed on her lap. The Nurse Practitioner note dated 1/23/19 evidenced the following documentation: .Today, was called by nursing to assess new skin concern noted to left upper thigh area. The area is raised, [DIAGNOSES REDACTED]tous (red) and swollen. Two blisters are noted and intact. Wound nurse consulted. After further information obtained from staff, it was noted that another resident spilled coffee on (Resident #74) and this is the cause of the blistering . AP (Action/Plan): Left leg [MEDICAL CONDITION]/burn: Started on Keflex (an antibiotic) 250 (mg-milligrams) QID (four times a day) x 7 days, consulted with the wound nurse. Will add [MEDICATION NAME] ointment and xarafoam dressing to protect site. Will follow up in 48-72 hours. The wound nurse assessment dated [DATE] evidenced the following documentation: 1. Wound type-Burn. 2. Wound location- left upper thigh. The wound measured 2 cm (centimeters) length x 6 cm width and 0.1 cm depth. Small amount of drainage, wound bed pink in appearance, periwound (surrounding skin) pink. Pain level: 4. The Weekly Wound assessment dated [DATE] evidenced the burn wound measured 1.6 cm x 3.0 cm x 0.1 cm, scant drainage, periwound pink. The Weekly Wound assessment dated [DATE] evidenced the burn area had resolved. 1b. Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) prior to the unusual occurrence incident on 1/22/19 was a quarterly with an assessment reference date of 12/8/18. The resident scored a 12 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had moderately impaired daily decision making skills. The resident exhibited hallucinations, delusions and behaviors of rejecting care. Review of the clinical record evidenced Resident #83 had a history of [REDACTED]. The documented behaviors included: 4/28/18 while in the hallway the resident attempted to take the purse of another resident, when the other resident picked up the purse so that Resident #83 could not get it Resident #83 threw a magazine toward her; 5/20/18 threw ice while in the hallway, 5/23/18 threw things on her floor, 6/24/18 combative, throwing things at resident's family members as they were coming through the door, 7/1/18 threw a cup of water at a C.N.[NAME] (certified nurse assistant) walking by her, threw a plate cover while at the nurses station towards a nurse, 7/13/18 while at the nurses station hit another resident in the chest. The Comprehensive Person-Centered Care Plan dated 11/2/17 identified a focus care area of mood and behaviors related to [DIAGNOSES REDACTED]. Identified behaviors included but were not limited to, throwing objects, throwing lunch and dinner trays, combativeness and impulsive behaviors. The care plan did not include interventions during meal times prior to the incident to prevent potential avoidable accidents of the resident throwing lunch and/or dinner trays, food and or beverages. The last psychiatric evaluation/consult was dated 1/9/18. The resident's mood was described as labile and combative at times. Insight and judgement were poor. (Labile/lability-excessive emotional reactivity associated with frequent changes or swings in emotions and mood referenced from Tabers Cyclopedic Medical Dictionary 19th Edition.) The five day facility follow up report to the FRI was received at the State Agency on 1/28/19. The report read in part: .The nurse on the unit made the coffee. She heated the water in the microwave for 1 minute and then added instant coffee and thickener. The facility replicated the making of the coffee; same type of cup, same amount of time and the temperature after heating was 124 degrees (Fahrenheit) . The facility will provide a sturdy cup with a lid for (Resident #83's name) .Care plans were updated on both residents . There is no evidence in the facility's report that the nurse obtained the hot beverage temperature at the point of service prior to serving the coffee. Table 1. Time and Temperatures Relationship to Serious Burns-Time Required for a 3rd Degree Burn to Occur at 124 degrees Fahrenheit is 3 minutes. Referenced from http://www.bt.cdc.gov/masscasualties/burns.asp On 7/25/19 the Comprehensive Person-Centered Care Plan dated 11/2/17 was reviewed for a second time and did not include the revision/ implementation of a sturdy cup per the five day follow up report. The care plan was revised on 1/22/19, the intervention was to educate staff and visitors that resident is not to receive hot beverages. On 7/26/19 at 5:53 p.m., the MDS Coordinator who revised the care plan on 1/22/19 was interviewed. She stated she failed to completely revise the intervention which should have read, Educate staff that resident is not to receive hot beverages unless it is in a cup with a secure lid. When asked if that was an important piece to have been left off the intervention she stated, Yes ma'am it sure was. On 07/25/19 at 11:48 AM, the resident's lunch tray was observed placed on top of the bedside drawer instead of the bedside table. A CNA approached the resident to inform her of the delivery of the tray. A mug of coffee was observed on the tray with a unsecured plastic cover. The resident removed the plastic lid and drank her coffee from the mug. The CNA did not place the coffee into the sturdy cup. 07/25/19 at 05:29 PM, the resident was asleep in a wheelchair in front of nurses station. The resident's dinner tray was delivered to the resident room. The tray was observed to have coffee and water as beverages. The CNA who delivered the tray left the coffee inside the coffee mug with an unsecured plastic lid instead of transferring it into the sturdy cup. The resident then wheeled herself slowly into her room and began to consume her dinner and drink her coffee from the mug. Observed on the bedside table was a black 14-16 ounce sturdy cup with a secure lid (travel mug) for use. On 7/25/19 at 5:45 p.m., Licensed Practical Nurse #3 and #4 were interviewed. LPN #3 stated, When I first got here she (Resident #83) was eating at the nurses station, she would have outbursts and push her trays onto the floor .this is why she now gets served in her room. When asked when was the last time the resident exhibited this behavior; LPN #3 stated, About 4-5 weeks ago. LPN#4, assigned to care for Resident #83 was asked if the resident was allowed to have hot beverages per the care plan. LPN #4 stated, I don't know, I am going to look that up. LPN #4 also stated the resident had coffee for all meals. On 7/26/19 at 10:58 am, the above findings was shared with the Administrator and the Interim Director of Nursing (DON). The Administrator provided this surveyor with a Corrective Action Plan in response to the unusual occurrence. The Administrator stated, We knew about her behaviors, combative with staff, throwing objects, throwing lunch and dinner trays .She has never been aggressive with other residents .it wasn't an issue with the temperature (the hot coffee), it was her behaviors . The DON stated the resident was, .very impulsive, she'll be quite and then she reacts according to what she hears in her head . They stated a thermometer to temp food and beverages was placed in the nourishment room, staff were educated, the resident was provided a sturdy cup with a lid for hot beverages, the resident was encouraged to eat at the nurses station to provide supervision, the DON stated, That's why we liked her at the nurses station and microwave heating instructions was added as part of general orientation. When asked if there was anything that could have been done differently to prevent this occurrence, the DON stated, The nurse not turn her back (after serving the resident hot coffee) and give her a lid (for the coffee). Review of the facility policy titled Hot Beverage Service effective date (MONTH) 22, (YEAR) reads as follows: Policy: Facility will provide hot beverages to residents in a manner that promotes safety and meal satisfaction. Procedure: 4. Appropriate supervision will be provided as needed for residents with decreased safety awareness and/or self-feeding deficits that could place them at risk for burns/scalds 5. Staff will monitor for increased behaviors or agitation at meals and consider an alternative for hot beverages if a resident is at increased risk of burning themselves or others. 6. Staff will monitor hot beverage temperatures periodically at the point of service and make adjustments as needed. An inspection of the facility's one nourishment room was conducted on 7/26/19 at approximately 5:00 p.m., there was a sign posted above the microwave for the staff that read: Attention Staff-When heating liquids for consumption the temperature should never exceed 155 degrees. Please obtain temperature before serving and do not serve if over 155 degrees. Please sanitize thermometer before and after use. A thermometer was observed stored inside a plastic bag on top of the microwave.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure adequate supervision and assistance devices were used to prevent an accident for 1 of 34 residents in the survey sample, Resident #78. Resident #78 was incorrectly transferred by pivot to stand, instead of two person Hoyer lift, resulting in a fracture of her knee. The findings included: Resident #78 was initially admitted to the facility on [DATE]. [DIAGNOSES REDACTED].#78 included but not limited to [MEDICAL CONDITION], Arthritis, [MEDICAL CONDITION] and Fracture. Resident #78's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date of 12/8/17, coded Resident #78 as scoring a 4 out of a possible 15 on the BIMS (Brief Interview for Mental Status) cognitive impairment. The resident was completely dependent on two staff for bed mobility, transfers and toileting. The resident's balance was assessed as not steady, and only able to stabilize with staff assistance for balance during transfers. The Comprehensive Person Centered Care Plan dated 6/1/16 identified the resident required total assistance with ADL (Activities of Daily Living) functioning d/t (due to) Alzheimer's, [MEDICAL CONDITION], dementia, visual impairment, [MEDICAL CONDITION] and pain. The goal was She will have ADL's met daily through next review. One intervention listed to achieve the goal was to transfer with total assist of two staff using a total lift. Resident #78 was at also identified at risk for falls related to decreased mobility, weakness, short and long term memory deficit, impaired vision (prefers to remain in bed for comfort .only gets up once-twice a week). One intervention included call bell within reach. The goal was She will have no preventable injury from falls thru next review. The care plan updated on 11/15/17 documented, Right Tibia Plateau fracture with the goal of Will have maximum functional mobility. Interventions: Included but were not limited to: Leg brace on and off per MD (Medical Doctor's) orders; Monitor Pain; Ortho follow up as needed; Circulation checks to affected limb. The Comprehensive Person Centered Care Plan dated 6/1/16 The CNA (Certified Nursing Assistant) Kiosk (a computer station CNAs use to document and see the Resident's assessed needs) documented on Page 3 of 3: ADL (Activity of Daily Living) Section: Transfers with total assist of two using total lift. The Kardex Report printed 1/24/18 and received on the same date at approximately 11:35 AM, documented the following: ADL: Transfers with total assist of two using total lift. A Facility Reported Incident received on 11/14/17 at the State Agency. The report stated the resident was found with an injury of unknown origin. An x-ray was obtained and confirmed a potential tibial fracture. The facility's investigation of the injury of unknown origin concluded, based on the results of the investigation, we determined the hairline fracture occurred during a bed transfer via total mechanical lift. The lift was used appropriately with two CNAs present. We believe when the resident was in the lift and being transferred from the bed to chair, her leg remained in contact with the mattress, potentially putting pressure at the knee and causing the hairline fracture. Further record review evidenced the following: 11/14/17 X-Ray Report: Knee Results: No previous studies are available for comparison. There is a depressed [MEDICAL