Every finding on record at Birmingham Green

Based on a complaint investigation, medical record review, staff interviews and facility document review the facility staff failed to ensure Rehabilitation Services were provided after 6 insurance rehabilitative service visits were authorized to 1 of 3 residents in the survey sample, Resident #2. The facility staff failed to provide Resident #2 with Rehabilitation Services after 6 insurance rehabilitative service days dated 3/27/20 through 6/25/2020 were authorized. The findings included: Resident #2 was initially admitted to the facility on [DATE] with diagnoses to include but not limited to Alzheimer's Disease, Dementia and Bilateral Osteoarthritis of Knee. Resident #2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/27/20 was reviewed. Under Section G Functional Status; Resident #2 was coded as requiring supervision set up assist only for locomotion/walking in the corridor and on/off the unit. Resident #2's Brief Interview for Mental Status was coded as 99, indicating the resident was severely cognitive impaired. Resident #2's significant change MDS with an ARD of 5/29/20 was reviewed. Under Section G Functional Status; Resident #2 was coded as activity did not occur for locomotion/walking in the corridor and on/off the unit. Resident #2's Brief Interview for Mental Status was coded as 99, indicating the resident was severely cognitive impaired. Resident #2's most recent MDS is a quarterly with an ARD of 3/31/21. Under Section G Functional Status; Resident #2 was coded as requiring extensive 2 person assist for locomotion/walking in the corridor and on/off the unit. Resident #2's Brief Interview for Mental Status was coded as 99, indicating the resident was severely cognitive impaired. Resident #2's Physician Orders were reviewed and are documented in part, as follows: Order Date: 3/17/2020 Order Summary: PT (Physical Therapy) evaluation for generalized weakness and bilateral knee pain. Resident #2's Comprehensive Care Plan last revised 3/31/22 was reviewed and is documented in part, as follows: Focus: Name (Resident #2) has a potential for ALTERATION IN COMFORT: REQUIRES PAIN MANAGEMENT AND MONITORING RELATED TO: KNEE PAIN, SHOULDER PAIN, JAW PAIN CHRONIC DISEASE PROCESS Date Initiated: 01/22/2018 Created on: 01/22/2018 Interventions: PT/OT FOR PAIN MODALITIES PRN(as needed). Date Initiated: 01/22/2018 Focus: Name (Resident #2) requires a restorative nursing program to maintain musculoskeletal function and current level of functional mobility. Date Initiated: 2/28/2022 Interventions: Restorative nurse to evaluate on an ongoing basis if a therapy evaluation is needed. Date Initiated: 2/28/2022 On 4/20/22 at 8:30 P.M. a phone interview was conducted with Resident #2's daughter who was also the complainant. The Resident's daughter stated, My mother had received insurance authorization for 6 physical therapy visits that were good from 3/27/20 through 6/25/2020 and she never received the therapy. My father brought the insurance authorization to the facility so they could start the therapy. On 4/21/22 at 10:00 a.m. Resident #2's Spouse provided this surveyor with a copy of the insurance authorization dated 4/1/20 which was reviewed and is documented in part, as follows: Referral Start Date: 3/27/2020 Referral Expiration Date: 6/25/2020 Number of Visits Authorized: 6 Referral Type: PT/OT/ST (physical therapy, occupational therapy and speech therapy). Your referral has been approved for services. On 4/21/22 at 10:00 a.m. an interview was conducted with Resident #2's Spouse regarding the provided insurance authorization dated 4/1/20. Resident #2's Spouse stated, I gave a copy of the authorization to the facility when I received it, but she never had the 6 therapy visits. I gave it to a nurse. Resident #2's Maryland Uniform Consultation Referral Form request dated 3/23/2020 that was completed by the facility Rehabilitation Director was reviewed and is documented in part, as follows: Patient Information: Name (Resident #2) Referral Information: Weakness, Arthritis to knees, Difficulty walking. Brief History: Dementia Services Desired: PT evaluate and treat. Number of Visits: 16 On 4/21/22 at 10:43 a.m. an interview was conducted with the Rehabilitation Director regarding the Resident #2's Maryland Uniform Consultation Referral request dated 3/23/2020 and subsequent follow-up. The Rehabilitation Director stated, On 3/23/20 we received a physician order for Name (Resident #2) to have PT. On 3/23/20 I initiated the insurance referral and sent the information off to her insurance company. We were not aware that the referral had been approved. The Surveyor asked the Rehabilitation Director how the facility is made aware when therapy referrals are approved. The Rehabilitation Director stated, We normally get a fax from the insurance company about the authorization. I used to have a rehabilitation tech that would follow-up and we had documentation to show we did the follow-up. I don't have any documentation to show we followed up for Name (Resident #2). The facility policy titled Specialized Rehabilitation, Nursing and Administration was reviewed and is documented in part, as follows: Policy: Specialized Rehabilitation Services; includes but is not limited to physical therapy, speech-language pathology, occupational therapy, or respiratory therapy and are provided or arranged by the nursing home. Policy Interpretation and Implementation: 1. In addition to Rehabilitative Nursing Care, the facility provides Specialized Rehabilitative Services by qualified professional personnel and in accordance with federal/state regulations. On 4/21/22 at 11:48 p.m. a pre-exit debriefing was held with the Administrator, the Assistant Administrator and the Director of Nursing were the above information was shared. The surveyor asked what was were the expectations regarding authorized therapy referrals. The Administrator stated, The rehab department completes the referral and sends it to the insurance company. If we haven't heard back in 24 hours I expected for them to call and follow-up. If we had known it was approved we would have provided the 6 visits and if she needed more we would have requested additional treatments until her prior level of care was reacted. Prior to exit no further information was shared. This is a Complaint Deficiency.

Based on information obtained during a complaint investigation, staff interviews, clinical record review, review of facility documents, and review of the facility's policies, the facility staff failed to provide the required supervision and institute interventions to prevent falls resulting in a right [MEDICAL CONDITION] (8/12/20) and a right humerus fracture (9/20/20) for 1 of 7 residents (Resident #4) in the survey sample resulting in harm; and failed to provide adequate supervision to prevent an unwitnessed exit from the facility for 1 of 7 residents (Resident #5) in the survey sample. The findings included: 1. Resident #4 was admitted to the facility 11/26/14. The resident was discharged to an acute care facility after a fall with injury on 8/12/20 and returned on 8/15/20 and discharged to an acute care facility after a fall with injury on 9/20/20 and returned to the nursing facility on 9/22/20. Resident #4's [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/15/20, coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired daily decision making abilities. In section G (Physical functioning) the resident was coded as requiring extensive assistance of one person with bed mobility, locomotion on the unit, dressing, toileting personal hygiene and walking off the unit, limited assistance of one person with transfers and walking on the unit, and total care of one person with bathing. The clinical record revealed a nurse's note on 8/12/20 which stated the resident had a fall in her room. An incident report revealed on 8/12/20, at 9:25 a.m., a certified nursing assistant (CNA) called the nurse to the Resident #4's room for the resident had experienced an unwitnessed fall. The report further stated upon the nurse's arrival to the room the resident was observed sitting on the floor leaning on the right hip with her back against the side of the roommate's bed. The call bell was in the resident's hand but it had not been activated. Prior to the fall the resident had been observed sitting in a stationary chair watching television. At 9:27 a.m. the nurse manager and nurse supervisor were called and after assessing the resident the nurse manager stated to keep the resident on the floor and call 911. On 11/13/20, at 8:40 a.m., an interview was conducted with the certified nursing assistant (CNA) who first observed Resident #4 on the floor on 8/12/20. CNA #6 stated he heard someone screaming for help when he was in another room assisting a resident. CNA #6 stated he followed the calling out which led him to Resident #4's room. CNA #6 stated he thinks the resident was wearing a gown, the resident had no shoes or socks on, doesn't recall a call bell or walker nearby. He stated I can't fully recall details then the nurse was notified. An interview was conducted with the Licensed Practical Nurse (LPN) #2 on 11/13/20 at approximately 8:50 a.m. LPN #2 stated she was the nurse assigned to Resident #4 on 8/12/20 and she had worked with resident many years. LPN #2 stated the resident was confused related to progressive dementia, exhibited impulsiveness and thought herself to be more independent than she was as evidenced by attempting to to walk without the walker and not asking for assistance. LPN #2 also stated the resident had a very unsteady gait and sometimes stated when she wanted to toilet that she was going home. LPN #2 further stated she didn't document certain required information on the report but she believes the resident was fully dressed and her brown moccasins were still on her feet. The room was bright, nothing was on the floor, the tray wasn't present and she had no recall of the walker. LPN #2 stated no one addressed details surrounding the fall with her after the report was completed therefore she didn't realize how important it was to fully describe the fall scene so the information could aid in developing interventions for fall prevention. LPN #2 stated the intervention she felt most appropriate for the resident upon return to the facility was to bring the resident out of her room to the dining area during awake hours so more staff could assist in monitoring her. Fall Risk Assessments were completed after each fall and each assessment indicated the risk for falls had increased. On 8/15/20 the score was 16, 9/20/20 the score was 19 and 9/22/20 the score was 25. Review of Resident #4's care plan revealed upon readmission to the facility on [DATE], she had a right [MEDICAL CONDITION] and the surgical site was held together with 36 staples. The only intervention added to the fall risk care plan was two people assistance with transfers (this was the assistance required since the right hip was fractured). The intervention to have the resident present in the dining area during awake hours wasn't added to the care plan as an intervention. Another incident report dated 9/20/20, revealed CNA #2 stated the resident was asleep in bed between 7:00 a.m. and 7:30 a.m., and at approximately 7:35 a.m., she heard someone calling for help and upon entering Resident #4's room the resident was observed on the floor with urine and feces also on the floor. The report further stated LPN #1 arrived to Resident #4's room at approximately 7:39 a.m., to find the resident lying on the floor beside her bed, on her right side, moaning in pain and holding her right shoulder. The report stated the resident was attempting to self-transfer from the bed and didn't use the call light to get help. A local hospital report dated 9/20/20, revealed Resident #4 suffered a closed right humerus fracture. A physician's progress note dated 9/28/20, revealed upon Resident #4's readmission to the facility on [DATE], the resident suffered a closed fractured of the right humerus which was being treated with a Wera sling and a narcotic for pain with an orthopedic consult. An interview was conducted with LPN #1 on 11/13/20, at approximately 9:49 a.m., regarding Resident #4's 9/20/20 fall. LPN #1 stated the resident's bed was dry and clean, she was lying on her right side, and she believes the resident was wearing a gown and socks, and was stating get me up. LPN #1 further stated the resident bed was wasn't all the way to the floor and she didn't recall if side rails were present. LP #1 stated she didn't add all the above information to the report because she didn't realize it was important to describe the fall scene and she didn't recall anyone requesting additional information about the fall scene. An interview was conducted with CNA #2 on 11/13/20, at approximately 10:00 a.m., about Resident #4's 9/20/20 fall. CNA #2 stated she was assigned to provide care for Resident #4 on 9/20/20. CNA #2 stated they were told if the resident wasn't awake on rounds don't awake her therefore she didn't get the resident out of bed during rounds between 7:00 a.m. and 7:30 a.m. CNA #2 also stated if Resident #4 was awake they should toilet her, provide a.m. care. CNA #2 further stated she provided frequent rounds on the resident because the resident thinks she can walk independently and constantly tries to get up unassisted. CNA #2 stated since the right arm fracture the resident goes to the dining room after a.m. care until after lunch, then she goes to bed for an afternoon nap. CNA #2 also stated Resident #4 was on every thirty minute checks for a while after the two fractures. Review of Resident #4's care plan dated 9/29/20 revealed the following problem; At risk for injury from falls related to impaired cognition with poor safety awareness, use of [MEDICAL CONDITION] medications, arthritis and a history of falls. Resident refuses to allow staff to place gait belt when assisting her with ambulation. (name of resident) has a shuffling gait and tends to walk with her head looking downwards. The goal read; (name of resident) safety will be maintained as evidenced by having no significant injuries from falls this review. The interventions added after the second fracture to aid in fall preventions included; 9/24/20 use of a perimeter mattress, 10/15/20 low bed with fall mats. Review of the clinical record revealed on 11/8/20, at approximately 2:25 p.m., Resident #4 was observed by the floor technician in the dining room, with no staff present. The resident slid from the wheel chair to the floor. The resident stated I pooped. I have to go to the toilet. Upon toileting the resident eliminated some urine and a soft formed stool. No injuries were sustained. The intervention was to place the resident in the dining room in visual sight of staff. An interview was conducted with the Floor Technician on 11/13/20, at approximately 10:13 a.m., the Floor Technician stated two nursing staff members were in the nursing station but no one was in the dining room with the residents when Resident #4 slid from the wheel chair on 11/8/20. The Floor Technician stated he informed the staff the resident was on the floor and needed help. The facility was unable to provide At Risk meeting notes or other documentation the Interdisciplinary Team had reviewed Resident #4's two falls resulting in fractures or developed strategies/interventions to aid in decreasing opportunities for future falls. An At Risk meeting note dated 11/9/20, was provided for review of the 11/8/20, fall. The Fall investigation forms and the Fall Risk assessments information wasn't thorough enough to determine causative factors of the falls, trends or patterns and drive creative preventive measure to add to the care plan when the Interdisciplinary Team reviewed the falls. The Fall Prevention and Management Program policy dated 10/5/15, stated the policy was to provide a comprehensive, consistent approach to assess residents at risk for falls and to implement interventions to reduce risk for recurrence and injury. #2 stated the Individual Service Plan is to contain a review and revision related to the causative factors and preventive measures. #7 stated the fall investigation form will be utilized in reviewing and revising the resident's Individual Service Plan to minimize the recurrence of falls or injury. #9 stated the Director of Nursing will review the incident report and fall investigation form and follow up on suggestions and or interventions implemented and ensure the care plan had been updated and communicated to the Interdisciplinary Team. #14 stated the Director of Nursing will assure that the recommended measures are put into place and the Individual Service Plan is updated to reflect the changes. The above information was shared with the Administrator, the Assistant Administrator, the Director of Nursing and the Unit Manager on 8/13/20 at 2:00 p.m. The Unit Manager stated that prior to the 8/12/20, fall the resident had not had falls and she thought new interventions had been instituted after that fall to prevent future falls but she was unable to locate where on the care plan they were incorporated, neither could any facility's staff provide what information had been given to the direct care staff to aid in preventing future falls with injury. 2. Resident #5 was admitted to the facility 5/18/17, discharged with return anticipated 7/1/19, and returned to the facility on [DATE]. Resident #5's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/30/20, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #5's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring supervision after se-up with transfers, walking on/off the unit, locomotion and eating, limited assistance of one person with bed mobility, toileting, and personal hygiene, extensive assistance of one person with bathing. A nurse's note dated 9/20/20 stated Resident #5 exited the front door of the facility by herself for approximately 15 minutes per the receptionist and came back in by herself. A full body assessment was completed, no apparent injuries were noted. No complaint of pain. Physician and Responsible Party made aware. A wanderguard was applied to the resident's left lower leg. The Physician ordered every thirty minute checks for safety. The resident's 7/14/20 wander risk assessment revealed a score of 13 which indicated the resident was at high risk. The assessment further revealed the resident was ambulatory, had a history of [REDACTED]. An interview was conducted with CNA #1 on 11/10/20 at approximately 5:28 p.m. CNA #1 stated on 9/20/20, Resident #1 received a meal from her family between 4:00 p.m. and 5:00 p.m., at the front desk and it was picked up from the front desk and delivered to the resident. CNA #1 stated the resident came to the desk to ask who brought the food to her and she stated her daughter but she was gone and the resident turned and walked away towards her room. CNA #1 further stated the resident enjoys reading, music talking on the phone and sleeping as well as sitting in the hallway near the bird cage. CNA #1 stated the bird cage wasn't actually on the unit but it was just outside the unit's doorway and in a frequently traveled area and the resident really enjoyed sitting in the area. CNA #1 wasn't aware of the resident wandering or having a history of exit seeking and she never noticed the resident wasn't on the unit. A witness statement written 9/20/20 revealed CNA #8 went to Resident #5's room to let her call her daughter-in-law at approximately 4:40 p.m., but the resident wasn't in her usual area by the bird cage. CNA #8 wrote she checked the resident's room and bathroom but still was unable to locate the resident therefore the nurse supervisor was informed of the missing resident. CNA #8 further wrote she went to the front desk area to try and locate the resident and as she started to look outside the resident walked through the front door returning inside the facility. An interview was conducted with the full time day shift front desk receptionist who stated she had worked in the position for three years. She there was only one resident who currently goes out to smoke with a staff member and stated no residents are allowed out the front door unattended. She further stated if a resident attempts to exit the facility unattended her roles would be to telephone nursing for assistance and attempt to get the resident to stay inside until the nursing staff arrives. The full time day shift front desk receptionist stated there had always been an elopement book at the front desk containing approximately 23-30 resident names and photographs and it is each receptionist duty to review the book daily and sign off that you have viewed the book and nursing staff are responsible for keeping the book updated. An interview was conducted on 11/13/20 at approximately 11:00 a.m., with the front desk receptionist who was on duty when Resident #5 exited the door. The front desk receptionist stated he was fairly new to the long term care facility and he wasn't aware at the time the individual (Resident #5) who left the building was a resident and that known residents are not allowed to leave the building unescorted. The front desk receptionist stated he had training to the duties but he wasn't aware of an elopement book at the front desk, that residents were not allowed to exit the door unescorted and he didn't know until later the person he saw exit the door was Resident #5 and Resident #5 wasn't within his line of sight after she exited the door on 9/20/20. The front desk receptionist stated he made a mistake and accepted full responsibility for the the resident leaving the facility unescorted and since the education was provided he now knows the difference in his usual work environment and the long term care work environment. The facility's investigation established that Resident #5's unescorted exit from the facility was simply a stroll outside to sit on a bench, while the resident waited to visit with her daughter-in-law, which was observed by the front desk receptionist. A consultant's analysis dated 10/26/20, included Resident #5's exit from the building unescorted. The event was categorized as an elopement and/or unsupervised wandering and a note in the comments section stated lets discuss what, why, resident outcome and action taken. The analysis also stated the interim security guard let resident go outside and the document stated the event was reported since the resident was on camera the entire time and the security guard was no longer employed. A nurse's note was observed in Resident #5's clinical record dated 11/11/20 which stated a call had been placed to the resident's son to discuss the potential of moving the bird cage to the unit the resident resides on because the birds bring great comfort to the resident. The note further stated moving the bird cage to a low traffic area would increase the ability to monitor the whereabouts of the resident by the staff. The nurse's note stated the son was in full agreement with the potential of increased monitoring of the resident combined with one of her treasured activities. On 11/13/20 at approximately 5:15 p.m., the evening shift front desk receptionist repetitively stated the Administrator the surveyors were attempting to make contact with wasn't listed on the extension list therefore calls were forwarded to the previous Administrator's voice mail. At that point an interview was conducted with the receptionist regarding allowing individuals to enter and leave the facility and if the elopement book review was something she was familiar with. The evening shift front desk receptionist wasn't a regular employee of the long term care facility and the interview revealed she wasn't knowledgeable of identifying persons leaving the facility or how to determine if the person was a resident or what to do if a resident attempted to exit the front door. The above information was shared with the Administrator, the Assistant Administrator, the Director of Nursing and the Unit Manager on 11/13/20 at 5:00 p.m. The Assistant Administrator stated the resident sat on the bench in front of the building the entire time she was outside and remained within sight of the front desk receptionist. The Administrator provided a document which stated upon beginning the assignment at the facility 11/5/20, a review of the 9/20/20 event for (name of the resident) aided them to reconsider their protocol. It was determined that re-education on the elopement protocols with receptionist and security teams would be beneficial in addition to reconstruction of the elopement book and review of procedures was immediately performed. An additional measure was to trial moving the bird aviary on to the residential unit to engage Resident #5 in self-determined activities.