CONDITION] tibial plateau which appears new. The knee joint is significantly narrowed. Conclusion: Findings are consistent with an acute fracture involving the medial tibial plateau. Addendum: There is proximal tibial shaft medical subcortical hairline fracture without displacement. An 11/16/17 Nurse Practitioner #4 note documented the following: (Resident #78) is a recent Tibial Plateau fx (fracture) to R (Right) leg. She states the knee was caught in a chair. She was seen by (Orthopaedic and Spine Specialist) today and knee Immobilizer with padding - has FU (follow up) in 2 wk's (weeks) 11/20/17 . A/P (Assessment/Plan) 1. R (Right) Tibial Plateau fx (fracture) - Keep knee immobilized. Skin/vascular (checks) q6h (every six hour) while awake. Rx (Prescription for [MEDICATION NAME] 5-325 mg, 1 po (by mouth) BID (twice daily) . Resident #78's 11/16/17 Orthopaedic and Spine Specialist note documented the following: CC: (Chief Complaint) Right Knee Pain HISTORY: (Resident #78) is 87 y.o. (year old) female who is seen for right knee pain. She first complained of pain on 11/14/17 after her knee got caught on a chair at (Facility) while getting her hair done. She had right knee x-rays at (Facility) on 11/14/17 that revealed a medical plateau fracture .History is somewhat lacking and unreliable due to non verbal state. Her daughter is present today. She has not walked since her great toe amputations 4 years ago by . She is hypertensive. She has a h/o (history of) [MEDICAL CONDITION] . Physical Exam: Range of motion: Unable to test due to pain Pt. (Patient) wearing a knee immobilizer. She is non-ambulatory on a stretcher. Patient is non-verbal on today's exam. RADIOGRAPHS: RIGHT KNEE: 11/16/17 Impression: Three views - [MEDICAL CONDITION] tibial plateau, no effusion, complete joint space narrowing, + (plus) osteophytes present. RIGHT KNEE 11/14/17 Impression: Findings are consistent with an acute fracture involving the medial tibial plateau. IMPRESSION: 1. Closed fracture of medical portion of right tibial plateau, Initial encounter 2. Acute pain of right knee 3. Amputated great toe of left foot 4. Amputated great toe, right 5. Equinus contracture of ankle 6. [MEDICAL CONDITION] 7. Primary oseteoarthritis of right knee severe. PLAN: She will be placed in a well padded knee immobilizer today. Pressure sore precautions provided. She will follow up two weeks. There is no need for surgery at this time. Instructions for skilled care facility provided today. During review of the facility investigation, staff statements revealed the following: CNA #20 documented that she cared for Resident #78 on 11/11/17 and she did not complain of any pain during care. CNA #21 documented that Resident #78, didn't complain of any pain during AM care on 11/9/17 or 11/10/17. On 11/9/17 after doing ADL's I got (Resident #78) dressed and up into her chair, and still there were no complaints of pain. Her daughter and son-in-law came to visit her on 11/9/17 and I left her sitting up in the chair with her family. I also had (Resident #78) on 11/10/17 I performed ADL care and (Resident #78) still never complained of any pain. I didn't get her up on Saturday 11/10/17 because she didn't' want to get up because she was up the day before. A statement taken from Resident #78's daughter and documented by the Unit Manager #1, dated 11/14/17 at 2 PM documented the following: .she was here on 11/9/17 to visit her mother. She stated that she (Resident #78) did not complain of any pain during the visit. There was nothing different with her while visiting. CNA #22 documented the following: . I (CNA #22) had (Resident #78) on 11/12/17. She didn't complain about pain while doing her ADL care and second rounds. CNA #23 documented the following: To whom this may concern, on 11/13/17, I (CNA #23) assisted (CNA #7) with patient transfer via hoyer lift bed . After transferring patient had no complaints. In addition to the above 11/14/17 dated staff statements, an undated and unsigned statement from the Social Worker #2, was reviewed. The Social Worker documented: (Resident #78) BIMS Score completed with (Resident #78), She Scored 3/15. When asked what happened to her leg she was unable to give a complete story. Social Services asked (Resident #78) what happen she stated she didn't want to go to dinner and she stayed in bed. She was then asked did she get up and fall, she stated she is unable to walk. She then pointed to her chair stated is (it) was not stretched out enough. (Resident #78) continued to state it was the bottom of the chair. When asked did her leg get caught she would not answer. When asked did she sit on it she would not answer. When asked how much pain she was in and where the pain was she stated in her right leg and only hurts when she moves it. Review of an 11/16/17 document from the Administrator documented the following: On Tuesday, (MONTH) 14, (YEAR) resident complained of pain in her leg and resident's right knee noted to be [MEDICAL CONDITION]. An X-Ray was ordered and taken. X-Ray results showed a right Hairline tibial fib fracture, Resident denied any further pain. Call placed to the MD and .NP ordered a leg immobilizer and ortho f/u. Administrator made aware of results and an investigation began. F.R.I. completed on 11/14/17. Spoke with CNA's who provided care to Resident dating back from 11/9/17. Interviews with (CNA #24, CNA #21, CNA #22, CNA #7, CNA #25, CNA #26, CNA #20 and CNA #23). Upon interviewing these individuals, it was noted that (Resident #78) did not complain of any pain while receiving care until 11-14-17. Resident has scheduled [MEDICATION NAME] 5-325 mg (milligrams) BID (twice daily) and a PRN (as needed) [MEDICATION NAME] 5-325 mg q4h (every 4 hours). Daughter .was made aware in the process. Information gathered from the above mentioned staff members and narrowed down to two individuals. After speaking with (CNA #7 and CNA #23) with role play return demonstration, it was concluded that poor procedure was used when transferring resident into geri chair. Policy and practice was followed per total lift use. However resident's bed was positioned in such a way as the residents legs were slightly dragging on bed when resident was removed from the bed via lift. With this information we have determined the resident's body left the bed before her feet potently (potentially) causing the hairline fracture. No deficient practice noted during return demonstration however we will be in servicing on observing leg placement while using Hoyer lift. A document dated 1/19/1 by the Facility Administrator #1, written to clarify his 11/16/17 document statement of poor procedure documented the following: As a clarification to my previous statement of poor procedure was used, this was intended to highlight the potential issue when using the total lift and the need to educate. The CNA's use of the lift at the time was in accordance to the training materials provided to them. The training material does not mention the need to lower the bed once the resident is secured in the lift. Review of a 11/17/17 letter sent to the State Agency, from the Administrator to follow up the 11/14/17 Injury of Unknown Origin FRI documented the following: . An investigation was completed to included interviews with the resident, staff members and a clinical record review. Based on the results of the investigation we determined the hairline fracture occurred during a bed transfer via total mechanical lift. The lift was used appropriately with two CNA's present. We believe when the resident was in the lift and being transferred from the bed to to chair, her leg remained in contact with the mattress, potentially putting pressure at the knee and causing the hairline fracture. No deficient practice noted during return demonstration however, we will be in-servicing on observing leg placement while using mechanical lift. Resident has no complaints of pain and is being followed by Ortho with no new orders noted at the time. Review of Physical Therapy Evaluation and Plan of Treatment dated 12/5/17 documented the following: Reason for Referral: . referred to PT (Physical Therapy) by nursing due to pressure ulcer development secondary to R (Right) extension brace. Reason for Therapy: Reason for Skilled Services: Patient requires skilled PT services to in order to enhance patient's quality of life by improving ability to decreased risk of additional wounds. Long Term Goals: CNA staff will be educated on positioning RLE (Right Lower Extremity) for decreased risk of additional pressure ulcers. Review of a document given by the DON on 1/19/18 at approximately 10:05 AM, documented a timeline of Resident #78's fall. This document was not dated and was not signed. The DON reviewed the documented information on the 1/19/18 document at approximately 10:05 AM. The document regarding the incident included the following: Fall: 11/14/17 resident c/o (complained of) pain in leg, right knee noted to be [MEDICAL CONDITION] 11/14/17 resident medicated for pain with no other c/o pain on 11/14/17 11/14/17 x-ray completed with result of hairline fx (fracture) of tib (tibia), fib (fibula). 11/14/17 M.D. (Medical Doctor) aware of x-ray results order for immobilizer placed and Ortho f/u (follow up) 11/14/17 Administrator made aware, investigation started, F.R.I. completed 11/14/17 Interviewed C.N.A.s providing care dating back from 11/9/17, resident did not complain of pain before 11/14/17 11/14/17 from staff interviews we narrowed investigation to two staff members. (CNA #23 and CNA #7) 11/15/17 second interview including role play with physical demonstration revealed cause of fx. (fracture). Staff members had resident in total lift when resident buttocks left bed causing increased pressure to legs that were still on bed. 11/16/17 Ortho appointment confirmed fx (fracture) Review of the education attendance logs done post fracture given by the ADON (Assistant Director of Nurses) on 11/20/18 regarding fall Protocol had CNA #23's signature but did not include CNA #7's signature. Review of CNA #23's employee file included a document for Resident Handling Competencies, dated and signed 12/19/17. Review of CNA #7's employee file included a document Employee Acknowledgement of Receipt of Fraud and Abuse Policy dated and signed 9/27/17. Review of CNA #7's employee file also included a documented dated and signed by CNA #7 on 9/27/17 that he had received, read, and understood the following policies: Safe Resident Transfer Policy. Review of CNA #7's employee file documented that he was removed from the payroll effective date 11/21/17 for insubordination. A documented received by the Director of Rehabilitation on 1/24/18 at approximately 11:28 AM, of staff that had signed for education done 9/27/17: Topic: Resident Handling New Hire/Quarterly, included CNA #7's name and signature. An observation was made of Resident #78 on 01/16/18 at approximately 10:45 AM during the initial tour. Resident #78 was lying in bed, eyes closed, Geri chair in room, air mattress on bed. Resident #78 was observed well-groomed and with no odor. Another observation was made on 1/26/18 at approximately 11:00 AM, of CNA #2 with two other CNA's in the room, the Hoyer Lift in room, and Resident #78 sitting in her Geri Chair. Resident #78 stated, Come in very softly. CNA #2 stated that Resident #78 was getting up for lunch. Resident #78's Right leg immobilizer splint was observed to be on. On 1/19/18 at approximately 12:30 PM, an interview was conducted with the Director of Nurses (DON) #2, the Administrator #1, and the Regional Clinical RN (Registered Nurse) #4. The Regional Clinical RN stated that the 2 CNAs involved performed the procedure correct per their investigation. The Administrator was asked to clarify his statement poor procedure was used and he stated that he meant due to fracture during transfer and was asked to write another document explaining his intention/meaning of the words. The group was asked if a Corrective Action Plan was done and the Regional Clinical RN stated: No, it wasn't as we felt there was not a deficient practice. The Administrator #1 stated that his investigation showed that Resident #78's pain began on 11/14/18 and the facility