Based on observations, staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure infection control measures were consistently implemented to prevent the development and/or transmission of a communicable disease (COVID-19) and other infectious diseases for 1 of 7 residents, Resident #1, in the survey sample. The findings included: The facility staff failed to ensure one resident wore a face covering for source control when leaving their room or around others according to CDC guidelines (1). Resident #1 was originally admitted to the facility on [DATE] from the community. Resident #1's [DIAGNOSES REDACTED]. The Admission Assessment Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/13/20, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring a 99. This coded Resident #1 as having short-term and long-term memory problems. In section G (Physical functioning) the resident was coded as needing extensive assistance with bed mobility, transfers, locomotion on the unit, dressing, eating, toileting and personal hygiene. Bathing required one person physical assistance. On 11/09/20 at approximately 1:20 p.m., an observation was made during the initial tour on the Garden Hill Unit (Observation Wing). Resident #1 was observed being transported by CNA (certified nursing assistant) #6 via wheelchair in the hallway near the nurse's station heading to the shower room. Resident #1 was not wearing a mask/facial covering. The door to the shower room remained opened as CNA #6 entered inside with Resident #1. The Unit Manager, (Registered Nurse-RN #1) standing nearby was asked what should have been done concerning the above issue. She stated, Outside of rooms, residents should wear mask. In the meantime CNA #6 exited the shower room, proceeded down the hallway, entered a room, returned and approached the unit manager (who was now standing at the entrance of the shower room with the surveyor), saying I can't find it. The nurse manager was observed removing an item from the medication cart, handing it to CNA #6, who then entered the shower room where Resident #1 was waiting. An interview was conducted with CNA (Certified Nursing Assistant) #6 at approximately, 1:30 p.m., concerning the above issue. She stated, I was so busy, I didn't notice that she wasn't wearing a mask. An interview was conducted on 11/10/20 at 4:50 p.m., with CNA #7 concerning residents wearing facial coverings. CNA #7 stated, They should wear a mask until they get in the shower and take it off. An interview was conducted on 11/13/20 at 4:43 p.m., with the Unit Manager (Registered Nurse) #1 concerning the above issue. She stated, I got a mask and CNA #6 put it on her. She was asked if Resident #1 resisted getting her mask put on. She stated, No, her cloth mask was in the laundry. I got her a surgical mask. She was then asked if she had revised the Resident's Care Plan on 11/10/20 after the above issue occurred. She stated, Yes. Revised Careplan Interventions read: Provide resident with a mask when out of room as she will allow. Resistant at times to wearing a mask. Initiated on 11/10/20, Created on 11/10/20, Created by Unit Manager, Registered Nurse #1. (1) Per CDC Guidance: Implement Source Control Measures .Residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room, including for procedures outside the facility . https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html On 11/13/20 at 5:00 p.m., an exit interview was conducted via phone with the Interim Administrator, the DON (Director of Nursing), the Assistant Administrator, Infection Control Nurse and Corporate Officer. All of the above observations, interviews and concerns were shared with the Administration staff.

Based on observations, staff interviews, clinical record review, and review of facility documentation, the facility staff failed to follow droplet precautions using the preferred or alternative Personal Protective Equipment (PPE) to provide care to 2 of 2 residents in the facility identified with the COVID-19 virus (Residents #1 and #2); and the facility failed to store resident equipment appropriately in the clean utility room on 1 of 3 units in the nursing facility to prevent the possible transmission of infection. The findings include: 1. During observations on the Colonial Heights unit on 6/24/20 at 1:00 p.m., Certified Nursing Assistant (CNA) #1 demonstrated the cleaning and storage of patient care equipment to include the vital sign machines. She stated all vital sign machines have two large clear bags tied on each side of the machine's storage basket. She said one bag stores clean wipes that are saturated with a mixed disinfectant in a spray bottle and the second bag designed to dispose of the used wipes. She stated when the vital sign machine was not in use it is stored disinfected and without any bags. She took this surveyor to the clean utility room only to find one vital sign machine that had the two bags attached to the storage basket with many used wipes in one of the bags. CNA #1 said, I can't believe someone put this vital sign machine in here like this. I have no idea who did it. Nothing is supposed to be in this room that is not disinfected or with used wipes in the disposal bag. The CNA removed the vital sign machine from the clean utility room, removed the bags and disposed of them, disinfected the machine and returned it to the clean utility room. The CNA stated, I was told in order to save money we were not routinely using Sani-wipes. We would not have to use those bags and it would be easier to dispose of after cleaning the vital sign machines. The facility's Action Plans for COVID-19 dated 3/5/20 and ongoing indicated each manager would be provided with the approved spray cleaner and that Sani wipes would also be provided and used for resident areas. One of the methods for monitoring the plan included environmental services to ensure all departments have sufficient cleaning supplies for equipment and guidance provided on how spray cleaners are to be used. 2. On 6/24/20 at 12:45 p.m., during observations on the Cardinal Heights Unit, Unit Manager Licensed Practical Nurse (LPN) #1 stated she had two residents cohorted together that were assessed to be PUIs (Persons Under Investigation) based on the fact that they had recent visits to the hospital and the emergency department (ED). She stated these residents were placed on droplet precautions and monitored for any signs and symptoms of COVID-19 as a precautionary measure for 14 days, after which they would return to their previously assigned rooms. She stated the PPE used by the nursing staff to care for these residents included gown, gloves, and a surgical mask. Staff were not observed wearing face shields. On 6/24/20 at 1:55 p.m. during observations on the Garden Hill Unit, the Unit Manager, LPN #2 stated she had two COVID-19 positive residents in an area behind double doors and were both on droplet precautions. The CNA (#2) providing direct care for both residents wore a reusable isolation gown, gloves and yellow surgical mask. When asked if she wore a face shield as a part of the isolation precautions, she stated, Approximately a couple of months ago, a doctor from (hospital name) came and told us we only needed a surgical mask to care for suspected or COVID-19 diagnosed residents. I get a surgical mask assigned to me every three days by the 11 p.m.-7 a.m. nursing supervisor. I will get one tomorrow. I wear it in and out of the facility, hang in in my car and put it on the next time I work, I am full time. I was fit tested for an N95 and also had a face shield but was told they were costly and we didn't need them. I don't feel comfortable being in such close contact with the COVID residents, but I pray I remain COVID free. She stated the 11 p.m.-7 a.m. nor the 3 p.m.-11 p.m. CNA wore an N95 or face shield to provide direct care for the COVID-19 positive residents. The CNA stated the licensed nurses that administered medications to the aforementioned residents wore a gown, gloves and surgical mask. During the above interview with CNA #2, she stated there was a sign out sheet for PPE and escorted this surveyor to the nurse's station located directly outside the double doors from the COVID-19 area. The Unit Manager, LPN #2 stated she had just returned after an extended leave and did not know what was going on or what changes had been made. Licensed Practical Nurse (LPN #3) retrieved a black binder that housed several sheets with six columns and the following headings: Item description, Date, Print Name, Signature, Badge Number and Work Location. LPN #3 stated the binder was only for the Garden Hill Unit nursing staff was signed out a gown and or surgical mask on a daily basis and as needed, but no N95s or face shields. Review of the sign out sheets evidenced a gown and or mask was allocated to the nursing staff daily. CNA #2's name was entered on the sheet to have been last issued a mask on 6/16/20. LPN #3 was wearing a personal mask over a yellow surgical mask and stated she was told she did not need to wear a face shield when caring for a suspected or positive COVID-19 resident or when she administered their medications unless their medications involved aerosol treatments. When asked, LPN #3 showed this surveyor where masks were located in the unit's medication room in a locked cabinet. Several yellow surgical masks were in a clear plastic bag and two face shields were on the shelf. LPN #3 stated, I had an N95 about two months ago, but the elastic broke and I could not be refitted for a new one because they did not have my size, but then we were told we didn't need them anyway. During all of the above discussions, two additional nursing staff at the nursing station voluntarily spoke up and added that they were also told no N95s or face shields were necessary to care for suspected or COVID positive residents. The Unit Manager, LPN #2 sat in the corner of the nurse's station desk and did not indicate that she would inquire about appropriate PPE use to provide direct care for suspected and or COVID-19 positive residents on her unit. Resident #1 was admitted to the nursing facility on 10/3/19 with [DIAGNOSES REDACTED]. The resident was diagnosed positive for the COVID-19 virus on 5/15/20. The quarterly Minimum Data Set ((MDS) dated [DATE] assessed the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact with the skills for daily decision making. Resident #2 was admitted to the nursing facility on 10/17/14 with [DIAGNOSES REDACTED]. The resident was diagnosed positive with the COVID-19 virus on 5/26/20. The significant change in status 5 day assessment dated [DATE] coded the resident with short and long term memory problems and severely impaired in the cognitive skills for daily decision making. On 6/26/20 at 12:48 p.m., a debriefing was conducted via phone with the Administrator. All of the above observations, interviews and concerns were shared with her. She stated there was a disconnect somewhere because initially there was a shortage of PPE, but the facility was fully equipped with the necessary PPE to include N95s and face shields. The Administrator said, We follow the Centers for Disease Control and prevention (CDC) and Virginia Department of Health (VDH) guidelines that I emailed to you. It was agreed to talk again after she had an opportunity to investigate the surveyors findings. On 6/26/20 at 4:00 p.m., an interview was conducted with the Administrator, Director of Nursing (DON), Chief Executive Officer (CEO) and Chief Operations Officer (COO). They stated they received supplies from several sources that were stored in the beauty shop and distributed from the supervisor's office to include N95s and face shields. The COO and the CEO stated that if N95s were not used, they expected the nursing staff to use a face shield with a surgical mask in caring for residents that are suspect for or diagnosed with [REDACTED]. The Administrator said when she interviewed LPN #3 on the Garden Hill unit, she told her about her broken N95 mask, the inability to issue one her size, but added she was allergic to the N95s. This information was not relayed to the surveyor at the time of the interview with LPN #3, nor was there a record provided that the LPN had an allergy to N95 mask. Since this was the medication nurse assigned to the COVID positive, if there was a need to wear an N95, this revelation indicated she would never be able wear one if aerosols were ordered for suspected or confirmed COVID residents. During the above interview, the DON stated the physician the staff was referring to instructed the nursing staff that they could wear a surgical mask along with a face shield to care for suspected and COVID positive residents, and to wear an N95 with face shield if administering aerosol treatments. The DON stated she made rounds and saw that staff were wearing the proper PPE to include N95s and or face shields. The DON also stated the sign out sheet for PPE on the units could have meant an N95 was issued while the documents only annotated mask. When asked how she or her designees determine when they issued the aides and nurses their fit tested specific N95s and or face shield, she did not have a definitely timeframe, only to say, They can have one anytime they needed one, especially if it got wet inside, maybe five days. The sign out sheet on the unit indicated a mask was given everyday to the nurses and aides that worked the unit, with the exception of CNA #2 who stated she was issued a surgical mask every three days and was observed on 6/24/20 wearing her surgical mask on and off the unit, as well as leaving for her shift with the same mask on at 3:00 p.m The CEO, COO and DON stated it was not an acceptable practice for CNA #2 to have left out of the COVID area with the same facemask, through other resident areas to exit the facility. The Administrator stated, If the staff is not getting what they need, they were not telling us because the equipment is available. The facility's Policy and procedures titled Optimization Strategies for PPE in Long-Term Care Facilities (LTCFs) dated 4/7/20 indicated relative to surgical facemasks, for any contact with residents in LTCFs with respiratory infection, the health care personnel (HCP) must follow standard, droplet and contact precautions with eye protection. HCP must wear a facemask (unless for aerosol-generating procedure, where a fit tested respirator must be used), eye protection or face shield and gloves. A face shield/goggles/safety glasses to be used during prolonged face-to face or close contact with infectious resident. The VDH and CDC guidelines referred to in this policy indicated the preferred COVID-19 PPE use for HCP was the N95 or higher respirator with face shield or goggles. The acceptable alterative PPE was a facemask with Face shield or goggles. The policy indicated HCP must be fit-tested prior to the initial use of a respirator with the same make, model, style and size respirator that will be used annually after that and whenever a different respirator is used. The QA Action plan dated 4/27/20 indicated that for PUI individuals, full PPE and N95 to be worn until status is known.