investigation felt it was related to the 11/13/17 transfer of two CNA's (CNA #7 and CNA #23). The DON was asked if the fracture was caused by a fall as documented on the timeline form. The DON stated that Resident #78 did not fall. On 1/19/18 at approximately 10:05 AM, the DON #2 stated that Resident #78's pain started on 11/14/17. The DON was asked for an employee statement from CNA #7 as it was not included in the group of employee statements. On 1/19/18 at approximately 1:30 PM, the DON along with CNA #27 and LPN (Licensed Practical Nurse) #2 performed a simulation of a transfer using a Hoyer lift. The DON stated that he felt that during transfer the Resident's leg may have bumped back into the mattress as the resident's leg was coming off the mattress. On 1/19/18 at approximately 2:45 PM, CNA #23 was interviewed. CNA #23 stated that she was asked to help by CNA #7 for the transfer. CNA #23 stated she had hands on bar of lift, the bed was raised, as she was pulling back, CNA #7 was assisting the patient. CNA #23 was asked if Resident #78 started complaining of pain during the transfer, or if she saw the resident's legs hit or get stuck during the transfer. CNA #23 stated: Not that I remember. CNA #23 stated that staff were in-serviced about being mindful of objects surrounding, to always use two people and to immediately report any pain the resident may have. CNA #23 was asked if there is a document on the inside of the Resident's closet door that states how a resident is to be transferred. CNA #23 stated, No. CNA #23 stated that she was involved in a re-enacted role-play of transfer with a Hoyer lift. She stated that CNA #7 was not involved in the role-play as he was off on 11/14/17. On 1/19/18 at approximately 1:30 PM the Facility Administration produced the Video, titled Proper Body Mechanics and Mechanical Lift Training that the DON stated was used to orient new CNAs on use of lift. The video was progressed to the portion related to Hoyer lift transfers. The surveyor observed this portion of the video. A copy of a slide that correlated to the Video was provided to the Surveyor. It documented steps of a sling transfer. On 1/23/18 at approximately 10:48 AM, Resident #78's daughter was called. The daughter stated that she was notified of the fracture and she recalled on the day that she had requested that her mother be gotten up so that she could go to the beauty parlor. The daughter was not in the room when Resident #78 was gotten out of bed. On 1/23/18 at approximately 4:16 PM, CNA #7 was called by phone, by the Administrator with the DON and survey team present. After introductions of all present in the room, CNA #7 was asked to explain what happened as he was caring for Resident #78 on 11/13/17. CNA #7 stated that he had to have all his residents up before lunch. CNA #7 stated that he was in the room performing ADL care on Resident #78 and he needed help to get her out of bed. He stated he asked CNA #23 to help. When asked how Resident #78 was gotten out of bed, CNA #7 stated that he did a Pivot to stand transfer. CNA #7 stated that Resident #78 had complained of hurting before the 11/13/17 transfer. CNA #7 stated that he was on the Resident's Right side while CNA #23 was on the Resident's Left side. CNA #7 stated they put their arms under the Resident's arms and stood her and placed her in the chair. CNA #7 stated he thought there was pressure on the Resident's legs. CNA #7 stated that the next day (11/14/17) he was off. CNA #7 stated on 11/14/17 he received a call from the DON and was informed that Resident #78's leg might be broken. CNA #7 stated during the phone interview that on 11/15/17 when he returned to work, he was informed that the DON wanted to talk with him. CNA #7 stated that the conversation included the Unit Manager #1, LPN #1, the DON #2 and himself CNA #7. CNA #7 stated that the DON asked him what happened, and encouraged him to tell the truth. CNA #7 stated that he told them that he did not use the Hoyer lift when he transferred Resident #78 on 11/13/17. Then CNA #7 stated that he did not receive a verbal warning or a written statement regarding the transfer. CNA #7 stated that he did do a witness statement and gave it to the DON. CNA #7 did not keep a copy of his witness statement. Neither the Administrator nor the DON recalled the specifics of CNA #7's missing Witness Statement. During the phone conversation with CNA #7, as he stated he did not use the Hoyer Lift, the Administrator and DON were observed shaking their heads from left to right as in a no response. The Administrator was asked about the cause of the fracture. The Administrator stated that the conclusion was when removing the Resident from the bed her feet had contact with her bed. After the phone call, both the Administrator and the DON stated that CNA #7's statement was not what he had told them previously. Both the Administrator and the DON stated that they have not found a copy of CNA #7's written statement. When asked why CNA #7 was not included in the education that was done for the facility, the DON stated that CNA #7 did not work on 11/14/17 and was terminated soon after. The Administrator stated that it was the Facility's conclusion based on information they had received during their investigation, was that the fracture cause was related to the lift. The Administrator was asked if as the Administrator if he had seen CNA #7's Witness statement. The Administrator stated he spoke with him and was never told that the transfer did not occur in any way other than by the Hoyer lift. The Social Worker's written statement was read by another surveyor and commented that the document was neither dated nor signed. On 1/25/18 at approximately 2:45 PM, the Social Worker when asked when she wrote her document, went into her document history and pulled up the same document to show that it was written on 11/14/17 at 4:18 PM. The Administrator stated: We can't be having this. That's going to change. The Administrator also stated, This building had a history of [REDACTED]. The Administrator on 1/23/18 at approximately 4:56 PM, stated that he constantly tells staff if they feel they are not heard they can go above him and call the Hot Line Number. The Administrator stated that if he (CNA #7) was told to do something fraudulent he should have come to him or called the hot line number. On 1/23/18 at approximately 6:15 PM, the Regional Clinical RN stated that after the incident of Resident #78's fractured leg, the facility identified that a second CNA will be used to guide the legs during a Hoyer lift transfer. She stated, We didn't identify a deficient practice, so we didn't do a Corrective Action Plan. The Administrator was informed that the Policy and Procedure of Hoyer Lift #8 stated: Provide Support and the Administrator stated that there are many ways of support, and that the word support doesn't just mean hands on support. He stated it could also mean emotional support during the transfer. On 1/25/18 at approximately 11:48 AM, CNA #23 was interviewed again. CNA #23 was informed that on 1/23/18 a meeting with the DON, the Administrator and CNA #7 on phone along with the State Surveyors was conducted. CNA #23 was informed that CNA #7 had stated that he did not use a Hoyer lift during transfer of Resident #78. CNA #23 was asked if she would like to amend or to change her previous written witness statement. CNA #23 was silent for a few moments. CNA #23 was asked again if she wanted to amend or change her previous statements of using a Hoyer lift with CNA #7 on 1/13/18. After a few more moments, CNA #23 stated that CNA #7 put his arms under the Resident's arms and lifted her and then twisted her into the Geri Chair. CNA #23 stated that she felt influenced to say she assisted in a Hoyer Lift transfer as it was the correct way that Resident #78 was to be transferred. CNA #23 was heard by three Surveyors to say prior to her exit from the conference room, I'm sorry; I should not have done that. The Facility Policy and Procedure titled, Incident/Accident Report with a revision date of (MONTH) (YEAR), documented the following: Section 6. Witness statements: a. Witnessed incident/accident - The nurse will immediately begin collecting witness statements from any staff, family member, visitor and/or other residents that witnessed incident/accident. The Facility Guidance given to the surveyor from the Administrator titled, Transfer Techniques without a date and without a reference, documented the following: Responsibility: Therapist Before initiating treatment, the patient/resident is evaluated by the therapist to determine appropriateness and method of transfers to be utilized. Staff to know patient/residents [DIAGNOSES REDACTED].>Apply Gait/transfer belt as determined by Therapist: Recommended if patient/resident requires physical assistance greater than 25% of task and position of belt does not compromise respiratory status, incisions, IV's etc Explain entire procedure to patient/resident. The DON stated on 1/26/18 at approximately 2:45 PM, that he could not find any guidance for stand pivot transfers for CNA use. The DON stated that it was his expectation that if a stand pivot transfer was used, that a gait belt should be used and that the resident be able to pivot. The DON stated that Resident #78 was not able to pivot. The Facility Policy and Procedure titled, Personal Care with a Revision date of (MONTH) (YEAR), documented the following: Policy: A mechanical lift may be used for moving residents that cannot safely move by themselves and are too heavy to be safely lifted by one or two assistants. Number 8 documented, Guide the resident away from the bed with one staff member supporting the resident and one manipulating the lift. The facility administration was informed of the findings during a pre-exit conference on 1/26/18 at approximately 11:05 AM and again during the Exit Conference on 1/26/18 at approximately 3:30 PM. The facility did not present any further information about the findings.

Based on staff interviews, clinical record review, facility document review and during the course of a complaint investigation the facility staff failed to develop and implement written policies and procedures that prohibit and prevent abuse. The facility's abuse policy and procedure revised January, 2017, failed to define the use of chemical or physical restraints as abuse. As a result, the facility staff failed to train employees on issues related to abuse, prevent abuse, identify abuse, thoroughly investigate abuse, protect residents from harm during an investigation, and report all alleged violations. Based on the complaint investigation Resident #1 in a sample of 10 residents, had been physically restrained with a gait belt to a wheelchair to prevent movement and not to treat medical symptoms. Multiple staff observed the abuse and failed to stop the abuse, protect the resident and as Mandated Reporters report immediately. The facility Administration team to include the Administrator, the Director of Nursing and the Rehab Manager, and Licensed Practical Nurses failed to recognize the use of a physical restraint as abuse. The facility staff failed to protect other residents from abuse during the ongoing investigation of the physical restraint. The facility staff failed to provide training to their staff that at minimum educated staff on activities that constituted abuse. During the course of the complaint investigation another resident was identified as having been physically restrained with a gait belt, Resident #3. Immediate Jeopardy was called on 2/21/17 at 10:00 am., under Abuse Prohibition Policies and Procedures-Freedom from Abuse, Neglect and Exploitation. The findings included: The State Survey Agency received an anonymous complaint on February 15, 2017, that alleged a resident had been left in a chair restrained all day and overnight. The resident identified in the complaint was Resident #1. 1. Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] following a short hospital stay from 12/28/16 through 1/4/17 for acute [MEDICAL CONDITION] (1). [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) a 30 day with an assessment reference date (ARD) of 1/31/17 coded the resident as scoring a 3 out of a possible 15 on the BIMS (Brief Interview for Mental Status), indicating the resident had severely impaired daily decision making skills. The resident had a Foley catheter for bladder drainage. An initial tour of the facility was conducted from 2:30 am to 3:00 am, on 2/21/17. During the initial tour of the facility all residents were observed in their beds asleep, to include Resident #1. A night shift nurse (Licensed Practical Nurse/ LPN #3) working on the East unit where Resident #1's room was located was interviewed at 3:00 am. She was asked if she was aware of any allegations of a resident having been restrained to a wheelchair. She stated, Yes, (name of Resident #1). She was asked about the circumstances for the use of the restraint. She stated, He had fallen earlier in the shift (3-11 pm shift), when I arrived to work he had a gait belt on .it was buckled behind the wheelchair, he was behind the nurses station in the wheelchair, he stayed up all night at the nurses station, periodically would be asked if he wanted to go back to bed .he was alert with confusion .he sat quietly, did not try to fight the restraint. When asked why the restraint was not removed, she stated, Out of sight, out of mind. She stated she had asked the CNA (Certified Nurse Aide/CNA#3) assigned to the resident to remove the gait belt and place the resident to bed at approximately 5:00 am. LPN #3 was asked if she was the one who initiated the gait belt restraint and stated, No, she repeated that it had been placed on the resident by the 3-11 shift. She did not know who placed the restraint on the resident. When asked as a Mandated Reporter what should you have done? Her response was Report it to the DON (Director of Nursing). LPN#3 stated she was suspended for three days (2/10/17-2/12/17), inserviced and given a copy of the abuse and restraint policy. LPN #3 failed to stop abuse, and immediately report it. The gait belt was buckled in the back of the wheelchair; therefore, the resident could not remove it at will, which restricted freedom of movement. On 2/21/17 at 3:20 am, the Director of Nursing (DON) arrived at the facility. The DON was interviewed about the allegation of Resident #1 being restrained with a gait belt. While in the DON's office this surveyor was provided with a copy of the facility's investigation report dated 2/10/17. This report noted Resident #1 was found with a gait belt restraining him to the chair. The DON did not obtain written witness statements. The DON was asked if the Physician and the Resident Representative were notified by the facility that a gait belt was used to restrain Resident #1, she stated, No. The DON was asked if a FRI (Facility Reportable Incident) had been sent to the State Survey Agency for this incident, she stated, No. When asked why a FRI had not been sent her response was that she did not consider this incident as abuse, as there was no harm. She stated the staff failed to follow the facility's restraint policy. The DON stated she was made aware of the restraint when the Rehab Director wheeled the resident to her office between 10-10:30 am on 2/10/17. The resident had a gait belt around his waist that was buckled in the back of the wheelchair. The investigation noted the 11-7 nurse was suspended for three days. The other two licensed nurses (LPN#1 and #2) involved were not suspended during the investigation. The investigation report failed to include all staff working the 3-11 pm and 11 pm-7 am shift on the East unit on 2/9/17. Of the ten (10) staffed worked five (5) were interviewed. The DON failed to recognize that a physical restraint used to prevent movement and not to treat a medical symptom was abuse. The DON failed to thoroughly investigate an allegation of abuse, report the allegation of abuse to the State Survey Agency and other officials as required by State law, and failed to protect other residents from harm during an investigation of abuse. On 2/21/17 at 4:00 am., the Administrator was interviewed about the physical restraint use for Resident #1. He stated, I asked (DON name) the DON to do the investigation, we disciplined parties involved, write-ups were done, re-education and inservices. He stated the facility was a restraint free facility, when asked to clarify he stated, As in we don't use them, we don't use restraints. When asked if the gait belt used as a restraint was abuse, he stated, Abuse, no, we considered it not following procedure for gait belt use. When asked why a FRI was not sent to the State Survey Agency, he responded, Because there was no injury involved. When asked if the staff involved were reported to the Board of Health Professions he stated that he did not report them as it was a procedural issue (a failure to follow the restraint policy). The Administrator failed to recognize that a physical restraint used to prevent movement and not to treat a medical symptom was abuse. The Administrator failed to ensure a FRI of an allegation of abuse was reported to the State Survey Agency and other officials as required by State law to include appropriate licensing agencies and registries. On 2/21/17 at 9:15 am, the 3-11 CNA (CNA#1) assigned to care for Resident #1 on 2/9/17 was interviewed. She stated, He (Resident #1) gets agitated easily .if the nurses talk to him in a certain tone he gets really agitated .he was fine when I got here, after dinner he was up and down and up and down from the wheelchair to the bed .he was having one of those nights .the nurse (LPN#1) didn't want him to fall, they bought him up out of his room .he didn't want to come out of his room .they put him in the hallway near the nurses station .he kept trying to go back to his room .at one point he got up . then he was behind the nurses station .they got tired of him .(LPN#3) got the gait belt. When asked if she witnessed LPN#3 apply the gait belt to Resident #1 she stated, No, but she has done this before .with (name of Resident #3). When asked when she stated, it was in the last couple of months. When asked why they had restrained Resident #1 she stated, They don't want to do the extra paperwork .they told me to leave him there .I didn't know what to do. When asked if restraining a resident with a gait belt is a form of abuse, she stated, Yes .you should stop it first, and then report it. When asked why she did not report the abuse she stated, I was scared of (name of LPN #1). CNA#1 failed to stop abuse and immediately report it. On 2/21/17 at 2:15 pm, the 11-7 CNA (CNA #3) assigned to care for Resident #1 on 2/9/17 was interviewed by phone. She was asked who had placed the restraint on the resident and stated, He was already in the restraint at the nurses station .3-11 put the restraint on him . She stated the resident was taken to his room at approximately 3:00 am to empty the Foley drainage bag, the restraint was removed and the resident was placed back at the nurses station in the wheelchair. She stated when she finished rounds at approximately 4:00 am, she noticed the restraint had been reapplied. She did not know by whom. She stated, We are always short staffed. CNA#3 failed to stop abuse and immediately report it. On 2/21/17 at approximately 2:20 pm, LPN #1 was interviewed in person. She stated the resident had a fall during the evening medication pass at approximately 8:00 pm. The resident was found at his bedside on his knees. The resident was placed back into the wheelchair and then placed at the nurses station. She stated, (name of LPN #2) was at the nurses station .when I went to go give more meds she had put the restraint on him .I had a lot to do with the computer and the fall .I didn't realize it (the gait belt) was tied to the chair .it didn't hit me it was a restraint .When asked if the resident was provided care by CNA #1 after he was placed in the wheelchair and before the next shift came in she stated, I didn't recall she did. She continued to state that LPN #2 reported to the oncoming nurse (LPN #1) We have him up here with a belt on. When asked if a restraint with a gait belt was a form of abuse, she stated, Yes, I have just learned that . The nurse was asked who was responsible for the resident she stated, I am .I should have corrected that action and reported it to the Supervisor or DON immediately. When asked if the Supervisor was aware of the resident being restrained with a gait belt she stated, I think she probably did know. When asked who placed the gait belt restraint on Resident #1 she stated, I assume it was her (LPN #2). LPN #1 failed to recognize a physical restraint to prevent movement and not to treat a symptom was abuse, failed to stop abuse and failed to report it immediately. Review of the Nursing Daily Sheets noted LPN #1 was not suspended during the investigation to protect others from harm and allowed to work on 2/12/17. On 2/21/17 at 2:50 pm, LPN #2 was interviewed in person in the presence of Surveyor #2. Her immediate response to explain the circumstances for the use of a gait belt as a restraint for Resident #1 was, (name of LPN#3) is a liar .the resident was extremely agitated, he had fallen and she bought him to the nurses station .he kept wrapping his Foley catheter around the foot petals .(LPN #3) stated, I wish I had a gait belt .I helped her (LPN #3) put the gait belt on him .in between we tried to care of the other residents .we are always short (staffed) .it got to be a game .just to keep him from falling and pulling out his catheter .I asked (LPN #3) do you want me to take that gait belt off him, she said No, keep it on him. When asked if the use of the gait belt as a restraint to prevent movement and not to treat a symptom was abuse, she stated, I don't believe it is .I don't know what else to do .your under pressure to get your stuff done .we were understaffed . When asked if the physician was called for a restraint order, she stated, No. When asked if the chain of command (the Administrator, DON, Supervisor) were okay with the use of the gait belt as a restraint she stated, Yes, because I know the chain of command has seen it .and they haven't said anything. When asked if it was common practice, she stated, No, it is not. LPN #2 failed to recognize the use of a physical restraint to prevent movement, for staff convenience and not to treat a medical symptom was abuse. Review of the Nursing Daily Sheets noted LPN #2 was not suspended during the investigation to protect other residents from harm and allowed to work on 2/10/, 2/11, and 2/12/17. The facility's Abuse policy was reviewed. The policy was revised January, 2017. The revised Abuse Policy failed to define the use of chemical and physical restraint(s) without a physician order [REDACTED]. The facility's abuse training for employees was reviewed. LPN #1 did not receive on-going sessions/ in-services on issues related to abuse prohibition practices, Resident Rights or Restraint Training. During the complaint investigation multiple staff stated understaffing was a concern. The Nursing Daily Sheets for 2/9/17 evidenced the following staffing: East Unit: 3 pm-11 pm= 2 nurses, 3 CNAs plus on orientee East Unit: 11 pm-7 am=1 nurse, 3 CNAs West Unit: 3 pm-11 pm=2 nurses, 4 CNAs West Unit: 11 pm-7 am=1 nurse, 2 CNAs During the initial tour of the facility on 2/21/17 at 2:30 am, the census in the building was 105 residents, staffing consisted of: East Unit: 11 pm-7 am=1 nurse, 1 CNA West Unit: 11 pm-7 am=1 nurse, 2 CNAs The facility's investigation of the physical restraint for Resident #1 failed to: 1. Identify the staff member(s) responsible for the initial reporting. 2. Protect residents from harm during the investigation by failure to suspend all parties involved, to include LPN #1 and LPN #2, who were allowed to work during the investigation. 3. Report the alleged violation and substantiated incident to the State Survey Agency and all other agencies as required. 4. Prevention-deployment of staff on each shift in sufficient numbers to meet the needs of the residents. 