Based on observation, staff interview, resident interview, clinical record review, and facility documentation review, the facility staff failed to ensure 8 residents were free from abuse (Residents #118, #161, #69, #120, #167, #20, #368, #95) by two residents (#50, #61) in a survey sample of 46 residents. This resulted in harm to Resident #118. The findings included; 1) For Residents #118, #69, #20, #161, and #120, the facility staff failed to ensure that they were free from abuse by Resident #50. Resident #118's [DIAGNOSES REDACTED]. The Minimum Data Set assessment tool review revealed that Resident #118 was coded as having a Brief Interview of Mental Status Score of 15 out of a possible 15 points indicating no impaired cognition. The Resident was coded as requiring 1 staff member for physical assistance with all activities of daily living, with the exceptions of, eating with set up help only, and the Resident was able to self propel a wheel chair, although, slowly. Resident #50's [DIAGNOSES REDACTED]. The Minimum Data Set assessment tool review revealed that Resident #50 was coded as having a Brief Interview of Mental Status Score of unable to complete indicating severe impaired cognition. The Resident was coded as requiring staff members for physical assistance with activities of daily living, with the exceptions of locomotion off of the unit in a wheel chair, and the Resident was able to self propel a wheel chair, and was coded as needing supervision. On 1-28-2020 at 11:30 a.m., on initial tour of the facility, an observation and interview were conducted with 2 surveyors and Resident #118 in the hallway of the Resident's room. The Resident was sitting in a wheel chair. An activity was being conducted in the dining room area of the unit and Resident #118 was asked by surveyors if she would like to attend. The Resident stated no, I can't do that because (Resident #50's name) is in there and she is mean. Resident #118 was asked if Resident #50 had hurt her in the past, and she stated yes, twice, the first time she pinched me and left a big bruise on my arm, and the second time she grabbed my arms and hit me and left bruises on me. Immediately following the 1-28-2020 11:30 a.m. interview with Resident #118, an interview was conducted with Resident #50's room mate (Resident #53). The room mate stated that Resident #50 did curse and yell at her and the staff, and threatened to Kill staff, but stated that Resident #50 had not hit her, and further stated when she's like that I just stay quiet, and don't say anything, she is sick in the head, you know, you can't get mad at someone acting that way if they are sick in the head. On 1-30-2020 at 3:20 p.m., an interview was conducted with Resident #118. Two surveyors, and the Administrator were present in an open empty dining room. The Resident was asked to tell the Administrator if Resident #50 had hurt her. She stated yes . When asked how many times she had been hurt by Resident #50, she stated Twice, I told (LPN C) the first time when she pinched me, and then the nurses came and saw when she grabbed me the second time. Resident #50's clinical records and facility records were reviewed. On 7-8-19 facility investigation documents revealed Resident #50 wandered into the room of Resident #161, grabbing and hitting Resident #161 inflicting bruises. Note: Residents #161 was not able to be interviewed due to dementia. 8-6-19 Psychiatric physicians notes read Per staff acute worsening of behavior, having difficulties sleeping. Patient aggressive toward peer this morning, entered peer's room. Often sleeps during the day and awakes at night. Agitated attempted to elope during exit. Start [MEDICATION NAME] 0.5 mg (milligrams) for PRN (as needed) aggression with risk of harm to self or others. On 8-6-19 at 3:28 p.m., facility investigation documents revealed Resident #50 wandered down the hall of Resident #118, grabbed and pinched the Resident on the elbow while Resident #118 was gazing outside from the exit door where she liked to sit, inflicting bruises. On 8-6-19 at 3:38 (nursing notes) Resident #50 wandered down the hall of Resident #118 again, and grabbed her arms inflicting bruises. The 2 Resident's rooms are on different halls. The record review showed no other instances of Resident #50 assaulting Resident #118. 8-20-19 Psychiatric physicians notes read Patient has been sleeping poorly, got almost no sleep last night. She's had more episodes of aggressive behavior toward staff and residents in the last week, and these are notably more frequent when she does not sleep well. 9-3-19 Psychiatric physicians notes read Agitated /frustrated because she's tired. She just pierced another resident with a fork for no reason .Close monitoring .as there is no medication even off label that is appropriate. On 9-3-19 facility investigation documents revealed Resident #50 was sitting at the dining table with Resident #69, and attempted to take meat off of Resident #69's plate with a fork. When Resident #69 tried to brush Resident #50's hand away from her plate, Resident #50 pierced her (per doctor's note) with the fork leaving a red mark on Resident #69. Residents #69 was not able to be interviewed due to due to extreme hearing loss and language barrier. 10-22-19 Psychiatric physicians notes read Patient seen wheeling self about loud and hostile difficult to redirect is responding well to PRN (as needed) [MEDICATION NAME] On 10-30-19 facility investigation documents revealed while in an activity, Resident #50 grabbed and hit Resident #20 on the left arm. On 1-29-2020 at 10:00 a.m., an interview was conducted with Resident #20. The Resident was alert, oriented to person, place, and situation. She stated she did remember Resident #50 leaving bruises when she grabbed me, and I was minding my own business in my own room. She came in here. The Resident denied being afraid of Resident #50, however, did state that she stayed out away from (name) Resident #50, so she can't get ahold of me. On 12-10-19 facility investigation documents revealed Resident #50 wandered into the room of Resident #120, and when Resident #120 told her to leave Resident #50 kicked her in the shin causing pain. On 1-29-2020 at 9:30 a.m. an interview was conducted with Resident #120. The Resident was oriented to person, place, time, and situation, and was also found to be a good historian. The Resident stated that Resident #50 wandered daily, and had wandered in her room several times, taking things that belonged to Resident #120. Resident #120 stated that the time she was kicked by Resident #50, she had told her to leave her room, and that Resident #50 kicked her in her sore leg causing pain, but no other injury. Resident #120 stated that Resident #50 (name) yells, curses you out, and beats on staff and Residents both, and if Resident #50 (name) comes back in my room, there's gonna be trouble. Resident #120 was asked what kind of trouble, she stated I will kick her back. Staff interviews on 2 units (staff wished to remain anonymous due to fear of retaliation) indicated that Resident #50 had aggressive behaviors of lashing out at Residents and staff. Nursing staff stated they were told to go to urgent care by Administration if Resident #50 hurt them, and asked if they wanted to press charges, however, the staff chose not to. Staff also stated that the Resident will routinely sleep for 3 days then be up for 3 days. On 1-30-2020 after the 3:20 pm interview (see above), the Administrator joined the surveyors back in the conference room after the interview, and stated that the staff had already placed Resident #50 on 1:1 (one to one) supervision that morning, and it would continue at all times while she was out of bed. The Administrator stated that the Resident needed assistance to get out of bed, and so the only time supervision was required would be when Resident #50 was in her wheel chair. The facility policy entitled Freedom from abuse, neglect, and exploitation was reviewed and revealed at area 6 protection The facility will provide increased supervision of the alleged victim and residents. Room changes or staffing changes will occur if necessary to protect the resident(s) from the alleged perpetrator. On 1-30-2020 at the end of day debrief, the Administrator and DON were notified of the findings for Resident #118. The facility stated they had no further information to provide. 2a. For Resident #167 the facility staff failed to ensure the Resident was free from abuse from Resident #61. Resident #167 was discharged from the facility on 1/15/2020, so a closed record review was performed. [DIAGNOSES REDACTED]. Resident #167's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 1/9/2020 was coded as an annual assessment. Resident #167 was coded as having had a BIMS (brief interview for mental status) score of 15, which indicated cognitively intact. The Resident was also coded on this assessment as having had no behavioral symptoms. Resident #167 required extensive assistance of staff for dressing, personal hygiene and bed mobility. The Resident was totally dependent upon staff for transfers, bathing and toileting. Resident #61 was an active Resident at the time of survey. Resident #61 is Spanish speaking. [DIAGNOSES REDACTED]. Resident #61's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 11/12/2019 was coded as an annual assessment. Resident #61 was coded as having had a BIMS (brief interview for mental status) score of 15, which indicated cognitively intact. The Resident was coded as having required extensive assistance of staff for transfers, dressing, personal hygiene and toileting. On 1/29/2020 the facility staff was asked to provide all FRI's (facility reported incidents) involving Resident #61. Review of these documents revealed that on 9/25/2018 the facility staff were made aware that Resident #61 had assaulted Resident #167 on 9/24/2018. Enclosed in the investigation file was a hand-written letter, signed by Resident #167 that read, yesterday, Mon. 24, Sept. I had an altercation with (Resident #61's). I know you know who that is. As I was entering the dining room to get a seat for Bingo, (Resident #61's) came up behind me, and started pushing my chair and assaulting me with hard blows. I was shocked. I wasn't going to sit at her table, I was just going past it. She even pulled my hair, hard, and continued hitting me! Someone pulled her away and I went on. I think you need to have a talk with her, as I was hurt with the blows and pulled hair. Thanks (Resident #167's signature). The nursing notes in the closed record of Resident #167 revealed an entry on 9/25/2018 that read, Resident states, I was wheeling in the main dining room getting ready for bingo and (Resident #61) started pounding my back and pulled my hair and she hurt me. On 1/31/2020 at 8:50 AM an interview was conducted with the facility Administrator (Employee A) and Assistant Administrator (Employee C) in the Administrator office. When asked who wrote the hand-written letter, Employee C stated Resident #167. On 1/31/2020 at 11:53 AM, the Social Work Supervisor (Employee D) came into the conference room to discuss the incident of abuse towards Resident #167 by Resident #61. Employee D reported that Resident #167 had left the hand-written letter describing the assault under her office door. Employee D stated Resident #167 would frequently write letters when she had concerns. Employee D went on to state, (Resident #167) was pretty upset by having her hair pulled, she said it hurt her. She felt she had done nothing to provoke it. She wanted us to talk to Resident #61 and tell her it wasn't appropriate. She had no lingering pain, just at the time. She denied being fearful of her, and said she just avoided her. The facility investigation revealed that Resident #61 stated, she did hit (Resident #167's) because she took a bingo card. Further review of FRI's regarding Resident #61 revealed Resident #61 had displayed prior aggression toward other Residents prior to the assault of Resident #167. 2b. For Resident #20 the facility staff failed to ensure the Resident was free from abuse from Resident #61. Resident #20 was an active Resident of the facility at the time of survey. [DIAGNOSES REDACTED]. Resident #20's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 10/24/2019 was coded as a quarterly assessment. Resident #20 was coded as having had a BIMS (brief interview for mental status) score of 14, which indicated cognitively intact. The Resident was also coded on this assessment as having had no behavioral symptoms. Resident #20 required limited assistance of staff for bed mobility, dressing, toilet use, and personal hygiene. On 1/29/2020 the facility staff was asked to provide all FRI's (facility reported incidents) involving Resident #61. Review of these documents revealed that on 6/18/2019 Resident #20 came to the dining room, sat at the table, Resident #61 got upset and intentionally knocked the cup of coffee over onto Resident #20. Included in the documents the facility provided was a witness statement that read, she (Resident #20) went into the dining room and proceeded to sit at the table with (Resident #61's). (Resident #61's) became very mad and agitated, shook the table, yelling at Resident. (Resident #20's) sat her coffee on the table and (Resident #61's) intentionally hit it and knocked it over onto (Resident #20's) lap. (Resident #20's) yelled out, you knocked over my coffee, it's hot. Facility record review also revealed a two-page hand written note dated 6/25/2019 titled Psychiatry, which read, Staff has updated me on recent events- last week throwing cup of hot coffee on another resident for no reason then laughing about it. Patient is known to me since admission and above behaviors resulting in harm to others is not new. She has never shown any remorse. When her wants/needs are not immediately met, she acts out. Resident #20 was assessed by nursing staff and not noted to have any injury as a result of Resident #61 knocking coffee into her lap. The facility had taken the temperature of the coffee prior to it leaving the kitchen and being delivered to the nursing unit. Resident #61 was presented a behavioral contract as a result of this incident, which included not eating meals at the table with other Residents. 2c. For Resident #368 the facility staff failed to ensure the Resident was free from abuse by Resident #61. Resident #368 was discharged from the facility on 12/7/19, therefore a closed record review was performed. [DIAGNOSES REDACTED]. Resident #368's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 10/10/2019 was coded as a quarterly assessment. Resident #368 was coded as having had a BIMS (brief interview for mental status) score of 4, which indicated severe cognitive impairment. The Resident was also coded on this assessment as having had no behavioral symptoms. Resident #368 required limited assistance of staff for dressing, toilet use, and bed mobility. The Resident was totally dependent upon facility staff for bathing and required extensive assistance with personal hygiene. On 1/29/2020 the facility staff was asked to provide all FRI's (facility reported incidents) involving Resident #61. Review of these documents revealed that on 5/6/18 Resident #61 started yelling at Resident #368, when Resident #368 walked over to Resident #61, Resident #61 kicked her on the leg. A witness statement was included in the documents from a staff member (not identified) who witnessed the altercation. After Resident #61 kicked Resident #368, Resident #368 hit Resident #61 with a plastic spoon and then Resident #61 grabbed the shirt of Resident #368 before staff could intervene. Resident #61 was educated as a result of this incident of abuse towards Resident #368. Following the end of day meeting held on 1/31/2020 the facility staff provided the survey team with a color coded copy of the HEAR (health, environment, approach, resident) document where they discussed interventions for Resident #61's behaviors and aggression/abuse towards other residents. Following the abuse inflicted on Resident #368 on 5/6/18, the following entry was made on this document: different seating arrangement for her to protect others- we need to protect others from her because she becomes physically violent. 2d. For Resident #95 the facility staff failed to ensure the Resident was free from abuse from Resident #61. Resident #95 was an active Resident of the facility at the time of survey. [DIAGNOSES REDACTED]. Resident #95's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 12/2/2019 was coded as a quarterly assessment. Resident #95 was coded as having had a BIMS (brief interview for mental status) score of 14, which indicated cognitively intact. The Resident was also coded on this assessment as having had no behavioral symptoms. Resident #95 required extensive assistance of staff for all ADL's (activities of daily living), with the exception of bathing, in which the Resident was totally dependent upon staff. Review of nursing notes revealed an entry on 7/31/19 that indicated Resident #95 and Resident #61 were observed hitting each other. The FRI prepared by the facility staff described the incident in more detail and stated, On 7/31/19 at approximately 1:25 PM Resident #61 became physically and verbally aggressive with (Resident #95's). (Resident #61) pushed another Resident's wheelchair out of her way but made no physical contact with the Resident. (Resident #61's) then struck (Resident #95) with her fists on his arms. This report further states that the two Residents began hitting each other and staff intervened. The community services board was contacted and recommended the facility contact the police for Resident #61's behavior. However, the facility chose not to carry out this recommendation and stated, Resident's behavior was calm immediately following the incident. Facility records revealed a letter dated 8/7/19 to Resident #61's son, with a copy being given to the Resident and other son as well. The letter stated, (facility name redacted) has determined we can no longer meet her needs. In addition, we have determined that (Resident #61's) behavioral status continues to endanger the health of other in the facility. Nursing notes revealed an entry dated 8/12/19 that read, Staff witnessed Resident getting too close to Resident #61, who yelled at him (referring to Resident #95), and both Resident's observed hitting each other on the arms. The facility investigation revealed the following details: Resident #61 was sitting at the nursing station when Resident #95 wheeled by, Resident #61 started yelling at him. Resident #95 yelled back and swung to hit Resident #61 and both started hitting each other. On 1/31/19 an interview was conducted with Resident #95 regarding the relationship with Resident #61. Resident #95 indicated they don't get along. The facility investigation file revealed that on 10/16/19 Resident #95 reported to the facility social worker there was a personality conflict between the two. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation read on page 1 under the definition heading, abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. 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 or harm. Page 4 of this policy under the heading prevention read, (facility name redacted) will prevent verbal, mental, sexual or physical abuse. Page 5 read, (facility name redacted) will maintain protocols and procedures to identify, correct and intervene in situations in which abuse, neglect, mistreatment and/or misappropriation of resident property is more likely to occur. During an end of day meeting held on 1/30/2020 the facility Administrator, Director of Nursing and Assistant Administrator were made aware of the concerns surrounding Resident #61's behaviors towards other Residents. No further information was provided.

Based on observation, interview, clinical record review, and facility documentation the facility staff failed to implement care plan for 2 Residents #3 and #147 in a survey sample of 46 Residents. The findings included: 1. For Resident #3 the facility staff failed to develop a person centered care plan to address contractures to the Left hand. Resident # 3, a [AGE] year old man, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/28/20 at 11:00 AM, the Resident was observed in his room lying in bed with no orthotics in his Left hand which was also contracted. On 1/29/20 at 9:00 AM, the Resident was observed in his room lying in bed, Left hand contracted, and without orthotic. On 1/28/20 at approximately 2:30 PM, an interview was conducted with RN A, and she was asked if Resident #3 wore any sort of orthotics for contractures. RN A responded that he did not. On 1/29/20 review of clinical record reveal the care plan did not reflect the past use of palm guards and did not address the use of orthotics or devices for prevention or treatment of [REDACTED]. On 1/29/20 at 4:30 PM, an interview was conducted with the Director of Nursing (DON). When asked about Resident #3 wearing orthotic for contracture she stated that she was not sure but would have PT/OT look at him. On 1/30/20, the DON submitted Interdisciplinary Therapy Data Collection Form. Excerpts from the form are as follows: Contractures - No recent changes per patient. Comments - Patient screened per nursing request for hand contractures and possible palm guards. Patient reports not liking palm guards in the past and doesn't wish to have them. Patient stated he would like to have a ball (therapy ball). Patient will benefit from OT eval to determine appropriate orthotics. On 1/31/20 during end of day meeting the Administrator was made aware of concerns no further information was provided. 2. For Resident #147 the facility staff failed to implement the care plan for use of 2 person assistance for turning and repositioning. Resident #147 an [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #147's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 12/27/19 the Resident was coded as having a BIMS (Brief Interview of Mental Status) score of 99 indicating severe cognitive impairment. Resident #147 was also coded as requiring 2 person assistance for bed mobility turning and positioning. The resident was also coded as requiring 1 person physical assistance for bathing, dressing, eating as well as locomotion on and off the unit using a wheel chair. On 1/30/2020 at 10:30 am this surveyor observed RN a performing wound care on Resident #147. The resident was in bed dressed with blanket over her. RN A gathered her supplies and placed them on the clean over bed table, on top of a disposable absorbent pad. RN A closed the door and pulled the privacy curtain before raising the bed to a comfortable working height (about waist high) RN A positioned Resident to be able to observe heel wound, right foot first. RN A then turned Resident towards the window onto her left side as to observe the sacrum area. RN A did not engage the assistance of another person. The Resident has no order for side rails on her bed and RN A was standing on the side of the bed facing the Residents back. On 1/30/20 during a clinical record review it was discovered that Resident #147's care plan read as follows: FOCUS: I am at risk for falls related to impaired cognition, impaired mobility, and impaired safety awareness. Date initiated - 7/3/19 Goal: I will not have any fall related injuries Date initiated - 7/3/19 Interventions: After care make sure resident is in center of bed not too close to edge Date initiated - 7/3/19 Provide assistance of two with bed mobility and repositioning. Date initiated - 7/3/19 On 1/30/20 at 4:34 PM an interview with the DON was conducted and she stated that the care plan was correct, Resident #147 requires 2 person physical assistance for turning and repositioning. The DON said There should have been someone standing on the other side of the bed. When asked why she replied For safety, to prevent her falling out of the bed. On 1/31/20 during end of day meeting the Administrator was made aware of concerns no further information was provided.

Based on observation, staff interview, and clinical record review, the facility staff failed to mitigate accident hazards for one resident (resident #147) in a survey sample of 46 residents. The findings included; For Resident #147 the facility staff failed to provide interventions to prevent accidents. Resident #147, an [AGE] year old woman, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 147's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 12/27/19 the Resident was coded as having a BIMS (Brief Interview of Mental Status of 99 indicating severe cognitive impairment. Resident #147 was also coded as requiring 2 person assistance for bed mobility turning and positioning. The resident was also coded as recurring 1 person physical assistance for bathing, dressing, eating as well as locomotion on and off the unit using a wheel chair. On 1/30/2020 at 10:30am, this surveyor observed RN A performing wound care on Resident #147. The resident was in bed dressed with blanket over her. RN A gathered her supplies and placed them on the clean overbid table, on top of a disposable absorbent pad. RN A closed the door and pulled the privacy curtain before raising the bed to a comfortable working height (about waist high) RN A positioned Resident to be able to observe a heel wound RN A then turned Resident towards the window onto her left side as to observe the sacrum area. RN A did not engage the assistance of another person. The Resident has no order for side rails on her bed and RN A was standing on the side of the bed facing the Residents back. On 1/30/20 during clinical record review it was discovered that Resident #147's care plan read as follows: FOCUS: I am at risk for falls related to impaired cognition, impaired mobility, and impaired safety awareness. Date initiated - 7/3/19 Goal: I will not have any fall related injuries Date initiated - 7/3/19 Interventions: After care make sure resident is in center of bed not too close to edge Date initiated - 7/3/19 Provide assistance of two with bed mobility and repositioning. Date initiated - 7/3/19 On 1/30/20 at 4:34 PM an interview with the DON was conducted and she stated that the care plan was correct, Resident #147 requires 2 person physical assistance for turning and repositioning. The DON said There should have been someone standing on the other side of the bed. When asked why she replied For safety, to prevent her falling out of the bed. On 1/30/20 the Administrator was made aware of the concerns and no further information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to properly secure active prescriptions for controlled substances on one of three units (neighborhoods). The findings included: On 01/30/2020 at approximately 2:20 PM, this surveyor approached the nurse's station and requested the hard chart clinical record for Resident #50. A facility nursing staff member was unable to locate the hard chart and stated she would look for it. Within approximately 10 minutes time, the facility staff confirmed the hard chart was in the MDS office and provided the hard chart to this surveyor. While reviewing Resident #50's hard chart clinical record, an active prescription dated 10/22/2019 for [MEDICATION NAME] 0.5 mg (75 tablets, 4 refills) was observed in the hard chart in a plastic sleeve. The handwritten prescription contained the Resident #50's name; the physician's name, DEA number, and signature. There were no marks on the prescription to indicate it had already been filled. On 01/30/2020 at approximately 2:35 PM, an interview with Licensed Practical Nurse B (LPN B) was conducted. When asked about the process for handing of prescriptions, LPN B stated when a physician writes a prescription (from their prescription pad), the prescription gets faxed to the pharmacy and then the original prescription is placed in the pharmacy bag to go to the pharmacy. This surveyor requested to see the pharmacy bag. LPN B and this surveyor observed 2 unsealed plastic bags in a letter holder mounted on the wall behind the nurse's station. A quick glance in the bag revealed there were prescriptions for controlled substances that were not voided or marked as already being faxed to the pharmacy. When asked why it would be important to store active prescriptions in a secure (locked) area, LPN B stated So that they can't be taken to another pharmacy and filled. When shown the active prescription for [MEDICATION NAME] in Resident #50's hard chart, LPN B removed the prescription from the hard chart and stated that it shouldn't be there. On 01/30/2020 at approximately 2:50 PM, the administrator and DON were notified of findings and the DON stated the prescriptions should have been locked in the med room. On 01/31/2020 at approximately 12:45 PM, the DON provided contact information for their pharmacist consultant, Employee F. The facility staff also provided a copy of all the contents of the 2 unsealed pharmacy bags. Of the 56 documents in the bags (collectively), there were 14 active prescriptions handwritten from provider prescription pads. All medications on those 14 active prescriptions were either Schedule II, IV, or V controlled substances including [MEDICATION NAME], and [MEDICATION NAME]. On 01/31/2020 at approximately 12:55 PM, a telephone interview with Employee F was conducted. When notified an active prescription for [MEDICATION NAME] was observed in a resident's hard chart and active prescriptions were located in unsealed bags at the nurse's station, Employee E stated, They should be secured. A copy of facility policy on handling of prescriptions and controlled substances was requested and the facility staff provided a copy of their policy entitled, LTC (long-term care) Facilities Receiving Pharmacy Products and Services from Pharmacy. Under the header, Applicability it was documented, This policy 4.2 sets forth procedures relating to new orders for Schedule II controlled substances. The policy did not address the secure handling of active prescriptions.

Based on interview clinical record review and facility documentation the facility staff failed to ensure PRN Anti Anxiety medication was limited to 14 days for 1 Resident (#62) in a survey sample of 46 Resident. The finding include: For Resident # 62 the facility staff failed to ensure the PRN use of [MEDICATION NAME] was for 14 days. Resident #62 a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date of 12/9/19 coded as a significant change. Resident was coded as having a BIMS (Brief Interview of Mental Status) score 0 indicating severe cognitive impairment. On 1/31/20 resident was selected for Unnecessary Medication Review and during clinical record review it was discovered that Resident # 62 had an order for [REDACTED]. Resident had the following orders for [MEDICATION NAME] ([MEDICATION NAME]): [MEDICATION NAME] concentrate 2 MG (Milligrams) / ML (Milliliter) - Give 0.5 ml by mouth every 4 hours as needed for Anxiety Start Date - 12/1/19 - D/C Date 12/27/19 On 1/31/20 an interview was conducted with the DON who stated that she didn't know the Resident's order was for longer than 14 days. On 1/31/20 DON provided copy of the pharmacy review that read as follows: Recommendation date 12/7/19 Comment: (Resident name redacted) has a PRN order for an anxiolytic without a stop date [MEDICATION NAME] ([MEDICATION NAME]) Recommendation: It continued greater than 14 days, current regulation require that the prescriber document the indication for use, the intended duration of therapy, and the rationale for the extended time period. Rationale for Recommendation: CMS requires that PRN orders for non-antipsychotic, [MEDICAL CONDITION] drugs be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period and the duration of the PRN order. Physician Response: (box checked) I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Pt under hospice care now. - (physician signature redacted) - 12/23/19 Resident #62 was placed on hospice 12/23/19. On 1/31/20 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to follow physician orders [REDACTED].#166) in a survey sample of 46 residents. The findings included: For Resident #166, the facility staff failed to administer low blood pressure medication ([MEDICATION NAME]) as scheduled. Resident #166, a [AGE] year old male, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. On 01/30/2020, a clinical record review was conducted for Resident #166. Physician orders [REDACTED]. Doses were scheduled to be given at 9:00 AM and 6:00 PM every day. A Weights and Vitals Summary and a Medication Administration Audit Report for the month of January 2020 was requested and provided by facility staff. Review of these documents for Resident #166 revealed the following: 01/14/2020, time scheduled 9:00 AM and 6:00 PM, no blood pressure readings, no [MEDICATION NAME] administered 01/15/2020, time scheduled 9:00 AM, no blood pressure reading, no [MEDICATION NAME] administered On 01/31/2020 at approximately 11:30 AM, the Director of Nursing (DON, Employee B) was interviewed and stated, (Resident #166) receives [MEDICATION NAME] to increase his low blood pressure, a blood pressure reading is necessary to be able to assess whether or not the [MEDICATION NAME] should be given, I have reviewed his (Resident #166) records and found that the nurses failed to document vital signs as ordered on January 14th and 15th, (Resident #166) could experience dizziness and low blood pressure if not treated properly with the [MEDICATION NAME], the doctor would not be able to review his vital signs and adjust his treatments as needed, and there is no way to validate the clinical decision that was made by the nurse with regard to administering or holding the [MEDICATION NAME], we will be re-educating these nurses. Review of the facility's policy entitled, 6.0 General Dose Preparation and Medication Administration (revision date 01/01/13), under subheading Procedure, item 6.1 read, Document necessary medication administration/treatment information. On 01/31/2020 at approximately 12:45 PM, the Facility Administrator (Employee A) and Director of Nursing (Employee B) were informed and no further information was received.

Based on observation, clinical record review, and facility documentation review, the facility staff failed to ensure privacy and confidentiality of resident clinical records for 1 resident (Resident #99) in a sample size of 46 residents. Findings included. For Resident #99, the facility staff left the Resident's protected health information on top of the medication cart unattended while LPN D was in a resident room at the end of a hallway rendering care to a resident. Resident #99 was admitted with [DIAGNOSES REDACTED]. On 1-28-2020 during initial tour of the facility, documents were observed on a medication cart with no attendant. The documents were picked up and reviewed, revealing chest x-ray results, new physician's orders [REDACTED].#99. Also found in the documents was a form with every resident name and room number on the hallway, to include diagnoses, diets, allergies [REDACTED]. The surveyor waited at the cart for approximately 10 minutes and asked another nurse who eventually approached if he was responsible for the medication cart, and he stated no, and supplied the surveyor with the name of the nurse responsible (LPN D) Licensed Practical Nurse. LPN D finally returned to the cart and stated she had been assisting a resident and knew she should not have left the documents open and available to view. Copies of the documents were provided by her to surveyors. During the end of day debriefing on 1-29-2020 at 4:30 p.m., the Administrator, and Director of Nursing were informed of the findings. No further information was provided by the facility.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to review and revise the careplan for 2 Residents (Resident #61, #24) in a survey sample of 46 Residents. The findings included: 1. The facility staff failed to review and revise the careplan for Resident #61 following 7 altercations with other Residents. Resident #61 was an active Resident at the time of survey. Resident #61 is Spanish speaking. [DIAGNOSES REDACTED]. Resident #61's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 11/12/2019 was coded as an annual assessment. Resident #61 was coded as having had a BIMS (brief interview for mental status) score of 15, which indicated cognitively intact. The Resident was coded as having required extensive assistance of staff for transfers, dressing, personal hygiene and toileting. Review of the clinical record revealed the following incidents related to Resident #61: 1. 5/16/2018 Resident #61 yelled at Resident #368 and kicked her leg. 2. On 9/24/2018 Resident #61 assaulted Resident #167, pulled the Resident's hair and hit them. 3. On 11/3/2018 Resident #61 yelled at Resident #369 and hit them on the head, then kicked their wheelchair. 4. 6/18/2019 Resident #61 knocked coffee onto the lap of Resident #20. 5. On 7/31/2019 Resident #61 was physically and verbally aggressive with Resident #95. 6. On 8/12/2019 Resident #61 and Resident #95 had another altercation resulting in both Residents hitting each other. 7. On 10/13/2019 Resident #95 ran over Resident #61's toes with the wheelchair and Resident #61 slapped Resident #95 several times. Review of the careplan for Resident #61 revealed the following: * The behavioral careplan was initiated on 10/29/2016 * From the time of 5/16/2018-10/13/2019 (dates of the above referenced incidents) the careplan had the following intervention revisions: 1. Staff to intervene when Resident because upset and yelling (sic) when another resident sits at her table. Staff will be calm and ask resident to calm down or we need to sit at another table. Give emotional support. This was initiated 12/15/2017 and revised on 5/30/2018. 2. Minimize disruption/changes to Resident's environment and routine was initiated 5/29/2019. 3. Resident and family presented with behavioral contract with facility expectations that resident cannot hurt self or others. Also, resident presented with alternate dining choices but is no longer dining at group tables, was imitated on 8/14/2019, despite the behavioral contract being issued 6/18/2019. The facility investigation files and Behavioral Management Plan for Resident #61 revealed the facility had consulted psychiatry for Resident #61, issued a discharge notice, attempted to avoid Resident #61's contact with specific Residents, called the Community Services Board to attempt to obtain psychiatric in-patient treatment, assist Resident's with maneuvering in the dining to prevent contact, and considered a private room. However, none of these interventions were noted in the clinical record for Resident #61. On 1/31/2020 at 11:18 AM an interview was conducted with RN A. RN A was asked to describe what a careplan is and it's use. RN A stated, the careplan is when the resident and family gets with IDT (interdisciplinary team) to discuss goals and what the plan of care will be. Everyone should use them to see how they want to be called, what treatment is needed, special needs, it drives the care. RN A was asked what the importance of the careplan being current was, RN A stated, safety, satisfaction and well-being. On 1/31/2020 at 11:21 AM an interview was conducted with CNA A. She was asked if she has access to the careplan, what it is for, if she uses it, etc. CNA A stated, I do have access, right here (and showed the surveyor on the computer she was using). It tells me what they like, don't like, resident care, splints, etc. CNA A was asked if it is important for her to use the careplan, CNA A stated, yes, I don't want to walk in not knowing what to do. I look at them everyday. On 1/31/2020 at 11:26 AM an interview was conducted with CNA B. CNA B stated, I am just prn (as needed) the careplan tells me how to transfer the Resident, what they need. CNA B was asked how often she looks at the careplan for Residents. CNA B stated, I look at it anytime I come to work, I look at the Kardex, it is important, we have to look at it day by day for what we are capable of doing for the Resident. Review of the facility policy titled Care Planning revealed the following: Each Resident will have a comprehensive, person-centered care plan developed to identify resident's care needs and goals for care. Page 3 of the policy stated, the comprehensive careplan will be reviewed and revised by the IDT after each assessment, including comprehensive and quarterly review assessments. The facility Administrator and Assistant Administrator were made aware of the facility staff's failure to review and revise the careplan for Resident #61 following incidents with other Residents during a meeting held in the Administrator's office the morning of 1/31/2019. No further information was provided. 2. For Resident #24, the facility staff failed to revise the care plan to include the ROHO wheelchair cushion. Resident #24's [DIAGNOSES REDACTED]. Resident #24's most recent Minimum Data Set with an Assessment Reference Date of 10/23/2019 was coded as a significant change in status assessment. The Brief Interview for Mental Status was coded as 99 meaning an incomplete interview. Cognitive skills for Daily decision-making were coded as severely impaired. Transfers and locomotion on unit were coded as total dependence on staff. Mobility device selected was wheelchair. During the course of the survey, fall investigations for Resident #24 were requested and the facility staff provided two investigations dated 09/23/2019 and 11/10/2019. On the fall investigation document dated 09/23/2019 under the header Staff/Other Interviews it was documented that Resident #24 was calm and sitting in dining area. Under the subheader, Did you see or hear anything that may have resulted in the resident's fall?, it was documented, Yes, she slipped. Under the header Investigation Findings/Conclusions and subheader Action/Behavior/Reason for fall, it was documented Related to resident behavior possible wheelchair cushion. Under the sub-header Specific Action (s) Taken to Minimize Recurrence, it was documented, PT/OT (physical therapy/occupational therapy) to eval (evaluate) and treat, possible wheelchair cushion replacement. An excerpt of a physical therapy Treatment Encounter note dated 09/24/2019 under the header Summary of Skill documented, Pt (patient) fitted for new cushion post fall yesterday. The fall investigation dated 11/10/2019 was reviewed. Under the header Witnessed Fall it was documented, no. Under the header Staff/Other Interviews and sub-header What was the resident doing at the time of the fall? it was documented, sitting, at the dining room. (sic). Under the header Known Risk Factors, the option poor trunk control was selected. Under the header, Environmental/Situational Conditions .that may have impacted this fall, the options Unsafe positioning in bed/chair and attempting to reach for fluid/food were selected. Under the header Investigation Findings/Conclusions and subheader Action/Behavior/Reason for fall, it was documented, Res (resident) slipped out of w/c (wheelchair) on hoyer lift sling in sitting position in front of w/c (cushion thick on chair may be cause of sliding out of wheelchair). Under the sub-header Specific Action (s) Taken to Minimize Recurrence, it was documented, PT (physical therapy) to assess w/c cushion for safety. An excerpt of an occupational therapy Treatment Encounter note dated 11/11/2019 under the header Summary of Skill documented, Pt (patient) encountered sitting in WC (wheelchair) with pt daughter at table; pt daughter noted concerns about new WC cushion firmness slippery texture of hoyer sling; OT (occupational therapy) informed daughter that gel wedge cushion and counter 2 chambered ROHO cushion ordered for trial to inc (include) pt WC positioning. Rolled towel placed at pt L (left) side in WC to inc posture. On 01/31/2020 at approximately 11:30 AM, an interview with Registered Nurse B (RN B) was conducted. When asked about Resident #24's wheelchair cushion, RN B stated that therapy staff had trialed wheelchair cushions and found that the ROHO cushion was best. When asked if she would expect to see that on the care plan, RN B stated that she would put it on the care plan so staff would know. RN B and this surveyor observed the care plan on the electronic health record. RN B confirmed there were no interventions associated with use of the ROHO wheelchair cushion as recommended by therapy. RN B stated that she would update the care plan now. On 01/31/2019 at approximately 12:00 PM, an interview with Employee E, Therapy Program Manager, was conducted. When asked about therapy recommendations for Resident #24's wheelchair cushion, Employee E stated that Resident #24 started using the ROHO cushion on 12/02/2019 and the staff was in-serviced on 01/08/2020 regarding management of ROHO cushion. Employee E provided a document dated 01/08/2020 entitled, Inservice Training Sign-In Sheet. Under the header, Topic, it was documented ROHO Cushion Management. Under the header, Training Objectives, it was documented, 1. Management of ROHO Cushion 2. Storage of pump in tx (treatment) cart or decided location 3. Schedule to check cushion pressure 1x/wk (once a week) on shower day. A physician's order dated 01/10/2020 under the header Order Summary documented, REHAB orders: check pt WC (patient wheelchair) cushion for air pressure before placing pt in WC. A copy of the updated care plan was requested and the facility provided a copy. A care plan focus initiated on 09/12/2016 entitled, AT risk for injury from falls r/t (related to) impaired mobility, [MEDICAL CONDITION](history of [MEDICAL CONDITION]) w/right (with right) side weakness/[MEDICAL CONDITION] . was reviewed. An intervention associated with this focus initiated on 01/31/2020 documented, Resident is out of bed into wheelchair with a roho cushion. The facility staff provided a copy of their policy entitled, Care Planning. Under the header Policy Statement, it was documented, Each resident will have a comprehensive, person-centered care plan developed to identify resident's care needs and goals for care. In summary, the care plan was not revised to include the implementation of ROHO wheelchair cushion as recommended by therapy and summarized in physician's orders. On 01/31/2020 at approximately 1:00 PM, the administrator and DON were notified of findings. The DON stated that the care plan should have been updated.