2. During the course of the complaint investigation it was found that another resident had been affected by the same deficient practice of using a gait belt restraint for preventing movement, staff convenience and not to treat a medical symptom, Resident #3. Resident #3 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3 resided on the West unit. The most recent Minimum Data Set (MDS) assessment was a Quarterly with an Assessment Reference Date (ARD) of 1/16/17. The Brief Interview for Mental Status (BIMS) was a 3 out of a possible 15 which indicated Resident #3 was severely cognitively impaired and incapable of daily decision making. On 2/21/17 at 9:15 am, the 3-11 CNA (CNA#1) was interviewed. During the interview she was asked if she had witnessed any other resident's restrained. CNA #1 stated, Yes, in the past couple of months (Name of Resident #3) with a gait belt. When I have a break I walk around the halls. She (Resident #3) was sitting in the hallway in a wheelchair by the nurse's station with a gait belt around her, she is another one that is up and down and becomes combative easily. The surveyor asked, Who was the nurse taking care of the resident that night? CNA #1 stated, (Name of LPN #2) (Licensed Practical Nurse). CNA #1 failed to stop abuse and report it. On 2/21/17 at 2:50 p.m. an interview was conducted with LPN #2. During the interview LPN #2 was asked if she had witnessed any other residents being restrained. LPN #2 stated, Yes, (Name of Resident #3) about a month ago with a gait belt in her wheelchair. She is restrained quite often, she gets real combative and combative with others. The Surveyor asked, What else could have been for the resident instead of restraining her? LPN #2 stated, They could have looked at the care plan for interventions like a lap-buddy, alarms, walking her, or toileting her. The surveyor then asked, Have you ever restrained (Name of Resident #3)? LPN #2 stated, Yes, I have restrained her about a month ago with a gait belt. The surveyor asked, Do you remember what day you actually restrained the resident? LPN #2 stated, It was in January like the 9th or 24th. I think it was January the 9th because there was not enough staff to keep my other patients safe. The surveyor asked LPN #2 if Resident #3's physician had been notified by her on January 9th that Resident #3 had been restrained and if an order for [REDACTED].#2 stated, No, I did not call the doctor or get an order. I can't remember what she was doing all I remember is that we were short staffed. The surveyor asked LPN #2 if it was abuse to physically restrain a resident. LPN #2 stated, I don't believe it is. I didn't know what else to do, you are under pressure to get your stuff done and understaffed. LPN#2 restrained Resident #3 for staff convenience due to staffing. The Nursing Daily Sheets for 1/9/17 evidenced the following staffing for a census of 97: East Unit: 3 pm-11 pm= 2 nurses, 4 CNAs East Unit: 11 pm-7 am=1 nurse, 3 CNAs West Unit: 3 pm-11 pm=2 nurses, 4 CNAs West Unit: 11 pm-7 am=1 nurse, 2 CNAs On 2/23/17 at 1:30 p.m. the DON was asked who was the designated Abuse Coordinator for the facility. She was not able to answer. The Administrator was asked the same question. The Administrator was not able to definitively answer. The Regional Vice President of Operations answered and stated it is usually the role of the Administrator. The facility's abuse policy titled Virginia Resident Abuse Policy revised 1/2017 failed to recognize and define the use of chemical or physical restraints as abuse, it read in part, as follows: Policy: This facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy. 3) Prevention and Identification-Facility's procedures will include: f. The deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs. 6). Initial Reports a. Timing-All allegations of Abuse .must be reported immediately* to the Administrator, Director of Nursing (DON) and to the applicable State Agency. If the event that caused the allegation involves an allegation of Abuse or serious bodily injury, it should be reported to the DOH (Department of Health) immediately, but not later than 2 hours after the allegation is made. 7). Investigation Protocol. The person investigation the incident should generally take the following actions: i. Interview the resident, the accused, and all witnesses. Witnesses generally include anyone who witnessed or heard the incident; came in close contact with the resident the day of the incident .and employees who worked closely with the accused employee(s) . iii. Obtain written statements from the resident, if possible, the accused, and each witness. 9). Final report will be submitted to applicable State agency, after the investigation is completed, but no later than five (5) working days from the alleged occurrence. 10). In the case of staff-to-resident Abuse .the facility will follow Facility's procedure for disciplining an employee, depending upon the circumstances and results of the investigation. i. The facility will report the results of the investigation to the appropriate licensing agencies and registries in accordance with the law. Definitions: Abuse- Includes actions such as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, mental abuse including abuse facilitated or enabled through the use of technology, misappropriation of resident property, exploitation, involuntary seclusion and injuries of unknown source. (*Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury.) 11). Reporting: *Notify next of kin * Notify resident's physician when the facility receives a complaint of alleged abuse . Procedure: The plan for removal of Immediate Jeopardy was accepted on 2/21/17 at 3:45 pm. The plan included the following steps: 1. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. 1a. Both residents (#1 and #3) were assessed by an Registered Nurse for injury. 1b. Observe to ensure no physical restraint in place. 1c. FRI will be completed and submitted to the DOH (Department of Health)/OLC (Office of Licensure and Certification/State Survey Agency). 2. How will the facility identify other residents having the potential to be affected by the same deficient practice. 2 a. All residents have the potential to be affected. 3. Address what measures will be put in place or systemic changes made to ensure that the deficient practice will not recur. 3a. Every current resident will be physically examined to ensure that no form of physical restraint is in place. 3b. Will revise existing Abuse Prevention Policy & Procedure to include restraints as abuse if not in compliance with all regulatory requirements. 3c. All current staff employees will be educated/inserviced on Abuse Prevention P&P, use of restraints, reporting of events to Supervisor/DON/Administrator, or compliance hotline. 3d. Administrator and DON will be educated/inserviced to report any allegation/suspected abuse to DOH/OLC and other agencies as required per regulation. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. 4a. Audit will be completed 5x week, to inspect all current residents and ensure no physical restraints in place. Audits will be conducted randomly on all 3 shifts. Audit will be completed by DON or management designee. Audit will consist of visual inspections of each resident to ensure no restraint in place. 4b. Any occurrence of alleged/suspected abuse will be reported by the Administrator /DON to DOH/OLC and other required agencies. 5. Staff education/inservice will be provided on all 3 shifts 2/21/17 and 2/22/17. Part time, PRN (as needed) or staff who have not been scheduled to work by 2/23/17 will be contacted by phone and education provided. The facility revised it's existing Abuse Prevention Policy & Procedure to include restraints as abuse. The revision included: Restraints (physical or chemical)- may only be used per MD order and in compliance with regulations and guidelines of Fall Prevention and Management P&P. After accepting the plan for removal of Immediate Jeopardy from the Administrator, and determining that the Immediate Jeopardy was removed, the deficiency was assigned a Scope and Severity level two pattern. COMPLAINT DEFICIENCY

Based on observation, clinical record review, facility documentation, and staff interviews the facility staff failed to ensure an accident free environment by not providing adequate supervision and an assistive device resulting in harm for 3 residents (Resident #6, #16 and #12) of a 28 resident survey sample. 1. For Resident #6 while being transported the resident suffered a fractured tibia and fibula of the right leg due to lack of supervision and proper use of a wheel chair by assuring the leg rests were attached appropriately. 2. For Resident #16 the facility staff failed to ensure the wheelchair foot plates were utilized appropriately during transport to prevent accidents. 3. For Resident #12 the facility staff failed to provide supervision for Resident #12 which resulted in resident #12's unwitnessed fall in the shower room which resulted in an emergency room evaluation. The findings included: 1. Resident #6 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED].*Alzheimer's Disease, and *Hypertension. *Tibia and Fibula Fracture: a traumatic injury in the two bones of the lower leg in which the continuity of the bone tissue is broken. *Alzheimer's Disease: a condition characterized by progressive mental deterioration, often with confusion, memory failure, disorientation, restlessness, speech disturbances, inability to carry out purposeful movement, and hallucinosis. *Hypertension: a common disorder that is a known cardiovascular disease risk factor, characterized by elevated blood pressure over normal values of 120/80 mmHg (milligrams of mercury) in an adult. The above definitions were derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition. The most recent Minimum Data Set (MDS) assessment was an Significant Change assessment with an Assessment Reference Date (ARD) of 1/22/15 with a Brief Interview for Mental Status (BIMS) of a 3 out of a possible 15 which indicated the resident was cognitively severely impaired and incapable of daily decision making. On the MDS under Functional Ability Resident #6 was total dependence two person assist for transfers and total dependence one person assist for locomotion on and off the nursing unit. Under Functional Limitation in Range of Motion Resident #6 was coded to have upper and lower extremity impairment on both sides indicating that the limitations interfered with daily functions or placed the resident at risk of injury. Under Mobility Devices the resident is coded for a wheelchair. Resident #6's comprehensive care plan was reviewed and under the focus Wheelchair Mobility documented in part, read as follows: Focus: Wheelchair Mobility-Total assist needed, Leg rest(S) related to physical/medical condition, related to cognitive impairment, Elevate leg rests. Intervention: Uses manual wheelchair (started January 28, 2014- continuing). Needs someone to push wheelchair, Uses elevated foot rest (started January 28, 2014-continuing). Resident #6's nurse's note dated 7/10/15 at 12:40 p.m. documented in part, as follows: This nurse was called to the residents room. The resident was laying in bed, crying. The CNA (certified nurses assistant) stated, I was bringing her back from the dining room and her foot got caught in the wheel and I heard something pop in her foot. After assessing the right foot and ankle, it did appear to be swelling. Positive pedal pulses. The leg rest was not on the WC (wheelchair). Notified the Unit supervisor. Elevated the right foot and applied ice. Administered Tylenol for c/o (complaint) of pain rating at 8/10. Also per review of the nurse's notes Resident #6 was sent to the emergency room to be evaluated per order of the physician. Resident #6's nurse's note dated 7/10/15 at 18:20 p.m. (6:20) documented in part, as follows: Resident returned from (name) hospital with the following orders: Percocet 5-325 mg (milligrams) by mouth every four hours as needed for pain. Resident has Tibia/fibula fracture, needs appointment with Orthopedic Surgeon as soon as possible. Discharge instructions were rest, ice, elevate, pain medications as needed, and follow up appointment. Resident is non-weight bearing until seen by ortho. Resident transferred into bed, with help of floor nurse and transport staff, right leg has a splint with ace bandage around it. The discharge paper work from the local hospital emergency room visit dated 7/10/15 for Resident #6 under Chief Complaint stated ankle pain and leg injury. Under [DIAGNOSES REDACTED]. On 7/10/15 the Office of Licensure and Certification received a Facility Reported Incident (FRI) from Resident #6's current facility reporting the resident's injury. The FRI documented in part, read as follows: CNA was bringing resident back from dining room and resident's foot got caught in the wheel. CNA heard something pop in resident's foot. Resident was assessed by nurse, administered care to resident. Sent resident to ER (emergency room ). Resident arrived back from ER, has fracture of tibia. The facilities final investigation letter regarding Resident #6's injury that was sent to the Office of Licensure and Certification on 7/17/15 documented in part, as follows: Our investigation is as follows: Resident is a [AGE] year old total care female that has been here for 2 years. The resident is transferred daily from bed to wheelchair. 7/10/15 Resident was transported to dining room via wheelchair. 12:40 p.m. resident was being transported back to room via wheelchair when resident's foot got caught in wheelchair and CNA heard a pop sound. CNA reported this to unit supervisor who rendered care, notified physician and son. 13:15 p.m. transport arrived to take resident to hospital emergency room . 18:20 p.m. resident arrived back from hospital dx (diagnosis): tibia/fibula fracture. Appointment made with Orthopedic Surgeon. Conclusion: CNA's work as a 3 person team on resident's unit. The 3 CNA's are familiar with and have rendered care to this resident and transported resident on a daily basis. On this day CNA's did not follow care guide that indicated leg rest when transporting and transported resident to dining room without leg rest. Incident happened when CNA transported resident back to unit from dining room. Action: The three CNA's are long term employee's and have no incidents. They were very remorseful. The three were counseled and placed in personnel file. Staff education was conducted on leg rest and following care guides. On 11/13/15 at 1:15 p.m. an interview was conducted with CNA #43 regarding her involvement in Resident #6's right leg injury on 7/10/15. CNA #43 stated, After I gave her a bath I put her in the chair with the lift. I forgot to put the wheelchair legs on, and when I realized it, I went back to do it but she was already pushed to the dining room. I was going to put them on when she came back. An interview was conducted with CNA #42 on 11/13/15 at 1:20 p.m. During the interview CNA #42 was asked to explain what happened to Resident #6 on 7/10/15. CNA #42 stated, I feed everybody in the dining room. I was pushing (name) Resident #6 out of the dining room and the wheelchair stopped in front of the therapy door. Her body jumped, so I reached out to grab her and then I heard a loud pop. She said, 'Oh my leg, Oh my leg!' Another CNA was coming down the hall so I got her to hold the right leg up and we rushed her to east wing nurse's station. The nurse said to take her to her room. I told the nurse I heard a pop, I was crying it scared me. The nurse said to get her back to bed. Me and (name) CNA #43 got her back to bed. I did my incident report and gave it to the Director of Nursing and the Unit Manager. I told (name) Resident #6 I'm so sorry I would never do anything to hurt you. Surveyor asked CNA #42, Did you noticed whether or not the wheelchair legs were on Resident #6's wheelchair? CNA #42 stated, No, actually I did not. I just was trying to get her out of the dining room. She normally has the legs on her wheelchair. A review of facility documentation indicated that staff inservicing on the use of leg rests was conducted on 7/13/15, 7/15/15, 7/17/15, 7/20/15, 7/22/15, and 7/22/15. The Inservice title Leg Rest documented in part, as follows: -CNAs check care guides in closet to learn if resident needs leg rest, also Rehab. will be putting a tag on back of wheelchair indicating leg rest needed. -Place leg rest in wheelchair when resident is put to bed. -If a resident does NOT require a leg rest when using their wheelchair, the leg rests will be stored in the resident closet so they are accessible for use when the resident goes out of the facility on a leave. -Any questions about leg rest, go to lead CNAs, unit managers, or RN supervisors. The facility presented this surveyor with an Allegation of Past Non-Compliance dated 7/10/15 but due to an observation during the survey of a resident being transported without his/her foot on the footrest, it was not accepted. On 11/13/15 at 6:15 p.m. above information was shared with the Administrator, the Director of Nursing, the Assistant Director of Nursing, the Rehabilitation Manager, and the two Unit Managers no further information was provided by the facility prior to exit. 2. Resident #16 was a [AGE] year old admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 10/28/15 coded the resident as scoring a 2 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had severely impaired cognition. The resident was wheelchair bound and dependent on staff for locomotion on and off the unit. The resident had limited range of motion to both upper and lower extremities. The Care Planning Report for November 2015 identified the resident required wheelchair mobility and was total assist when needed. Related to physical, medical and cognitive impairment. The goal was the resident will be up daily as tolerated in wheelchair through next review. One of the interventions listed was to have bilateral legs rest on. On 11/12/15 at 12:25 pm, the resident was observed sitting up in the wheelchair in the main dining room finishing lunch. The East unit lead CNA (certified nurse aide) came into the dining room and asked the resident if he was done eating. She then proceeded to transport the resident from the dining room, down the East unit corridor to the activity room. During the entire transport the resident's left foot was not on the foot plate/ rest, it was observed dragging under the wheelchair. On 11/12/15 at 2:00 pm, the lead CNA was interviewed. The observation of Resident #16's left foot dragging during the transport from the dining room to the activity room was shared. She stated, He requires both foot rests on the wheelchair .there is a yellow tag on the wheelchair that says two foot rests .It was my fault I should have made sure both of his feet were properly positioned. When asked why is it important to use the foot rests during transport? She stated, He could hurt his leg. The above observation was shared with the administrator, the director of nursing, the corporate nurse and unit managers during the pre-exit meeting on 11/13/15. 3. Resident #12 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. (disorder of the brain), and Anxiety Disorder. Resident #12's Quarterly MDS (minimum data set - an assessment protocol) with an ARD (assessment reference date) of 10/27/15 coded the resident as having severe cognitive impairment as the BIMS (brief interview for mental status) was scored of 3 out of 15. In addition, the MDS coded Resident #12 as requiring extensive assistance with the assistance of one staff member for transfers, bathing and eating. Resident #12 was coded as always incontinent of both bladder and bowel. Record review revealed falls on 05/12/15, 05/20/15, and 06/22/15. Review of Resident #12's care plan with start date 05/14/15 Focus Need was identified as Ambulation Needs: Supervision, Oversight Needed, related to physical, medical condition, related to cognitive impairment, uses walker. Review of Physical Therapy discharge summary dated 12/08/14 noted the following: The patient is able to safely transition from sit to stand requiring supervision (needs verbal cueing but no physical assist) and a rolled walker and cues for safety. Review of Occupational Therapy discharge summary dated 12/24/14 noted the following; Goal not met on 12/25/14. The patient demonstrates high fall risk as evident by TUG (Timed Up and Go) score of 25 seconds. The patient is able to achieve balance on toilet commode utilizing toilet rails requiring stand by assistance (close enough to reach patient if assist needed). Note: according to the website http://physicaltherapy.about.com/od/Physical-Therapy-For-Seniors/a/Timed-Up-And-Go.htm (TUG scores greater than 14 indicate a high risk for fall). Review of Physical Therapy screen dated 05/13/15 noted the following: Patient ambulating with nursing with rolled walker. Wheel chair discontinued and patient is ambulating with nursing at this time, will re-screen in one week. Review of Physical Therapy screen done 05/20/15 revealed the following. Supervision Gait facility distances and discontinue wheel chair to maintain activities appropriate for gait with rolled walker and supervision. Patient ambulates with a rolled walker approximately 400 feet with supervision. Review of Fall Risk assessment dated [DATE] note the following risks for falls: intermittent confusion, history of 1-2 falls in past 3 months, legally blind, ambulatory but needs assistance, balance problem while standing, balance problem while walking, requires use of assistive devices, incontinent and needs assistance with elimination, antihypertensives, hypoglycemics, psychotropics, resident had change in the previously mentioned medications in the past 5 days, predisposing diseases: Cerebral Vascular Accident Review of Fall Risk assessment dated [DATE] revealed the following risks for falls: Intermittent confusion, history of 1-2 falls in past 3 months, legally blind, ambulatory but needs assistance, balance problem while standing, balance problem while walking, requires use of assistive devices, incontinent and needs assistance with elimination, antihypertensives, Cerebrovascular Accident, Review of medical records notes that Resident #12 on 06/22/15 sustained a fall with Resident #12 fracturing her humerus (arm bone) resulting in use of sling. Review of Progress Note dated 09/16/15 21:50 (9:50 p.m.) noted the following: unwitnessed fall in shower room (Resident #12 was left alone in the shower room) Oxygen level 95% (normal) Blood Glucose (sugar) 216 (above normal) Blood Pressure 156/66 (above normal) Review of Progress note dated 09/16/15 16:30 (6:30 p.m.) noted the following Personal alarm sounding followed by loud thud resident noted lying on back on floor resident's right hand positioned under her head. resident fully clothed resident's pants wet wheel chair to the right of the resident with the wheels locked resident unable to explain fall resident stated bumped head Review of the 09/16/15 fall investigation, does not mention why resident #12 was left alone in the shower room. Review of 06/22/15 progress note 15:36 (5:36 p.m.) noted the following: Fractured Left humerus detected via x-ray Sling to be worn for 6 weeks Fracture is on same side of hemiparesis An interview was conducted with Physical Therapy Manager #64 on 11/13/15 at approximately 5:40 p.m. Physical Therapy Manager stated, after the resident (resident #12) fractured her arm, she stopped using her walker as she couldn't hold on and then she began using her wheel chair again. When asked what his definition of supervision is, the Physical Therapy manager stated, Within eyesight, to assure they're doing safe things. A review of progress note dated 6/23/15 10:06 (10:06 a.m.) noted resident #12 use of wheel chair status [REDACTED]. An interview with Regional Coordinator #6 stated her definition of supervision is, when see a resident walking, she is using walker correctly. An interview was conducted with the Director of Nursing (DON) on 11/13/15 at approximately 4:30 p.m. The DON stated, the lap buddy (cushion used for residents in wheel chair) was started on 07/30/15. The policy and procedure entitled, Accidents with an effective date of 11/02/13 was reviewed. It noted the following: This facility believes the patient environment should remain as free from accident hazards as is possible and that each patient receives adequate supervision and assistance devices to prevent accidents. The policy and procedure entitled, Addendum to Falls - Nursing (Fall Prevention Program) with an effective date of 11/01/14 was reviewed. It noted the following: This program emphasizes assessment, identification, and intervention of patient falls while utilizing the least restrictive approach possible to keep the patient safe. The facility administration consisting of the Administrator, DON (director of nursing), ADON (assistant director of nursing), Unit Manager RN (registered nurse), Rehabilitation Manager and the RN Corporate Clinical Services Director were informed of the findings at a briefing on 11/13/15, at approximately 6:10 p.m. No additional information was submitted for review.