Based on observations, record review and staff interviews, the facility staff failed to provide the necessary preventative measures to prevent multiple acquired pressure ulcers for one resident (#156) in the survey sample of 42 residents. The facility failed to continue previous physician orders [REDACTED].#156 upon readmission from the hospital to the facility. Subsequently the resident developed a stage II pressure ulcer to his heel. The facility further failed to implement measures to prevent multiple toe pressure ulcers. The findings included: Resident #156 was admitted on [DATE] and re-admitted to the facility on [DATE]. Resident #156 was admitted to the facility with the following [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set ((MDS) dated [DATE] indicated the following: In the area of hearing, speech and vision this resident was assessed as having moderate difficulty hearing, rarely makes self understood, rarely understands others, has moderately impaired vision. In the area of Brief Interview for Mental Status (BIMS) this resident was unable to answer questions. In the area of cognitive patterns this resident was coded as having long and short term memory problems. In the area of activities of daily living (ADL'S) this resident was assessed being total dependent in the areas of bed mobility, transfer, dressing, eating, toilet use and personal hygiene. In the area of bladder and bowel this resident was assessed as always incontinent. In the area of nutritional status this resident assessed as having a mechanically altered diet and receives a therapeutic diet. In the area of skin assessment this resident was assessed as having no risk for pressure ulcer. In the area of current number of unhealed pressure ulcers at each stage was un-assessed. In the area of healed pressure ulcers on the prior assessment this area was un-assessed. In the area of skin and ulcer treatments this resident was assessed for pressure reducing device for chair, pressure reducing device for bed and applications of ointments/medications other than feet. A revised care plan dated 10/23/17 indicated: Focus- Resident #156 is at risk for skin breakdown due to IDDM (insulin dependent diabetes mellitus), lower extremity, [MEDICAL CONDITION], venous stasis, history of [DIAGNOSES REDACTED] (removed) to left forearm impaired mobility incontinence use of Aspirin Daily. Goal: - Resident #156 risk for skin integrity impairments will be minimized this review period. Interventions- Supplements per MD orders -see MAR (medication administration record) date initiated 12/05/16. APM (alternating pressure mattress) mattress to bed date started 10/23/17. Apply lotions/creams as ordered-see TAR (treatment administration record) date initiated 12/05/16. Diabetic Management as ordered (See TAR/MAR) date initiated 12/05/16. Encourage/Assist resident to consume all fluids and meals offered on trays document meal intake daily. Float heels using skill care heel boots date initiated 12/05/16. Monitor feet daily when assisting with removing shoes for proper fit. Notify family if new shoes are needed date initiated 12/05/16. Monitor for increased s/sx (signs and symptoms) of [MEDICAL CONDITION], encourage to elevate lower extremities, notify MD of changes. Monitor skin daily with AM/PM incontinence Care for breach in skin integrity. Notify nursing/MD of abnormals, date initiated 12/05/16. Treatments per orders and wound nurse eval (evaluate) as needed date initiated 12/15/17. Head to toe Skin assessment weekly date initiated 12/05/16. Float heels using skillcare heel boots, date initiated 12/05/16. Focus: Alteration in Comfort: requires pain monitoring due to inability to make his pain needs known to staff. Goal - will maintain adequate level of comfort - no verbal or non verbal s/sx of pain for discomfort. Interventions-monitor for non verbal s/sx of pain guarding, tearfulness, restlessness, moaning, agitation, frowning. A physician's orders [REDACTED]. Pressure reduction mattress to bed every shift. Weekly head to toe skin assessment. Document in progress notes and skin assessment every evening shift every thur document findings in skin assessment. A review of the orders after re-admission (12/14/17) did not include previous orders to float heels using skill care heel boots or heel manager while in bed or geri chiar/wheelchair with assistance every shift. During an interview on 3/4/18 at 10:06 A.M. with the Wound Nurse and Unit Manager, both acknowledged that the order was not continued after the resident was readmitted on [DATE]. The Treatment order for (MONTH) indicated: Float heels using skill care heel boots or heel manager while in bed or geri chair/wheelchair with assistance every shift, discontinue date 12/14/17. Review of a Wound Evaluation Flow Sheet identified a new pressure area as follows: Right medial heel found 1/30/18, Measurements (CM) centimeters L =3- W=3.5, Exuade -none, Wound Bed - Pain (no), Tissue type, intact fluid filled blister, Periwound - closed, surrounding tissue intact. A Guide for Wound Evaluation and Documentation form identified Pressure Ulcer- Definitions and Stages: Stage II Clinical- partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. *This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates suspected deep tissue injury. The (MONTH) (YEAR) treatment order indicated: Weekly head to toe skin assessment. Document in progress notes and skin assessment every evening shift every Thur (Thursday) document findings in skin assessment. Pressure reduction mattress to bed. Remove and replace skillcare boots Q (every) shift to monitor skin integrity every shift, start date 01/30/2018. Skillcare heel Protector boots on while resident is in bed. Use with foam anti-rotation devices to elevate heels and for positioning monitor placement Q shift every shift, start date 1/30/18. A 12/19/17 Wound Progress Note signed by the Wound Nurse indicated: Feet are clear, heels are reddened but blanch, resident tends to press his heels together. Has heel manager to float heels and has had good results. A 1/29/18 Physician's Telephone order indicated: Cleanse intact blister to (R) right heel with NS (normal saline) pat dry with gauze, apply skin prep over blister surface and treat surrounding skin. Apply transparent film over area. Change Q 7 days and PRN. A 1/30/18 Physician's Telephone order indicated: Skill care heel protector boots on while resident in bed. Use with Foam anti-rotation devices to elevate heel and positioning monitor placement Q shift. Remove inplace Q shift to monitor skin integrity. A Braden Scale for predicting Pressure Sore Risk was completed on the following dates, all assessing the resident for being moderately at risk for pressure sores: 12/14/17 12/21/17 12/28/17 01/04/18 2/25/18 Facility Weekly Skin Checks indicated the following: 12/01/17 - Skin intact. 12/08/17 - Skin intact, localized scattered redness to left hip, monitoring in progress. 12/21/17 - Open area to R antecubital and L anterior shoulder. 12/28/17 - No new areas 01/04/18 - No new areas 01/12/18 - Scars to R antecubital and l shoulder 01/19/18 - Scars visible to Rt. antecubital and Lt. shoulder 01/26/18 - No new findings on the skin A review of the Facilities Shower and Bed Bath Schedule and monitoring from 12/14/17 through 02/28/18 did not indicate Resident #156 was found with pressure areas. A Pressure Ulcer Investigation dated 1/30/18 indicated: Resident name, [DIAGNOSES REDACTED]. Location- Right med (medial) heel - Stage II. Was Risk Assessment completed prior to development of pressure ulcer? (Yes- 1/4/18). Were treatment and interventions implemented based on identified risk factors? (Yes) Does the record contain physician documentation regarding the presence of and/or change in the pressure ulcer? (this area was blank) Resident has been identified at risk for pressure ulcers related to the following factors/conditions: Urinary incontinence, poor nutrition (Dx (diagnosis) of partial malnutrition), impaired mobility, extensive assistance bed mobility and/or transfers, Has current ulcer - contracture- feet, unable to change position or shift weight in chair, [MEDICAL CONDITION] disease, diabetes, spasms, tremors, involuntary movements, Others Pulls feet together. Current Treatment and Interventions include: assist with turning/positioning, peri-care as needed, administer medications as ordered, administer nutritional supplements, encourage/provide good nutrition, encourage/provide good hydration, use of pillows or other cushioning devices, pressure relieving device in bed, weekly skin or body audits, float heels, elbow/heel protectors. Probable Causative Reasons for Development -Immobility, friction/pressure- Resident crosses clamps legs together. Recommendations: Skill care boots while in bed with anti rotator devices to further elevate heels and position legs and feet. During an interview on 3/5/18 at 3:15 P.M. with the Wound Nurse and Administrator they were asked what interventions were in place to prevent Resident #156 from rubbing his heels together. The Wound Nurse and the Administrator both stated, heel boots and a pillow to go between his legs. When asked for supporting treatment records none was presented to the survey team prior to 1/30/18. A 1/30/18 Progress note signed by the wound nurse indicated: Assessed (R) medial heel after report of blister observed on resident. Raised, intact, clear fluid filled blister measures approx. 3 X 3.5 cm, Transparent film in place. No indication of pain. Resident's feet were floated, however has been observed to clamp his feet together, pillows used to separate his legs. Placed feet in Skilcare boots to protect heels, also placed anti-rotation for positioning purposes. Primary nurse present. Further review of Facility Weekly Skin Checks indicated: 02/02/18 - No new issues scars to Rt. antecubital and Lt shoulder remain visible 02/09/18 - No new findings 02/16/18 - No new findings 02/23/18 (at 19:18 or 7:18 P.M.) - Reddened areas on toes and feet 02/23/18 (at 20:13 or 8:13 P.M.) - Reddened area on resident feet. Toes and in between toe. Especially on the right foot A wound evaluation sheet dated 2/22/18 documented: Right great toe tip - measurements - L = 0.6 - W = 0.3, Exuade - none, Wound Bed - pain (no), Tissue type (blank), Periwound - closed, surrounding tissue intact. Right 2nd toe top -measurements - L = 0.3 - W = 0.3, Exuade - none, Wound Bed - pain (no), Tissue type (blank), Periwound - closed, surrounding tissue intact. Right 3rd toe top-measurements - L = 0.2 - W = 0.4, Exuade - none, Wound bed - pain (no), Tissue type (blank), periwound -closed, surrounding tissue intact. Right inner aspect 2nd toe - measurements - L = 0.5 - W = 0.3, Exudate - none, Wound bed - pain (no), Tissue type (blank), periwound -closed, surrounding tissue intact. Right 3rd toe inner aspect - measurements - L = 0.2 - W = 0.2, Exudate - none, Wound bed - pain (no), Tissue type (blank), periwound - closed, surrounding tissue intact. Right 4th toe inner aspect, measurements - L = 0.5 - W = 0.2 -D = 4, Exudate - none, Wound bed - pain (no), Tissue type (blank), periwound - closed, surrounding tissue intact. Right 5th metatrsal head plantar, measurements - L = 2 - W = 1.5 -, Exudate - none, Wound bed - pain (no), Tissue type deep red with pale, soft center, not open. periwound - closed, surrounding tissue intact. Left great toe tip, measurements - L = 0.5 - W = 0.7, Exudate - none, Wound bed pain (no), Tissue type (blank), periwound - closed surrounding tissue intact. Left 5th metatarsal head plantar surface - L = 1.5 - W = 0.6, Exudate - none, Wound bed pain (no), Tissue type (blank), periwound - closed surrounding tissue in tact. A Pressure Ulcer Investigation Report dated 2/22/18 indicated: Resident name, Diagnoses, Current pressure ulcer status: Location: (R) great toe tip, (R) 2nd and 3rd toe tips, inter toes 2nd, 3rd and 4th, (R) 5th planter (met) head, (L) 5th met head. Was Risk Assessment completed prior to development of pressure ulcer? This area was (blank). Resident has been identified at risk for pressure ulcers related to the following factors/conditions: Urinary incontinence, poor nutrition (Dx of partial malnutrition), impaired mobility, extensive assistance bed mobility and/or transfers, Has current ulcer - contracture- feet, unable to change position or shift weight in chair, [MEDICAL CONDITION] disease, impaired immune system, spasms, tremors: Other increased CRP, protein metabolism, [MEDICAL CONDITIONS]. Current Treatment and interventions include: assist with turning/positioning, peri-care as needed. administer medications as ordered, referral to PT (physical therapy) date 2/23 (eval position), administer treatment as ordered, administer nutritional supplements (mal absorbed), encourage/provide good hydration, pressure relieving device in chair, apply protective barrier cream. ensure appropriate fitting shoes. use of pillows or other cushioning's devices, pressure relieving device in bed (on extended bed), weekly skin or body audits, float heels (heel magr.(manager) skillcare boots), assist with transfers, weekly wound assessment, monitor labs, encourage rest periods to break sitting for long periods of time. Probable causative reasons for development: Change in medical condition, immobility, disease process, poor tissue, friction/pressure, poor protein malnutrition, acute illness. The Wound Nurse was asked during an interview on 3/5/18 at 3:15 P.M. what caused Resident #156 wounds on his toes and inner toe areas? The Wound Nurse stated, he had some new tennis shoes that staff put on him. The Wound Nurse was asked if Resident #156 had been assessed for proper fitting of the tennis shoes prior to staff placing the tennis shoes on Resident #156? The Wound Nurse stated, No. A Progress Note dated 2/22/18 indicated: Resident slides down in the bed and frequently has to be repositioned up in the bed. Extension is on bed but resident still slides down at times. Maintenance in to make adjustments and add to padding. Brackets on the APM (mattress) motor are hard and fold over footboard of bed- toes may have come in contact with the brackets as well as feet on the foot board. PT consulted to evaluate position in the wheelchair, including foot position. Resident repositioned using soft pillows. The Wound Nurse was asked during an interview on 3/5/18 at 3:50 P.M. how long would it take for the blisters and deep tissue injuries (DTI) to develop? The Wound Nurse stated, about one hour given his compromised state of health. A deep tissue injury is defined by the National Pressure Ulcer Staging System (NPUAP) as purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Resident #156 was observed for wound care on 3/1/18 at 9:12 A.M. Physician orders [REDACTED]. (MONTH) wear his soft slippers or large non-skid socks when OOB. Padded foot board. Cleanse intact blister to right heel with NSS, pat dry with gauze, apply skin prep over blister surface and to surrounding skin. Apply transparent film dressing. Change every 7 days and PRN if loose. Skin care heel protector boots on while resident is in bed. Use with foam anti-rotation devices to elevate heels and for position monitor placement Q shift. Observed wound care. Nurse assessed bilateral feet and toes. Transparent film intact to R heel. Pressure areas on toes and feet are stable. Sensitivity with cleaning feet and toes. Cleaned and dried, applied skin prep feet and lower legs moisturized. Boots reapplied with anti-rotation foams, resident positioned in bed for breakfast. APM functioning, padding on the footboard intact. Bed low. A facility Timeline for Resident #156 Pressure Sores indicated the following: 12/11/17: Went to hospital for further evaluation and treatment due to altered mental status. 12/14/17: Returned to the facility with antibiotic [MEDICAL CONDITION]/acute [MEDICATION NAME] without hematuria. He also came with blister on his right antecubital, left hand/left thigh bruise, and reddened spotted areas on his stomach. 1/30/18: observed with stage 2 right heel (blister) Interventions: Skilcare boots with anti-rotation device for positioning Remove and replace skilcare boots Q shift to monitor skin integrity Apply skin prep with transparent film dressing and change every 7 days and PRN Continuation of protein supplement Continuation of APM mattress Continuation of extended bed 2/22/18: Observed with several areas of discoloration on toes and forefeet 2/23/18: Right great toe, 2nd toe, 3rd toe, 4th toe, with DTI not open Interventions: Continue Skilcare boots with anti-rotation device for positioning Avoid tennis shoes and tight socks. (MONTH) wear his soft slippers or large non-skid socks when OOB (out of bed) every shift Monitor toes and feet Q shift Padded foot board Place foot cradle to foot of bed to protect toe tips from weight of linens (discontinued 2/26/18) Continuation of protein supplement Continuation of APM mattress Continuation of extended bed. A facility Pressure Sore Prevention Policy no date available indicated: Policy: It is the philosophy of the facility to prevent pressure ulcers. Residents will receive care and services in a manner to promote skin integrity. Residents will receive early identification, prompt evaluation and treatment of [REDACTED]. Residents with problematic skin conditions will be provided care to support the healing process and prevent infection. Procedure: 1. Each resident will have a risk assessment (Braden Scale) completed upon admission or readmission by a licensed nurse. 2. A reassessment will be completed with each OBRA MDS assessment 3. Each resident will have a weekly skin assessment completed by a licensed nurse to assure timely identification and treatment of [REDACTED]. Residents with a Braden Score of 14 (moderate risk) or below (high risk) will receive preventive care. Residents with scores above 14 may have preventive care initiated as warranted by assessment. Identify and promptly institute risk reduction strategies in accordance with protocol and other preventive actions as indicated. Plan #1 Score 15-18 or Moderate risk 13-14 1. Turn and reposition every 2 hours if mobility is impaired 2. float heel intermittently 3. Monitor skin daily during personal care 4. Provide prompt incontinence care if incontinent 5. Apply moisturizer to skin daily 6. Monitor PO intake, Dietary Consult every quarter and PRN 7. Apply pressure reducing mattress and wheelchair pressure reduction cushion 8. Weekly skin assessment. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to provde a sanitary environment to help prevent the development and transmission of communicable disease and infection. 1. The facility staff failed to ensure the glucometer was sanitized prior and after use for (Resident #79) of 42 Residents in the survey sample. 2. The facility staff failed to ensure a fish bowl was cleaned in a designated dirty area to reduce the potential for cross contamination. 3. The facility staff failed to clean and disinfect glucometer after use and implement appropriate hand hygiene after performing a blood sugar check on Resident #68. The findings included: 1. Resident #79 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #79's Quarterly Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 10/3/17 coded Resident #79 as scoring a 15 out of a possible 15 on the BIMS (Brief Interview for Mental Status) indicating no cognitive impairment. Resident #79 was completely dependent on 2 staff for bed mobility, transfers, dressing, toilet use and personal hygiene. The Comprehensive Person Centered Care Plan dated 10/11/16 identified the resident required blood sugar monitoring. The goal was glucose will remain at a level so treatment is not required outside of established parameters. One intervention included: monitor blood glucoses per Medical Doctor Orders. The Physician order [REDACTED]. [MEDICATION NAME] 100 ml (milliliters) Unit inject as per sliding scale: if 300 to 350 inject 2 units if 351 to 400 inject 4 units 400 plus inject 6 units in addition to regular dose subcutaneously before meals and at bedtime. The Physician order [REDACTED]. [MEDICATION NAME] Solution Cartridge 100 unit/ml Inject 32 units subcutaneously with meals for diabetes give 32 units of [MEDICATION NAME] with meals On 2/28/18 During Medication Pass at approximately 11:20 AM, Licensed Practical Nurse (LPN) #2 was observed leaving the medication cart of Garden Hill to obtain the glucometer caddy. Upon return to the resident's room she proceeded to obtain Resident #79's glucometer with a glucometer intended for shared use. Upon completion the LPN returned the glucometer to the glucometer caddy. The Glucometer was not cleaned or sanitized prior to returning it to the Glucometer caddy. The LPN was asked on 2/28/18 at approximately 11:20 AM, if she cleaned and sanitized the glucometer prior to bringing it to the Resident's room. The LPN stated No, I didn't, I thought I only did that when I finished. The Acting Director of Nurses was asked on 3/5/18 at approximately 3:50 PM what her expectation was regarding cleaning of the glucometer. The Acting Director of Nurses stated that the glucometer was to be cleaned prior and after each use. The Acting Director of Nurses was asked if there was a difference in cleaning and sanitizing the glucometer. She stated, Yes, it is to be done per the manufacture's recommendations. The Facility Policy titled, Blood Glucose Monitoring with a revision date of 3/1/18 documented the following: Consult manufacturer's instructions for the use of the blood glucose meter. On 3/5/18 at approximately 4:15 PM, the Acting Director of Nurses #2, provided the Glucometer's Manufacturer's Recommendations. The Manufacturer's Recommendations documented the following from the Assure Prism User Instruction Manual dated 11/2015: Assure Prism Any disinfectant product with the EPA registration number listed on the table may be used on the device. A list of Environmental Protection Agency (EPA) registered disinfectants effective [MEDICAL CONDITION].[MEDICAL CONDITION], and [MEDICAL CONDITION] virus can be found at the following website: http://www.epa.gov/[MEDICAL CONDITION].pdf Cleaning and Disinfecting Procedures: Note: Two disposable wipes will be needed for each cleaning and disinfecting procedure: one wipe for cleaning and a second wipe for disinfecting. On 03/05/18 at 01:12 PM the acting DON #2, was interviewed. When asked the expectation for performing a glucometer to avoid the risk of obtaining bloodborne diseases, she stated her expectation is, The glucometer should be cleaned prior and after use. When asked is there a difference between cleaning and sanitizing, she stated, Yes. The Acting DON stated the sanitizer used at the facility was PDI Super Sani-Cloth Germicidal Disposable wipe. This wipe was included on the Assure Prism's manufacturer's recommendations. The Center for Disease Control (CDC) website: https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html documented the following: The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. Blood glucose meters are devices that measure blood glucose levels. Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. Unsafe Practices during Blood Glucose Monitoring and Insulin Administration An underappreciated risk of blood glucose testing is the opportunity for exposure to [MEDICAL CONDITION] (HBV, [MEDICAL CONDITION] virus, [MEDICAL CONDITION].through contaminated equipment and supplies if devices used for testing and/or insulin administration (e.g., blood glucose meters, fingerstick devices, insulin pens) are shared. Outbreaks of [MEDICAL CONDITION] virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. In the last [AGE] years, alone, there have been at least 15 outbreaks of HBV infection associated with providers failing to follow basic principles of infection control when assisting with blood glucose monitoring. Due to under-reporting and under recognition of acute infection, the number of outbreaks due to unsafe diabetes care practices identified to date are likely an underestimate. Although the majority of these outbreaks have been reported in long-term care settings, the risk of infection is present in any setting where blood glucose monitoring equipment is shared or those assisting with blood glucose monitoring and/or insulin administration fail to follow basic principles of infection control. For example, at a health fair in New Mexico in 2010, dozens of attendees were potentially exposed to [MEDICAL CONDITION] when fingerstick devices were inappropriately reused for multiple persons to conduct diabetes screening. Additionally, at a hospital in Texas in 2009, more than 2,000 persons were notified and recommended to undergo testing for [MEDICAL CONDITION] after individual insulin pens were used for multiple persons. Unsafe practices during assisted monitoring of blood glucose and insulin administration that have contributed to transmission of HBV or have put persons at risk for infection include: Using fingerstick devices for more than one person Using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses Using insulin pens for more than one person Failing to change gloves and perform hand hygiene between fingerstick procedures Best Practices for Assisted Blood Glucose Monitoring and Insulin Administration The following are infection control recommendations that anyone who performs or assists with blood glucose monitoring and /or insulin administration should review to assure they are not placing themselves or persons in their care at risk. These recommendations apply not only to licensed healthcare facilities but also to any setting where fingerstick procedures are performed and/or insulin is administered, including assisted living or residential care facilities, clinics, health fairs, shelters, detention facilities, schools, and camps. Protection from [MEDICAL CONDITION] and other infections is a basic requirement and expectation anywhere healthcare is provided. 2. On 3/2/18 at approximately 12:45 PM, during the Task of Medication Storage and Labeling on Cardinal Heights Unit's Medication Storage Room, a gallon jug of opened and dated distilled water was observed. LPN #7 stated the gallon jug of distilled water was used for a Resident's humidifier and also used to clean the Unit's fish bowl. The fish bowl was observed on 3/2/18 at approximately 12:50 PM, sitting on a shelf in the Unit's dayroom area. On 3/5/18 at approximately 12:45 PM, the Acting Director of Nurses #2 was asked if she saw a problem using a jug of distilled water for a resident's humidifier and to clean the fish tank. The Acting Director of Nurses stated, Absolutely, there would be a possibility of contamination. A few minutes later, the Acting Director of Nurses #2 brought the Unit Manager LPN #1 to explain how the fish bowl is cleaned. LPN #2 stated that only herself and one other nurse LPN #2 clean the fish bowl. LPN #1 stated the fish bowl is approximately a gallon sized bowl. LPN #1 states that she always obtains a new gallon of distilled water to use when she cleans the fish bowl. LPN #1 states she discards any water that is not used as it shouldn't be used for anything other than the fish bowl. LPN #2 stated that she cleans the fish bowl when the Unit Manager LPN #1 is unavailable to do so. LPN #2 stated that she obtains a new jug of distilled water that the Unit Manager LPN #1 leaves for her. LPN #2 stated that she also throws out any unused water after cleaning the fish bowl in the Medication Room of Unit Cardinal Heights. LPN #2 was asked if she cleans up after cleaning the fish bowl and she stated she sanitizes the counter in the Medication Room. The Unit Manager LPN #1 stated she also uses the Medication Room to clean the fish bowl. When asked why the soiled utility room is not used to clean the fish bowl, the Unit Manager LPN #1 stated that there is no counter space in the soiled utility room. On 3/5/18 at approximately 3:50 PM, the Acting Director of Nursing was asked if it would be an expectation to clean a soiled bed pan in the Medication room and she stated, Absolutely not. Then the Acting Director of Nursing was asked if the fish bowl should be cleaned in the Medication room, and she stated that the fish bowl should be cleaned in a designated dirty area to not potentially cross contaminate the clean items in the medication room from possible splatter that may occur from cleaning the fish bowl. The Acting Director of Nursing also stated, that it would not be the facility's expectation to clean the fish bowl in the medication room even if the counter top was sanitized after use. On 3/6/18 at approximately 1:30 PM, the Administrator was asked if there was any policy on cleaning a fish bowl. She stated that a fish bowl was acquired when the facility adopted the Eden Way Alternative. She stated the mission of the Eden Way Alternative was to improve the well-being of Elders and those who care for them by transforming the communities in which they live and work. The Administrator stated that the Vision of the program was to eliminate loneliness, helplessness, and boredom. The Administrator showed a 2009 Training Manual for the Eden Alternative and it documented the following: The training manual documented that opportunities included but are not limited to: Other Pets Chicken coop, birdfeeders, fish tank The training manual did not include any recommendations for cleaning of fish bowls. The Center for Disease Control (CDC) website (https://www.cdc.gov/healthypets/pets/fish.html) documented the following: Like all animals, fish may carry germs that make people sick. These germs can also contaminate the water in which fish live. Cleaning and maintaining your aquarium Be aware that fish and their aquariums may carry germs. ?Wash your hands before and after cleaning or maintaining the aquarium or aquarium water. Plan to wear gloves when working with rough rocks or spiny fish to avoid injury. If you have any cuts or wounds on your hands, wear Pink gloved hands and cleaning brush. gloves or wait until your wounds are fully healed before working with your fish or aquarium water to avoid possible infection. Avoid cleaning fish aquariums in areas where people with weak immune systems may be affected. The most common diseases associated with aquarium fish that can cause human illness are: Aeromonas is a type of bacteria that is commonly found in fresh water ponds and aquariums. This germ can cause disease in fish and amphibians. Aeromonas can cause discoloration of the limbs of amphibians and fins of fish. It can also cause internal bleeding in these aquatic animals. People can become infected through open wounds or by drinking contaminated water. Young children and adults with weak immune systems are most commonly affected and may have diarrhea or blood infections. [DIAGNOSES REDACTED] marinum is a type of bacteria that causes disease in fish, reptiles, and amphibians. This germ is found in fresh water ponds and aquariums. It is spread to people and animals through contaminated aquarium water. The most common sign of infection is development of a skin infection. In very rare cases, the bacteria can spread throughout the body systems. Infections progress slowly and may get better on their own. In some instances, antibiotics and surgical wound treatments are required to prevent deep infection. Salmonella is a type of bacteria that spreads to people and animals through contaminated food or contact with the stool or habitat of certain animals, including fish. People infected with Salmonella might have diarrhea, vomiting, fever, or abdominal cramps. Infants, elderly persons, and those with weakened immune systems are more likely than others to develop severe illness. Streptococcus iniae is a type of bacteria that causes serious disease in fish. People, especially those with open skin abrasions or scrapes, could get infected by Streptococcus iniae bacteria while handling fish or cleaning aquariums. Affected people usually develop a skin infection at the site of open cuts or scrapes. Though rare, more serious illness can happen in people with weakened immune systems. People can become infected through open wounds or by drinking contaminated water. Young children and adults with weak immune systems are most commonly affected and may have diarrhea or blood infections. Medline Plus website (https://medlineplus.gov/ency/article/ 8.htm) documented the following: Your immune system helps protect your body from foreign or harmful substances. Examples are bacteria, viruses, toxins, cancer cells, and blood or tissues from another person. The immune system makes cells and antibodies that destroy these harmful substances. AGING CHANGES AND THEIR EFFECTS ON THE IMMUNE SYSTEM As you grow older, your immune system does not work as well. The following immune system changes may occur: The immune system becomes slower to respond. This increases your risk of getting sick. The facility administration was informed of the findings during a pre-exit briefing on 3/5/18 at approximately 3:50 PM and again during the 3/6/18 exit briefing at approximately 1:45 PM. The facility did not present any further information about the findings. 3. Resident #68 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].*Type II Diabetes. Resident #68 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/21/2017 coded Resident #68 with a 03 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. *Diabetes Mellitus Type II is a lifelong (chronic) disease in which there is a high level of sugar (glucose) in the blood (https://medlineplus.gov/ency/article/ 5.htm). On 02/27/18 at approximately 5:10 p.m., during the medication pass and pour observation, License Practical Nurse (LPN) #6 removed an alcohol pad, 2 x 2 gauze, a lancet, a test strip and *glucometer from a blue caddy basket containing items to test blood sugars and insulin syringes. The glucometer was wiped down using a *Sani Cloth Wipe prior to using the glucometer. LPN #6 went into Resident #68's room then proceeded to clean resident's finger with an alcohol pad, pricked her finger with the lancet, inserted the test strip into the glucometer to obtain the blood sugar. After obtaining blood for blood sugar, LPN #6 returned to the medication cart, placed the glucometer back into the blue caddy basket without disinfecting the glucometer. The surveyor asked if the glucometer machine should have been cleaned after use, the LPN stated, Yes, I just forgot. The surveyor asked, Should you have washed your hands before and after doing a blood sugar check the nurse replied, Yes. The surveyor asked, What is the purpose of washing your hands and cleaning the glucometer before and after use: the LPN stated, To prevent the potential spread of infection between residents. *Glucometer is a device that uses a small drop of blood to measure your blood sugar level. Some glucose meters measure a drop of blood taken from your finger using a special lancet device (https://www.drugs.com/cg/how-to-check-your-blood-sugar-aftercare-instructions.html). *Sani Cloth Disposable Wipes is a disinfectant for use on hard, non-porous surfaces and patient care equipment (www.medline.com). On 3/01/18 at approximately 9:50 a.m., an interview was conducted with Unit Manager (UM) who stated, The glucometer should be cleaned before and after use and the nurse should have washed her hands before and after the blood sugar check on Resident #68. An interview was conducted with the Assistant Director of Nursing (ADON) on 3/5/18 at approximately 1:10 p.m., who stated, I expect for the nurses to clean the glucometer before and after the use and to wash their hands before and after any resident care. The facility administration was informed of the finding during a briefing on 3/05/18 at approximately 3:50 p.m. The facility did not present any further information about the findings. The facility's policy: Blood Glucose Monitoring (Last revision date 3/1/18). -After care induced but not limited to: Cleanse the glucose meter between resident tests. -Procedure: Clean/disinfect meter after each use. Hand Hygiene (Last revision date 8/30/17) -Policy statement: This facility considers hand hygiene the primary means to prevent the spread of infection. -Purpose of Handwashing/Hand Hygiene: All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -When to Wash hands: Employees must actively was their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions; (Hand sanitizer may be used when indicated up to 5 times, the Hand Washing Protocol) to include but not limited to: *Before and after direct resident contact. *Before and after performing any invasive procedure (e.g., finger stick, blood sampling). *After removing gloves or aprons. -Use of Gloves: The use of gloves does not replace handwashing/hand hygiene. Policy and Procedure (Standard Precautions) revision date 12/4/17. Policy statement: Standard Precautions will be used in the care of all residents regardless of their diagnosis, or suspected or confirmed infection status. Standard Precautions presume that all blood, bloody fluids, secretions, and excretions (except seat), non-intact skin and mucous membranes may contain transmissible infectious agents.

Based on observations, staff interview, and clinical record review, the facility staff failed to ensure 2 out of 42 residents (Resident #68 and #16) in the survey sample who were unable to independently carry out activities of daily (ADL), received necessary services to maintain grooming. 1. The facility staff failed to ensure Resident #68 was provided ADL care to include removal of excessive facial chin hair. 2. The facility staff failed to ensure Resident #16 was provided ADL care to include removal of excessive facial chin hair. Findings include: 1. Resident #68 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #68 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/21/2017 coded Resident #68 with a 03 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. In addition, the MDS coded Resident #68 requiring extensive assistance of one with dressing, personal hygiene and bathing. Section, E (Behavior) was not coded for rejection of care for ADL assistance. The comprehensive care plan documented Resident #68 with requiring assist with Activities of Daily Living (ADL) to include but not limited to dressing and grooming. The goal: the resident will participate in therapy and return to prior level of function. The intervention/approaches to manage goal included, require the assistance of one person with ADL's and PT (physical therapy) to evaluation and treat as indicated for unsteady gait. During the initial tour on 02/27/18 at approximately 12:45 p.m., Resident #68 was sitting in the common area on the secure unit. Resident #68 was observed with an excessive amount of chin hair. On 02/27/18 at approximately 5:10 p.m., during the medication pass and pour observation, Resident #68 remained with an excessive amount of chin hair. On 2/28/18 at approximately 9:40 a.m., Resident #68 was ambulating in the hallway, remained with an excessive amount of chair hair. An interview was conducted with CNA #1 on 02/28/18 at approximately 2:45 p.m., who stated, The resident refused her bath today and refused to be shaved. On 02/28/18 at approximaltey 2:55 p.m., an interview was conduced with the Unit Manager (UM) who stated, They were not aware of Resident #68 refusal to be shaved. The surveyor requested Resident #68's refusal care plan. On the same day at 3:20 p.m., the UM stated, We do not have a refusal care plan for ADL's to include shaving. Review of residents medical record did not reveal refusal of care for bathing or grooming. On 3/1/18 at approximately 2:00 p.m., Resident #68 was observed without facial hair to her chin. An interview was conducted with the Assistant Director of Nursing (ADON) on 3/5/18 at approximatley 1:10 p.m., who stated, Resdient #68 not being shaved is not acceptable; this is a dignity issue. The ADON proceeded to say, Not being shaved is the same as having dirty hands. If a resident refuses care, it should be clearly documented and care planned. The facility administration was informed of the finding during a briefing on 3/05/18 at approximately 3:50 p.m. The facility did not present any further information about the findings. 2. Resident # 16 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent quarterly MDS (minimum data set) assessment had an ARD (assessment reference date) of 11/24/17. Section C of the MDS assessed cognitive patterns and in Section C0500, Resident # 16 had a BIMS (brief interview for mental status) score of 3/15, which indicated severe cognitive impairment. Section G assessed functional status. In Section G0110 for J. Personal hygiene, the facility staff coded Resident #16 as 3/2, which indicated that Resident # 16 required extensive assistance with the assistance of one person for personal hygiene. According to the most recent plan of care for Resident # 16 which was reviewed and revised on 12/5/17, the facility had documented as a problem area, Resident needs limited assistance with ADL's to remain clean, neat, and free of body odors r/t (related to) cognitive deficits. Interventions included but were not limited to: PT/OT (physical therapy/occupational therapy) prn (as needed) and tx (treatment) as ordered for assist with ADLs (activities of daily living)/hygiene, transfers, and showers/ whirlpool 2 times every week to include nail care and shampoo, bed bath prn. On 2/27/18 at 2:15 pm, the surveyor observed Resident # 16 in her room sitting in her recliner watching TV. The surveyor observed long strands of grey and white hair on Resident # 16's chin. On 3/1/18 at 2:42 pm, the surveyor observed Resident # 16 sitting in the day room during activities. The surveyor observed several long grey and white chin hairs on Resident # 16's chin at that time. The surveyor asked Resident # 16 if she preferred to have chin hairs. Resident # 16 stated, No my son usually takes care of that .Do you have a razor? The surveyor responded, No but I am sure someone here has one and we will get it taken care of for you. Resident # 16 stated, I am going to become the bearded lady in the [MEDICATION NAME]. Resident # 16 then asked the activity director on the unit if she had a razor and the activity director stated, No. Resident # 16 stated, I am going to become the bearded lady in the [MEDICATION NAME], it's disgusting. On 3/1/18 at 3:00 pm, the surveyor asked CNA (certified nursing assistant) #1 who was responsible for providing care for Resident # 16 and CNA #1 responded, I am. The surveyor asked CNA #1 if she could shave Resident #16. CNA #1 told the surveyor that it would have to wait until the person from 3-11 shift came on because it was 3:00. The surveyor asked CNA #1 who assisted Resident # 16 in getting dressed today and the CNA #1 stated, I did. The surveyor asked CNA #1 why she did not shave Resident #16 when she got her dressed for the day. CNA #1 stated, Honestly I am scared that I am going to cut them so I don't do it. CNA #1 stated that she would report off to the next CNA on 3-11 shift that Resident # 16 needed to be shaved. On 3/1/18 at 3:10 pm, the surveyor reported to the unit manager about the incident as stated above. The unit manager stated that CNA #1 was one of their newer employees and that she would speak with the employee and send her to staff development to receive more training. According to the facility policy and procedure for Shaving the Resident, the purpose is to promote cleanliness and provide skin care. According to the facility policy for Shaving the Resident The following documentation should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. If and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure. 4. Any problems or complaints made by the resident related to the procedure. 5. If the resident refused treatment, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data. According to the facility Nursing assistant/certified nursing assistant orientation checklist, the Skills Evaluated included but were not limited to Shaving-men & women/P[NAME] No further information regarding this issue was presented to the survey team prior to the exit conference.