Based on a complaint investigation, clinical record review, staff and family interview, and facility documentation, the facility staff failed to implement interventions to include the necessary assistance and positioning to prevent avoidable accidents for 1 of 3 residents (Resident #3) in the survey sample. The facility staff failed to assure Resident #3 was safely positioned in bed during provision of a bed bath which resulted in a fall from the bed with a head laceration. After having fallen to the floor, the facility staff failed to assess the resident for further injuries before placing her in bed. In addition, the resident was not transferred to bed with the mechanical lift and two staff per her assessment and comprehensive care plan. Subsequently, the resident was admitted to the hospital and X-rays revealed multiple leg fractures and a head injury. The findings include: Resident #3 was admitted to the nursing facility on 9/14/07 with [DIAGNOSES REDACTED]. A contracture develops when the normally stretchy (elastic) tissues are replaced by non-stretchy (inelastic) fiber-like tissue. This tissue makes it hard to stretch the area and prevents normal movement. Contractures mostly occur in the skin, the tissues underneath, and the muscles, tendons, ligaments, and joint areas. Contractures can be caused by any of the following: Brain and nervous system disorders, such as [DIAGNOSES REDACTED] or stroke, inherited disorders (such as [DIAGNOSES REDACTED] nerve damage, reduced use (for example, from lack of mobility) scarring after traumatic injury burns (www.nlm.nih.gov/medlineplus/ency/article/ 5.htm). Resident #3 was discharged to the local hospital on [DATE] and did not return to the nursing facility. The Minimum Data Set ((MDS) dated [DATE] was a quarterly and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 3 out of a possible 15, which indicated the resident was severely impaired in the skills for daily decision making. She was coded sometimes understood by staff and sometimes understood others. Resident #3 was assessed totally dependent on two staff for bed mobility, transfer and toilet use. The resident was totally dependent on one staff for bathing. Resident #3 was not able to stabilize herself without staff assistance for surface to surface transfer. Range of motion was impaired on both sides of the body, upper and lower. The resident's mobility device was a wheelchair. She was coded incontinent of bowel and bladder. The revised care plan dated 4/1/15 through 5/8/15 identified Resident #3 had fall risk needs, safety needs, fracture risk needs related to cognitive impairment, history of falls and poor safety awareness. The resident was identified to require total assistance for bathing needs and bed mobility. Due to poor safety awareness, monitor for safety and injury risk to self and others, place bed up against the wall with left 1/2 side rail up and padded, mat on floor and mechanical lift for all transfers with two persons. Anticipate and meet needs (unable to use call system), allow adequate time for resident to respond. Contracture needs included passive range of motion (PROM) to both legs and a right arm splint when out of bed. Other interventions/approaches to address the resident's needs included reposition in bed with sheet and frequent re-positioning, pressure reducing mattress, concave mattress, observe for verbal/non verbal indicators of pain, personal alarm, concave backrest in chair. The nurse's notes dated 5/8/15 indicated at 8:20 a.m. Resident #3 rolled self onto floor during AM care. Large laceration noted to back of scalp. Pressure dressing applied by treatment nurse. physician's orders [REDACTED]. The nurse's notes indicated the resident was transported to theER on [DATE] at 9:02 a.m. The resident did not return to the nursing facility. The nurses notes also indicated some of the interventions in place at the time of the fall included a concave mattress and a mat on the floor. On 5/19/15 at 1:50 p.m., an interview was conducted with the West Wing Unit Manager (WWUM) where Resident #3 had resided. The WWUM stated she was in the morning meeting with other departments heads and the Administrator when informed the resident had fallen out of bed. She said when she entered the room around 8:30 a.m., the resident was in bed and treatment nurse Licensed Practical Nurse (LPN) #2 was applying pressure to the back of the resident's head. She stated the resident could communicate her needs and talk more at times, otherwise she was quiet. She said LPN #3 was also in the room and stated the resident was in the bed when she entered the room and proceeded to make an assessment. The WWUM stated she saw blood on the floor and blood on the sheets. According to the WWUM, she was told by Certified Nursing Assistant (CNA) #1 on 5/8/15 around 8:15 a.m., the resident rolled off the bed onto the floor during the provision of a.m. care when she turned to wet the wash cloth in the basin of water, sitting on the overbed table in order to wash her right shoulder. The CNA had placed the left arm in her blouse sleeve and had yet to wash the right shoulder and place that arm in the blouse's right sleeve. During the interview, the WWUM stated CNA #1 said she had the resident turned on her left side near the edge of the bed and her legs were drawn up her normally contracted position beyond the left padded side rail near the lower half of the bed just prior to falling out of bed (the right side of the bed was against the wall). The WWUM stated once the resident's contracted legs and knees began to fall off the bed and although the right hand was the good hand, the resident would not have been able to reach out and stop that type of momentum. She said the rest of the resident's body would have followed and she would not have the ability to stop the fall. The WWUM said the fall mat was not on the floor. She said, My assessment of the incident is that from what (CNA's name) said, she pushed the overbed table out from close to the bed because she was going to get the resident up when she saw food on her right shoulder, turned to dip the washcloth in the basin of water to wipe the right shoulder and the resident fell out of bed. The resident should have been positioned further back in the bed and pulled up in the bed, so when turned on her left side the padded side rail wound have also been a measure of protection. Since we work in teams, (CNA's name) could have gotten help to pull the resident up in bed and turn her from side to side. She also picked the resident up by herself and placed her back in the bed after she fell on the floor. She should have called for the nurse to assess the resident prior to moving her so as not to cause chances of further injury and she didn't use the lift either. The WWUM stated the CNA would have needed another CNA anyway to get the resident in the chair because she required assist of two to be mechanically lifted. She stated the chair was in the room and based on what the CNA said, she was going to get the mechanical lift and the help she needed to place the resident in the chair. On 5/19/15 at 2:20 p.m., the Rehabilitation (Rehab) Director and the WWUM brought into the conference room the type of bed that the resident used. They also stated the resident did not have a concave mattress, but a loss air loss, alternating pressure mattress (physician order [REDACTED].#1. He said the CNA told him she had pushed the table out on a 45 degree angle from the bed in anticipation of getting the resident ready to get up into the chair. The Rehab Director got into the bed and drew up his knees, placed his body at the lower part and edge of the bed beyond the side rails. He then proceeded to show how falling out of the bed leading with the contracted legs/knees would have caused the rest of the resident's body to follow. He stated, From what the CNA said, the resident hit her head on the base of the overbed table. On 5/19/15 at 2:55 p.m., and interview was conducted with CNA #2 who was the first staff called to the room by CNA #1 after the incident. CNA #2 stated when CNA #1 called her to the room, the resident was observed in bed on an air mattress, she saw blood on the floor and blood on the sheets. She said she immediately summoned LPN #3 to come in and assess the resident and they found the blood was coming from a gash in the back of the resident's head. She said, I learned (CNA #1's name) picked the resident up from the floor without using the (mechanical lift brand name) and getting one of us to help her with the transfer. We work in teams and help each other with anything. She should have called for the nurse first to make an assessment of the resident while she was on the floor, not me. You could move the resident and make something worse. She told me she went to dump the water in the sink and turned around and the resident was on the floor. CNA #2 stated she took care of the resident on many occasions and was able to bath her without difficulty, but needed help from another aide to properly position her and transfer her with the mechanical lift. She said the resident communicated and could tell you if she needed something or she was hurting. She stated the resident stayed where you position her and she had a hard time imagining Resident #3 rolling out of bed on her own because of her contractures, but could understand if she was so close to the edge of the bed her body would fall off the bed onto the floor. CNA #2 stated when she bathed residents, the bed was usually at waist level so as not to hurt her back (the CNA's) and it was easier to access the resident. On 5/19/15 at 3:15 p.m., an interview was conducted with LPN #3. She stated when CNA #2 called her to the room, the resident was in bed. She said she made an assessment of the resident and found blood coming from a gash in the back of the resident's head. She said, (CNA #1's name) said when she turned her back, and I not sure what she turned her back for, the resident fell out of bed after which she picked her up from the floor by herself and placed her back in bed. LPN #3 stated the nurse should have been the first person contacted to make an initial assessment after the fall while the resident was on the floor. She continued to say, the resident required two staff and a mechanical lift for all transfers. She stated they called the physician and prepared to send the resident out to the ER for an evaluation. On 5/19/15 at 4:00 p.m., an interview was conducted with the treatment nurse, LPN #2. She stated she was at the treatment cart when she was asked to help provide treatment to Resident #3 because she had fallen out of bed and suffered a laceration to the back of her head. She said she applied a pressure bandage to the resident's head and the WWUM and LPN #3 were in the process of sending the resident to the ER. On 5/20/15 at 12:45 p.m., a telephone interview was conducted with CNA #1. The CNA stated it was her first time caring for the resident. She said she was in the process of bathing the resident, had put all of clothing on her but the right arm sleeve. She said she pushed the overbed table further away from the bed, went to put the resident's right arm in the right sleeve of the blouse when she noticed some food on her right shoulder. She stated it was at that time she turned the resident on her left side, turned away to reach for the wash cloth, dipped it into the basin of water in order to wipe off the food on the resident's right shoulder when the resident fell to the floor, hitting the back of her head