Based on observation, staff interview, and clinical record review, the facility staff failed to communicate ongoing assessments of 1 of 42 residents condition and monitoring for complications before and after [MEDICAL TREATMENT] treatments received at a certified [MEDICAL TREATMENT] facility. (Resident # 165.) Findings: Facility staff failed to communicate ongoing assessments for Resident #165 who attended out patient [MEDICAL TREATMENT] three days per week. The resident's clinical record was reviewed on 2/28/18 at 11:00 AM. Resident #165 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The latest MDS (minimum data set) assessment, dated 12/15/17, coded the resident with slight cognitive impairment. She required the assistance of nursing staff members to assist her with all the ADLS (activities of daily living) and a set-up only to eat. The resident was coded as receiving outside [MEDICAL TREATMENT] services. Resident # 165 CCP (comprehensive care plan), reviewed and revised on 2/7/18, documented the resident with end stage [MEDICAL CONDITION] and [MEDICAL TREATMENT] services. The interventions included [MEDICAL TREATMENT] service three days a week and to check and record bruit/thrill. Report all changes to MD and [MEDICAL TREATMENT] center. Resident # 165's physician orders [REDACTED]. The nursing progress notes contained documentation that the resident's vital signs were obtained on each [MEDICAL TREATMENT] day. The thrill and bruit were documented as present and the perma-cath dressing was dry and intact. No information was observed in the clinical record or in the electronic chart that contained any communication to or from the [MEDICAL TREATMENT] center. On 2/27/18 at 5:00 PM Resident #165 was interviewed about the facility and her trips to [MEDICAL TREATMENT]. The resident was asked if she took any documentation (such as a notebook) over with her from the facility to share with the [MEDICAL TREATMENT] clinic or if the [MEDICAL TREATMENT] clinic ever sent anything back to the facility staff with her. Resident #165 said she did not have anything to take with her on [MEDICAL TREATMENT] days, except for her bagged lunch. She said she, personally, was not transporting anything (as far as documentation) to and from the facility to [MEDICAL TREATMENT] and back. On 2/28/18 at 11:42 AM 02/28/18 11:42 AM, RN I was asked about [MEDICAL TREATMENT] communication sheets. She said they don't have/use any. RN I said the [MEDICAL TREATMENT] facility communicated any issues, or changes in treatment or medications to facility staff via phone. No wet/dry weights or VS (vital signs) were sent to or from the [MEDICAL TREATMENT] clinic to facility. RN I said any unusual changes reported by the [MEDICAL TREATMENT] facility would be communicated to the physician and responsible party, but an ongoing exchange of information/communication was not in place. On 02/28/18, at 1:13 PM, the surveyor spoke to the administrator about these findings. The administrator provided the nursing home [MEDICAL TREATMENT] contract and a draft of the latest nursing policy with respect to communication sheets on residents. The nursing home contract, signed and dated by both parties on 5/23/12, documented the Center will develop a written protocol governing specific responsibilities, policies and procedures to be used in rendering [MEDICAL TREATMENT] services .including but not limited to, the development of a designated resident's care plan relative to the provision of [MEDICAL TREATMENT] services. The facility will provide for an interchange of information useful or necessary for the care of the designated resident and will inform the center of a contact person at facility . The facility's policy and procedure for [MEDICAL TREATMENT] included the following protocol for nursing staff members: .The intent of this policy is that the facility assures that each resident receives care and services for the provision of [MEDICAL TREATMENT] and/or peritoneal [MEDICAL TREATMENT] consistent with professional standards of practice including the: ~ Ongoing assessment of the resident's condition and monitoring for complications before and after [MEDICAL TREATMENT] treatments received at a certified [MEDICAL TREATMENT] facility; ~ Ongoing assessment and oversight of the resident before and after [MEDICAL TREATMENT] treatments; and ~ Ongoing communication and collaboration with the [MEDICAL TREATMENT] facility regarding [MEDICAL TREATMENT] care and services . The administrator also provided a copy of a blank communication sheet the nursing staff was supposed to be using for ongoing daily assessments for each [MEDICAL TREATMENT] visit between the facility and the [MEDICAL TREATMENT] clinic. The report included details for the resident's vital signs prior to the [MEDICAL TREATMENT] treatment and the pre and post [MEDICAL TREATMENT] weights from the center. The administrator told the surveyor this form had not been used to communicate daily on Resident # 165's [MEDICAL TREATMENT] treatment days, but it should have been. The administrator said training had been provided to staff about the ongoing use of the forms. No other information was provided prior to the survey team exit.

Based on staff interview and clinical record review, the facility staff failed to ensure that 1 of 42 residents in the final survey sample was free from unnecessary medications, Resident # 94. The facility staff failed to monitor the use of [MEDICATION NAME] according to the physician's orders [REDACTED]. The findings included: Resident # 94 is an [AGE] year-old female who as originally admitted to the facility on [DATE], with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment was a 14-day scheduled assessment with an ARD (assessment reference date) of 1/11/18. Section C of the MDS assess cognitive patterns. In Section C0500, the facility staff coded a BIMS (brief interview for mental status) score of 00/15 for Resident # 94, which indicated severe cognitive impairment. The most recent plan of care for Resident # 94 was reviewed and revised on 1/17/18. In the problem area, Resident is at risk for compromised quality of life and impaired cognition secondary to [DIAGNOSES REDACTED]. Interventions included but were not limited to Administer medications for cognition per MD (medical doctor) orders. The clinical record for Resident # 94 was reviewed on 2/27/18 at 3:54 pm. A physician's orders [REDACTED].½ tab (12.5 mg) po (by mouth) BID (twice a day) Hold for SBP (systolic blood pressure) < 100 and DBP (diastolic blood pressure) <60. On 2/28/18 at 9:15 am, the surveyor reviewed the MAR (medication administration record) for (MONTH) (YEAR) for Resident # 94. Upon review of the MAR for (MONTH) (YEAR), and the vital signs documented in the clinical record, the surveyor could not locate any documentation to support that the facility was monitoring the blood pressures to ensure that the [MEDICATION NAME] was being administered to Resident # 94 as ordered by the physician. On 2/28/18 9:39 am, the surveyor spoke with LPN #1 (licensed practical nurse) about the blood pressure parameters associated with the use of [MEDICATION NAME] for Resident #94. The surveyor asked LPN #1 if she assessed the blood pressure for Resident #94 prior to administering the [MEDICATION NAME]. LPN #1 stated Yes and showed the surveyor a piece of paper with blood pressures on it 137/86. The surveyor asked LPN #1 if she had any way to verify that the blood pressure readings were being checked daily prior to administering the medication. LPN #1 reviewed the MAR and stated No. LPN #1 stated that she would go in and update the MAR so that the documentation of the blood pressures are recorded on the MAR along with the nurses' signature. On 2/28/18 at 2:54 pm, the unit manager was made aware of the findings as stated above. No further information was provided to the survey team regarding this issue prior to the exit conference.

Based on observation, staff interviews and facility documentation review the facility staff failed to ensure medications were stored in a secured location, accessible to designated staff only on 1 of 3 units (Unit 3 - secure unit). The facility staff left medications unsecured on top of the medication cart and the cart unlocked, when not in direct sight of the nurse. The findings include: On 02/27/18 at approximately 5:10 p.m., during the medication pass and pour observation, License Practical Nurse (LPN) #6 pulled the following blister cards of medications from her medication cart; Metaformin, [MEDICATION NAME], Lisiniprol and [MEDICATION NAME] then popped one (1) pill off each card into a clear medication cup. The LPN and surveyor walked to room (number) where the LPN administered the medication to Resident #68. The LPN and surveyor returned back to the medication cart at 5:30 p.m., and noted four (4) blister cards of medication on the top of the cart; the medications were *[MEDICATION NAME], *[MEDICATION NAME], *[MEDICATION NAME] and *[MEDICATION NAME]. Ambulating in front of the medication were 2 residents. The LPN stated, I should have put the medication back inside the cart after I pulled them for Resident #68. *[MEDICATION NAME] is used alone or with other medications, including insulin, to treat type 2 diabetes (condition in which the body does not use insulin normally and, therefore, cannot control the amount of sugar in the blood)(https://medlineplus.gov/ency/article/ 5.htm). *[MEDICATION NAME] is used to treat ulcers; it decreases the amount of acid made in the stomach (https://medlineplus.gov/ency/article/ 5.htm). *[MEDICATION NAME] is used alone or in combination with other medications to treat high blood pressure (https://medlineplus.gov/ency/article/ 5.htm). *[MEDICATION NAME] is used alone or with other medications to treat certain types of [MEDICAL CONDITION]. Divalpoex is also used to [MEDICAL CONDITION](episodes of frenzied, abnormally excited mood) in people with [MEDICAL CONDITION] disorder (manic-[MEDICAL CONDITION]; a disease that causes episodes of depression, episodes of mania, and other abnormal moods) (https://medlineplus.gov/ency/article/ 5.htm). An interview was conducted with the Unit Manager (UM) on 3/01/18 at approximately 9:50 a.m., who stated, The nurse should have ensured the medications were secure before she left her medication cart. On 3/5/18 at approximately 1:10 p.m., an interview was conducted with the Assistant Director of Nursing (ADON) who stated, That is not how the nurses are educated. The medication are to be put back in the medication cart after they are pulled and the cart locked. The facility administration was informed of the finding during a briefing on 3/05/18 at approximately 3:50 p.m. The facility did not present any further information about the findings. The facility's policy: Medications - 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles (Last revision Date: 01/01/13). -Applicability: This Policy 5.3 sets for the procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles. -General Storage Procedures: 3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Based on observation, staff interview, and facility documentation review, the facility staff failed to ensure privacy of healthcare information for one unit (Unit Garden Hill) of three Units. The findings included: During Garden(NAME)Unit's Medication Pass Task on 2/28/18 at approximately 11:20 AM, Licensed Practical Nurse (LPN) #2 walked away from the medication cart C, leaving her daily assignment sheet face up on top of the medication cart. The daily assignment sheet included resident names and resident diagnoses. During the time the LPN was away from her cart, one facility staff, maintenance staff, and one visitor walked past the medication cart and had the ability to see personal health protected information. LPN #2 was interviewed on 2/28/18 at approximately 11:30 AM, and asked if she saw anything wrong with walking away from her assignment sheet with Resident protected healthcare information visible to anyone who would walk by. LPN #2 took her assignment sheet and turned it face down so no protected healthcare information was visible to anyone. She stated that she should not have left the healthcare information visible to others. When asked if she felt this was a HIPPA (Health Insurance Portability and Accountability) violation, she stated, Yes. On 3/2/18 at approximately 12:15 PM, an observation was made of Garden(NAME)Unit's Medication Cart B. Resident Protected Healthcare Information was visible to anyone walking past the cart. The Protected Healthcare Information was the assignment sheet of LPN #5. LPN #5 informed the Unit Manager #2, that she had given the assignment sheet to the aide to write in vital signs. Garden Hill's Unit Manager #2 was asked what the expectation was for Protected Healthcare Information and she stated on 3/2/18 at approximately 12:15 PM, The information should not be left visible to others. On 3/5/18 at approximately 12:45 PM, the Acting Director of Nursing #2 was asked what her expectation was for Protected Healthcare Information. The Acting Director of Nursing #2 stated, Healthcare information should not be visible. The Facility provided education on the topic, Best Practice Tips for Med Pass on 3/1/18. LPN #2 and LPN #5's signature was included on the sign in log. The topics of this education included but were not limited to: HIPPA - information/privacy The Facility Policy and Procedure titled Reporting Unauthorized Access, Use and Disclosure of Protected Health Information (PHI) dated 5/2012 documented the following: Policy Statement The protection of resident and facility information is the responsibility of all facility personnel, including business associates. Unauthorized access, use, and/or disclosure of protected information must be reported. Incidents include, but are not limited to, the unauthorized access, use, or disclosure of the following information: Resident personal and medical information Resident names or other identifying information Any other resident or facility information that has not been publicly disclosed or has been de-identified according to established facility policy The facility administration was informed of the findings during a pre-exit briefing on 3/5/18 at approximately 3:50 PM and again during the 3/6/18 exit briefing at approximately 1:45 PM. The facility did not present any further information about the findings.