on the base of the overbed table. She said, When she fell the bed was in the highest position because I was bathing her, but when she fell on the floor I lowered the bed to the lowest position so I could pick her up in my arms from the floor and put her back in bed. When asked why she did not call the nurse to assess the resident prior to putting the resident in bed especially since the resident was actively bleeding from her head, she responded, I was never told not to put someone back in bed after they had fallen. I put my arms under her head and knees and picked her up from the floor to put her back to bed. Was there something wrong with that? When asked if there was a problem with a resident, an accident occurred or a possible change in condition what would she have done, she responded, I would have called the nurse, but I was never told to leave someone on the floor for a nurse to check them out on the floor. During the above interview, CNA #1 stated the resident was below the left padded siderail toward the end of the bed and on the edge of the bed when the resident fell off the bed. She further stated she was pulled from her normally scheduled unit because there was a call in and said, I did not know how to talk to the other nurses to help me. She stated she used the Care Card that was posted inside the resident's wardrobe to see what she needed to do for the resident because it was her first time caring for her, but did not think to use the mechanical lift with transfers even though it was noted on the care card. CNA #1 stated, If I had it to do over, I would use the team approach like I did on my regular unit to help position her up in the center of the bed while bathing, dressing and turning from side to side. I would also call the nurse and not the aide first to check the resident while she was still on the floor. Disparities were identified upon review of the event report dated 5/8/15, the nurse's notes dated 5/8/15, the current care plan dated 4/1/15 through 5/8/15 and staff interviews. The event report indicated both 1/2 side rails were up at the time of the fall, but all staff interviews indicated only the left 1/2 side rail was up. The nurse's notes indicated there were mats on the floor and a concave mattress at the time of the fall. All staff interviews indicated there was no mat on the floor, nor was the resident on a concave mattress at the time of the fall. The physician's orders [REDACTED]. On 5/20/15 at 1:10 p.m., a telephone interview was conducted with the Director of Nursing (DON). She recalled the fall incident as described in the aforementioned interviews with staff. The DON stated she brought CNA #1 in the morning of the incident between 11:30 a.m. and 12:00 p.m. to have her role play how the incident occurred. The DON verified that the resident was not on a concave mattress, as documented in the nurse's notes and care plan, nor was there a mat on the floor to help break her fall. On 5/20/15 at 1:30 p.m., the Administrator stated, along with the WWUM, the DON, the Rehab Director and CNA #1, they decided to do a role play after the incident on 5/8/15 to best understand how the incident occurred. He validated the aforementioned statements from CNA #1 as to how she said the fall from the bed happened. On 5/20/15 at 1:45 p.m., the Maintenance Director, along with the West Wing Unit Manager (WWUM), was asked to measure the height of the bed at waist height to facilitate bathing to the floor with the low air loss mattress and the same with the bed in the lowest position. The height at the top of the mattress to the floor in it's highest position measured 32 inches. The height at the top of the mattress in it's lowest position to the floor measured 17 inches. The WWUM stated the care plan indicated the resident had a scoop mattress and an air mattress but she did not have both, only the air mattress. On 5/20/15 at 3:05 p.m., an interview was conducted with the Staff Development Coordinator (SDC). She stated although CNA #1 did not call the nurse when the resident had fallen to the floor, she taught them to call for anything unusual besides skin integrity problems, pain and behaviors. She said a fall to the floor with bleeding was an unusual occurrence and she expected the CNA to first alert the nurse and the nurse would make the decision to move or not move the resident. She also stated CNA #1 was a new CNA and newly hired 3/3/15 and had new hire orientation that included use of the mechanical lifts with two staff required for transfers and transfers with use of sheets. In addition, she stated she was not responsible for the 30, 60 and 90 day performance, but it was a valuable evaluation tool that evaluates areas of improvement and what additional education was needed. She returned with the new hire evaluation review tool that had not been completed for CNA #1's 30 and 60 day evaluation. The CNA was on her way toward the 90 day new hire evaluation. The SDC stated new hires were paired with seasoned CNAs for at least 2 weeks before released to take a resident assignment, but still was able to elicit help if needed from any CNA and nurse. She also said the DON was responsible to complete the evaluations. On 5/21/15 at approximately 11:00 a.m., a telephone call was placed the DON to ask her if she had CNA#1's new hire evaluations, to which she responded, I have not done them. I am behind. Review of the hospital records indicated Resident #3 was groaning in general, obvious contractures of lower extremities with the left side more contracted than the right and a left contracted arm when she arrived in theER on [DATE] at around 9:13 a.m. and had an obvious scalp laceration. The laceration was repaired at 9:30 a.m. and closed with 7 staples. On 5/8/15 at 11:23 a.m., the ER physician informed the family the resident was able to verbalize, now talking and stated she was dropped at the nursing home. X-rays revealed two right leg fractures; the femoral neck fracture which was surgically repaired on 5/9/15 through an Open Reduction and Internal Fixation (ORIF), the other fracture required splint placement to help with straightening/correction. The thigh was noted to be swollen and misshapen. The resident was discharged from the hospital on [DATE] to another nursing facility. On 5/21/15 at 1:40 p.m., an interview was conducted with the Responsible Party (RP). She stated the resident was able to communicate and was in lots of pain as a result of the fall and surgery. She stated she was upset that the least contracted leg (right) was now fully messed up because it had two separate fractures in it and her right leg is in an 'S' shape. She said she spoke with the local ombudsman and he stated based on the nature of the fall, there would be an immediate investigation and she would receive a report and/or some explanation from the Administrator or DON about what happened. She stated, I had to initiate getting information from them days later, they obviously were not going to tell me what happened. The RP did state she was called and told the resident had fallen and would be on her way to the hospital. On 5/21/15 at 2:40 p.m., two random interviews were conducted together with CNA #3 and #4. Both CNA's stated they provided care for Resident #3 on a consistent basis. They stated the resident was not able to roll over by herself, but required at least two aides to turn and reposition her in bed, as well as with transfers in and out of bed along with the full mechanical lift. They stated the only thing you could do alone was to feed her and bath her, but needed the help of another aide for everything else. They both stated the resident wore a splint on the left arm and bilateral leg splints and boots when out of bed only. On 5/19/15 at 2:48 p.m., the Assistant Director of Nursing (ADON) stated she and the Director of Nursing (DON) were in the process of educating all the CNA's on safety to include never turning your back on residents during bed bath, making sure side rails are being used appropriately and correct positioning of the resident for safety. The original inservice sign in sheet indicated 28 CNAs were educated, but there were 64 total on the list in order to complete remaining CNA training. There was nothing in the training about not moving patient after injury until assessed by the nurse. The following facility policy, entitled Accidents effective 11/1/13 indicated the following: The intent of this requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each patient to prevent avoidable accidents. This includes: -Incorporate patient choices into Plan of Care (POC) to help facility balance interventions to reduce risk of an accident, while honoring patient's autonomy. -Facility will have a process in place to identify hazards and risks. -Facility will have a process to evaluate and provide analysis of interventions to be used. -Facility will implement interventions to reduce risks from hazards. -Facility will monitor the process and make modifications as needed. -Facility will provide adequate supervision to prevent accidents. Effective ways to avoid accidents: -Implement systems that address patient risk, and identify environmental hazards to minimize the likelihood of accidents. -Directs resources to address safety concerns, evaluate, monitor, modify, care plan, and analyze risk of hazards. Provide adequate supervision (may vary patient to patient) to prevent accident risks. -Evaluating and analyzing hazard(s) and risk(s). -Implementing interventions to reduce hazard(s) and risk(s); and -Monitoring for effectiveness and modifying interventions when necessary. Federal regulations hold the facility ultimately accountable for the patient's care and safety. Verbal consent or signed consents do not eliminate a facility's responsibility to protect a patient from an avoidable accident. The following facility policy, entitled Fall Prevention Program effective 09/07/12 indicated the following: Definition of a fall: a sudden, uncontrolled, unintentional downward displacement of the body to the ground or other object at a lower level. Delegation of Authority and Responsibility: -The facility administrator is responsible for ensuring that falls and fall-related injury prevention are viewed as a high priority at the facility, promoted across the facility through patient care, administrative, and logistical staff to provide a safe environment for patients and staff. -The DON/QA (Quality Assurance) nurse is responsible for establishing fall risk program, deploying evidence-based standards of practice, and oversight of this policy. -The Unit Manager/Nursing Supervisor is responsible for assuring the implementation of this policy, for providing a safe environment, for maintaining appropriate equipment, and for appropriate Care Planning of individualized fall prevention and management intervention, including ensuing revisions to Care Plans if a fall event should occur. -The Medication/Charge Nurse is responsible for implementing and oversight of individualized resident/patient fall prevention as follows: -Supervise ancillary personnel in delivering safe and personalized care. The NCPS Care poster can be used for training purposes. -In the event of a fall, perform an assessment of the fall event, at the location of the event and prior to the patient being moved, to include: -Head to toe physical assessment. -Effectiveness of existing fall prevention interventions. -Questioning of patient, staff, and witnesses about circumstances surrounding event. -Document/report the fall event: -Obtain the CNA Fall Questionnaire and submit it with printed event investigation for review by Falls Committee (Enclosure 3). The Nursing Assistant is responsible for providing patient care in accordance with the plan of care, to include: -Immediate reporting of actual fall events to the Medication/Charge Nurse or Unit Manager/Nursing Supervisor. -Maintain the patient in the position as found (unless patient safety is at risk in which case the patient should be removed to a place of safety), until a nurse reports to the scene to assess the event. -Complete the CNA Fall Questionnaire, enclosure (3), and submit it to the Medication/Charge nurse. COMPLAINT DEFICIENCY