Based on resident interview, staff interviews, clinical record review and facility document review the facility staff failed to implement assistance devices and supervision to prevent avoidable falls with injuries for 2 of 28 residents in the survey sample, Resident #10 and #14. 1. The facility identified Resident #10 was a fall risk. The facility developed a plan of care to prevent falls which included the use of two staff for transfers. The resident was transferred on 2/10/16 by one staff instead of two. During the transfer the resident's knee gave out and the resident was lowered to the floor. Furthermore, the staff failed to use a gait belt, an assistance device. As a result of the fall the resident sustained [REDACTED]. 2. For Resident #14, the facility staff failed to ensure necessary supervision/assistance and fall prevention interventions were implemented to reduce and/or prevent falls for a known high fall risk resident. The resident sustained [REDACTED]. The findings included: 1. Resident #10 was originally admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set-a resident assessment and care screening) with an assessment reference date of 1/13/16 coded the resident as scoring a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was intact. The resident was assessed as requiring two staff for transfers (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position). The resident was not steady, only able to stabilize with staff assistance when moving from seated to standing position .surface-to-surface transfers. Under Section J. Health Conditions had one fall since admission/entry or reentry or the prior assessment. The resident was 63 inches tall and weighed 174 pounds. The Fall Risk Assessment Form dated 1/20/16 assessed the resident's score as a 13. A score of 10 or more indicates a High Risk for falls. The plan of care with a review date of 1/27/16 identified the resident was at risk for falls related to impaired mobility, OA (arthritis), OP, and restless leg syndrome. The goal was listed as the resident's safety will be maintained as evidenced by having no significant injuries from falls. One of the approaches listed to maintain/achieve the goal was that the resident required 2 person assist with transfers. Review of the clinical nurses notes evidenced an entry dated 2/10/16 at 10:55 a.m. The nurse documented she was called to the resident's room by a certified nurse aide (CNA). The resident was observed on the floor. The CNA reported she was transferring the resident out of bed to the wheelchair, the resident complained of right knee pain and the leg started to slide. The resident was slid to the floor. The nurse assessed the resident. The resident complained of right ankle pain when touched. The physician was called, and ordered an x-ray of the right knee and right ankle, and Norco 5-325 mg (milligram) one tablet by mouth every six hours as needed for pain (Norco is a controlled drug). The responsible party was called and notified. The x-ray report exam date 2/10/16 impression was an acute right ankle fracture. The physician was notified of the x-ray result. New orders to ace wrap the right ankle to stabilize the right foot/ankle, non-weight bearing until seen by the podiatrist on 2/11/16. The resident was seen by the podiatrist on 2/12/16. A Cam boot was placed on the resident's right foot that was to be kept on at all times and orders to maintain non-weight bearing to the right leg. Cam is an acronym meaning controlled ankle motion. Its primary purpose is to prevent or limit ankle and foot movement. On 10/19/16 at 3:20 p.m., the resident was observed sitting up in a wheelchair at the beside watching t.v. and drinking a cup of coffee. The resident was asked about the fall with fracture. She stated she slid off the side of the bed during a transfer. She stated, she (CNA) should have had 2 people .my foot got caught between the spokes of the wheelchair. The fall incident report and investigation dated 2/10/16 was reviewed. Under contributing factors the No box was checked for Gait belt in use? The Post Incident Staff Interview dated 2/10/16 was completed by the involved CNA. One of the interview questions was, What do you think will help prevent incident from occurring? The answer was: 2 person assist transfer. The CNA is no longer employed at the facility. An interview with the Administrator and the Acting Director of Nursing (ADON) was conducted on 10/20/16 at 11:00 a.m. They were asked by this inspector, Did the CNA use a Gait belt while transferring the resident? The Administrator answered, No. When asked, Should the CNA have used a Gait belt? The administrator answered, Yes. When asked, Should the CNA have had a second person to assist with the transfer? The Administrator stated, Yes. The Administrator stated she understood that the CNA was not aware that the resident required a two person assist, although the CNA had been assigned to care for the resident previously. The Administrator stated as a result of this fall, all staff were inserviced on the use of Gait belts and appropriate number of staff for transfers. The Staff Development Coordinator provided this inservice to educate all CNAs on the importance of always having their Gait belt on them as part of their uniform. Gait belts are to be used for all 1-2 person assist, excluding Hoyer (a mechanical lift) transfer. The Administrator stated a Care Card is stored inside each residents wardrobe closet. The care card contains information for staff to use that includes how the resident is to be transferred. Resident #10's care card was correct for a two person transfer at the time of the fall. The purpose of a Gait Belt is to provide safety and protection from possible injury during transfer and ambulation. www.vdh.virginia.gov/mrc/wthrc/document/pdf/Transfer-Using-Gait-Belt. The facility staff failed to implement approaches per Resident #10's plan of care to ensure resident safety due to fall risk; as a result the resident sustained [REDACTED]. The instituted a plan of correction for falls as follows: 1. all licensed staff educated on knowing and following each resident's plan of care for safe transfers. Completion date 2/16/16 2. All nursing and CNA report sheets will be updated on (name of unit) to include how each resident is care planned for transfers. Completion date 2/12/16 3. Nurses on (name of Unit) will be reeducated on the importance of knowing each each resident's plan of care and communicating changes immediately to the direct care staff. Completion date 2/15/16 4. Nurses on all neighborhoods will be reeducated on the importance of knowing each resident's plan of care and communicating changes immediately to the direct care staff. Completion date 2/26/16 5. All nursing and CNA report sheets will be updated on (name of units) to include how each resident is care planned for transfers. Completion date 2/26/16 6. All CNAs will be reeducated on the importance of always having their gait belts on them as part of their uniform. gait belts are to be used for all 1-2 person assist, excluding Hoyer transfers. Completion date 2/26/16 7. Audit 100% of the care cards will be conducted for accuracy to the care plan. Variances will be investigated and corrective action will be taken as appropriate. Completion date March 2016 This incident is found to be Past Non-Compliance, as the facility identified the non-compliant practice and corrected it prior to survey. 2. Resident #14 was originally admitted to the facility 5/29/14 and readmitted [DATE] after an acute hospitalization . The current [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/11/16 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 0 out of a possible 15. This indicated Resident #14 cognitive abilities for daily decision making were severely impaired. Resident #14 was coded as not having mood or behavior problems, requiring extensive assistance of 1 with walking in the room and eating, extensive assistance of 2 with bed mobility, transfers, walking in the corridor, locomotion on the unit, dressing, toileting, personal hygiene and total care of 1 with bathing. The resident was coded as frequently incontinent of bowels and bladder. Resident #14 was coded for walking with a walker and stabilizing only with staff assistance. Unsteadiness was coded when the resident was moving from sitting to standing, turning around while walking, moving on an off the toilet and transfers/bed to chair and wheel chair. A history and physical from a local hospital dated 11/17/15 read; Resident #14 had multiple falls recently. The first fall on 11/3/15 resulted in a right hip fracture. The resident had another fall 11/4/15 after getting tripped on a wheel chair trying to get up from the wheel chair and hit her head. Today 11/17/15 the resident woke up in the middle of the night and tried to walk and had another fall and was sent to the emergency room . This time the resident was with a fracture of the left hip. The Plan; hospitalize the resident, plan for left hip surgery in the morning and pin the right hip at the time of surgery to prevent any concerns for displacement of the right hip fracture going forward. Review of the clinical record and facility Incident Accident Forms evidenced the resident had the following falls: 11/3/15 at 4:55 p.m.- Resident was in the dining room, stood up to go to the bathroom, tripped over feet and fell to the floor. The resident sustained [REDACTED]. The physician's treatment plan was to watch the fracture and not operate at that time. The facility's investigation stated there were 2 certified nursing assistants (CNA) present at the time of the fall but no interventions were initiated when the resident stood. One of the 2 CNAs was on 1:1 duty with another resident. Intervention: use of wheel chair. 11/4/15 at 4:20 p.m. - Resident observed on the dining room floor when the Unit Manager walked into the dining area. The resident had been in a wheel chair. There was no facility investigation of this fall. Interventions instituted included 1-2 persons to aid with transfers and 1:1. During an interview with the Unit Manager on 10/20/16 at approximately 11:30 a.m., the Unit Manager stated an investigation was not conducted for this fall. The resident's care plan did not include 1:1 interventions. 11/16/15 at 10:50 p.m. - Resident observed on the floor in a sitting position with the back towards the bathroom door. Had previously been in bed. The resident complained of left hip pain. The resident sustained [REDACTED]. The facility's investigation revealed the resident had gotten out of bed toileted herself and was returning to bed when she fell . The staff was alerted by the roommate. Interventions initiated included moving resident to a room closer to the nurses' station and away from the resident awaking her during the night. Bed pad alarm and non-skid shoes when in bed. 11/18/15 - The resident had open reduction and internal fixation of the left hip fracture and percutaneous pinning of the right hip fracture simultaneously. A bed or chair alarm is a personal alarm that allows a caregiver to monitor the activity of a resident when in bed or in a chair and alert the staff of unassisted movements. A tab alarm has a string which attaches to the resident's clothing and another item such as a chair. When the resident stretches the string by rising the action removes the tab from the alarm box and it sounds. The pad alarm has a sensor which operates through detection of a reduction of pressure when the resident rises or moves off the pad. The Unit had one large room used for dining and activities. The residents were observed seated at a long table in this room most of the day. An interview was conducted with Resident #14's Responsible Party by phone on 10/20/16 at 11:50 p.m. The Responsible Party stated she is worried about the number of falls the resident has experienced and she desires something be done about it. The Responsible Party stated the resident always enjoyed walking and believes she is aware of toileting needs but she wonders if the resident's safety can be accomplished with the current staff. The clinical record review revealed Resident #14's Fall Risk Assessments. The assessment form stated a score of 10 or more indicates a high risk for falls. The 9/7/15 assessment score was 6, 11/4/15 score was 13, 11/16/15 score was 15, 11/23/15 score was 15, 12/1/15 score was 20, 12/11/15 score was 19, 3/16/16 score was 21, 5/21/16 score was 21, 6/7/16 score was 21, 8/30/16 score was 21, 9/1/16 score was 23 and the 9/25/16 score was 21. The care plan dated 6/17/15 and was in use at the time of the 11/3/15 fall, the problem read; At risk for injury from falls related to impaired mobility, impaired cognition with poor safety awareness, CLBP (sic), compression fracture lumbar 2, vision impaired, and use of daily antipsychotic medication. The goal read; Resident's safety will be maintained as evidenced by having no significant injuries from falls this review. The approaches were; Be aware resident is receiving antipsychotic, diuretic and two blood pressure medications daily - Monitor for any potential interactions or side effects from medications. Evaluate resident's room for easily modified hazards (poor lighting, poorly arranged furniture, etc., which might contribute to falls) Keep bed in the lowest locked position. Keep frequently used items within reach. Keep pathways free of obstacles/clutter/spills. Make sure resident has her eyeglasses on during waking hours. Monitor for complaints of pain both verbal and non verbal, medicate with as needed medications and alert the physician if a change may be indicated. Non-skid shoes when out of bed, or appropriate of footwear when up out of bed. Place call bell in position - Be aware cognitive status prohibits use of the call bell. Provide frequent checks when in room in bed. physical therapy/occupational therapy as needed to develop a plan and maintain/increase mobility. Resident needs limited hand held assistance with bed mobility, transfers and ambulation. Review fall risk assessment scores quarterly and adjust plan of care as needed. Care plan approaches added 11/30/15 were: bed and wheel chair alarm in place to alert staff of unassisted transfer attempts. Bed pad alarm in place to alert staff of unassisted transfer attempts. Non-skid socks to be on when in bed. Encourage rest periods. Orthopedic consult with follow-ups per orders - see treatment administration records. Physical Therapy/Occupational Therapy to develop a plan to maintain/increase safe mobility. Extensive assistance with bed mobility, transfers and ambulation. Also use of wheel chair for longer distances. Resident #14 was observed 10/18/16 at approximately 1:15 p.m., seated in the dining/activity area at the table with a tab alarm attached to self and the straight back chair. Resident #14 was observed 10/19/16 at approximately 9:30 a.m., seated in the dining/activity area at the table with a tab alarm attached to self and the straight back chair. Resident #14 was observed 10/20/16 at approximately 1:30 p.m., seated in the dining/activity area at the table with a tab alarm attached to self and the straight back chair. The resident had physician's orders [REDACTED]. Bed pad alarm in place while Resident is in bed. Tab alarm on at all times in bed and chair to alert staff of unassisted transfers. Monitor placement of fall mats bedside bed while resident is in bed. The facility's undated policy titled Fall Prevention and Management Program read; #1. All residents will have a Fall Risk Assessment completed upon admission, readmission, quarterly or a significant change. The results of the fall risk assessment will be communicated to the interdisciplinary team. #7. The fall investigation form will be utilized in reviewing and revising the resident's care plan to minimize the recurrence of falls or injury. #11 The interdisciplinary team will evaluate the need for preventative/corrective measures and will make recommendations to reduce risk of reoccurrence. #12. The Nurse Manager will assure that the recommended measures are put into place and the care plan is updated to reflect changes. The above findings were shared with the Administrator, Assistant Administrator and Director of Nursing during the pre-exit meeting on 10/20/16 at approximately 2:20 p.m. The facility staff present was asked if the residents are left unsupervised in the dining/activity room frequently. The Assistant Administrator stated they have now instituted assigning a staff member (CNAs and/or activity) to monitor and remain in the dining/activity room from 7:00 a.m. to 7: 00 p.m. to ensure the residents are supervised.

Based on staff interviews, clinical record reviews and complaint investigation the facility staff failed to immediately call for 911 emergency services during an acute change in condition requiring emergency medical care for 2 of 3 residents in the survey sample, Resident #1 and 2. 1. Resident #1 had an acute change in respiratory status on [DATE] requiring emergency care. The physician ordered the resident to be sent to the emergency room at 10:50 am, the nursing supervisor did not call 911 until 24 minutes later. The nursing staff failed to monitor and obtain the resident vital signs to include respiratory rate, blood pressure and pulse. Upon first responder arrival the resident was found unresponsive, unconscious and having agonal breathing. The resident was in [MEDICAL CONDITION], admitted to the ICU and expired two days later. 2. The facility staff failed to ensure that Resident #2 was provided the necessary care and services from Emergency Medical Services in a timely manner after an assessed acute medical change on [DATE]. The findings included: 1. Resident #1 was a [AGE] year old who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was a full code. Intellectual disability (ID), once called mental [MEDICAL CONDITION], is characterized by below-average intelligence or mental ability and a lack of skills necessary for day-to-day living. Referenced from www.nih.gov (National Institute of Health). [MEDICAL CONDITION] is a disorder of movement, muscle tone or posture that is caused by an insult to the immature, developing brain, most often before birth. www.nih.gov [MEDICAL CONDITION] are symptoms of a brain problem. They happen because of sudden, abnormal electrical activity in the brain. Not all [MEDICAL CONDITION] cause convulsions. There are many types of [MEDICAL CONDITION] and some have mild symptoms. [MEDICAL CONDITION] fall into two main groups. Focal [MEDICAL CONDITION], also called partial [MEDICAL CONDITION], happen in just one part of the brain. Generalized [MEDICAL CONDITION] are a result of abnormal activity on both sides of the brain. www.nih.gov The current MDS (Minimum Data Set) with an assessment reference date of [DATE] coded the resident as having long and short term memory deficits and severely impaired daily decision making skills. The resident's speech was unclear. The resident had some difficulty communicating some words or finishing thoughts but was able if prompted or given time. The resident responded to simple, direct communication. The complainant alleged the facility staff obtained a physicians order to transport the resident to the emergency room (ER) at 9:50 am on [DATE], the nursing supervisor did not call EMS (emergency medical services/911) until 10:15 am. The clinical record was reviewed and the following information was obtained: On [DATE] during the night shift Resident #1 had four episodes of large loose watery foul smelling stools. The night shift nurse notified the supervisor and a physician order [REDACTED]. The Immodium was administered at 2:20 am. The day shift nurse (Licensed practical nurse #1) documentation on [DATE] evidenced the following: At 8:00 am, the resident was in front of his room with the breakfast tray in front of him. At 9:00 am, the resident went to the bathroom and put the call light on. The CNA (certified nurse aide #1) entered the bathroom and observed BM (bowel movement) on the floor, the resident was requesting to use the toilet. The CNA called the nurse and stated the resident was unable to stand. The nurse told the CNA to assist the resident to the bed and clean the resident. At 9:30 am, the nurse went to the residents room to administer the morning medications. The resident took the medications "with some difficulty." The resident was observed to be "restless." At 9:35 am, the nurse called the supervisor to inform her of the resident's condition. The nurse indicated she had attempted to obtain a set of vital signs but was unable to due to the resident's restlessness. An electronic vital sign machine was utilized. At 9:40 am, the nurse indicated the CNA attempted several times to take the resident's vital signs and was unable to (due to restlessness) except for an oral temperature which was 97.4 degrees. The nurse documented the resident was "very restless and moaning." An electronic vital sign machine was utilized. At 9:45 am, the CNA again attempted to get the resident's vital signs and was unable to except for an oral temperature of 97.6. The CNA "came out and stated the resident hands and feet were cold." The nurse and supervisor went to the resident's room. The resident (skin) was "cold." The nurse checked the resident's pulse oxygen saturation level (Sp02%) on room air and it was 80%. The nurse then obtained a portable oxygen tank and placed a face mask (a simple mask) on the resident and started oxygen at 5 LPM (liters per minute). At 9:50 am, the resident's pulse oxygen saturation level was rechecked and was still at 80%, the nurse increased the oxygen to 10 LPM. At 9:50 am, the supervisor texted the attending physician and notified him of the resident's change in condition and need to be transferred to the emergency room for emergency care services. The physician texted back an order to send the resident out to the ER for evaluation and treatment. At 10:00 am, the order was written. At 10:10 am, the POA (power of attorney) for Resident #1 was notified of the resident's condition and need to transport to the ER. At 10:15 am, the Nursing Supervisor called EMS. Oxygen is vital to human life. It makes up about 21 percent of the air (the rest is nitrogen and other gases). In emergency situations, medical professionals use special types of oxygen masks to help patients breathe more easily. *A simple mask can provide up to 60 percent and allows room air to mix with the delivered oxygen. A partial rebreather can deliver concentrations up to 70 percent and is similar to a simple mask but has a bag attached to collect the first half of exhaled oxygen, which is rebreathed by the patient. **A nonrebreather has a one-way valve to prevent rebreathing of exhaled air and is used when high levels of oxygen up to 95 percent are required. ***Oxygen saturation is a term referring to the concentration of oxygen in the blood. The human body requires and regulates a very precise and specific balance of oxygen in the blood. Normal blood oxygen levels in humans are considered ,[DATE] percent. If the level is below 90 percent, it is considered low resulting in hypoxemia. Blood oxygen levels below 80 percent may compromise organ function, such as the brain and heart, and should be promptly addressed. Continued low oxygen levels may lead to respiratory or [MEDICAL CONDITION]. Oxygen therapy may be used to assist in raising blood oxygen levels. ****Pulse oximetry (Sp02% ) is a method used to measure the concentration of oxygen in the blood. A small device that clips to the body (typically a finger but may be other areas), called a pulse oximeter, uses infrared light to estimate the amount of oxygen in the blood. The clip attaches to a reading meter by a wire to collect the data. The above information was referenced from www.nih.gov (National Institute of Health). The clinical record failed to evidence the facility staff utilized a manual stethoscope and blood pressure cuff in attempts to obtain and monitor the resident's blood pressure after recognizing the electronic monitor machine was not working on the resident due to the resident's restlessness. The nursing staff failed to obtain a blood pressure or pulse rate during the course of an acute change in respiratory status from 9:35 am until EMS arrived at the resident's bedside at 10:22 am, a total of 47 minutes. The clinical record failed to evidence the facility staff obtained a respiration rate to monitor the resident acute change in respiratory status from 9:35 am until EMS arrived at the resident's bedside at 10:22 am, a total of 47 minutes. The clinical record failed to evidence the facility staff monitored the resident's pulse oxygen saturation (Sp02%) level during an acute change in respiratory status from 9:50 am until EMS arrived at the resident's bedside at 10:22 am, a total of 32 minutes. According to the nursing supervisor who was interviewed on [DATE], a **non-rebreather mask was available but never used for Resident #1. A copy of the Fire-Rescue report was obtained. The report evidenced EMS was called and dispatched at 10:14:27. The unit arrived at the scene at 10:20:23, the paramedics were at the resident's bedside at 10:22 am. The EMS unit departed the facility enroute to the ER at 10:54:56 am. The description/details documented by paramedic #1 were as follows: The resident was found lying on his back, unresponsive. The residents airway was partially obstructive, the resident was having agonal breathing. The resident's temperature was 97.2, his skin was cold and pale in color. The resident's eyes/pupils were non-reactive and dilated. Pulse was 129 and Sp02% was 86. At 10:35 am, the resident was placed on a non rebreather mask at 15 LPM and then transferred to a stretcher and loaded into the medic unit. While inside the medic unit at 10:44 am, the paramedic placed an IO access (Intraosseous) . The resident's Sp02% dropped to 79 and the patient was ventilated via the BVM (bag valve mask a manual respirator that delivers pure oxygen to the patient). At 10:49 am, the resident was intubated and then transported to the ER. Intraosseous infusion (IO) is the process of injecting directly into the marrow of a bone to provide a non-[MEDICATION NAME] entry point into the systemic venous system. This technique is used in emergency situations to provide fluids and medication when intravenous access is not available or not feasible. Referenced from www.nih.gov (National Institute of Health). The paramedic documented while intubating the resident 2 pills were found in the back of the resident's throat. One pill was orange and one was white. On [DATE] at 10:05 am, paramedic #1 was interviewed at the local rescue station. He stated he was the first responder to enter the resident's room. Upon entering the resident's room a nurse was there. The nurse (LPN#1) stated the resident was fine that morning and then left the room without providing any additional information. The paramedic stated the resident was unresponsive, unconscious and was having agonal breathing. The paramedic stated the resident's pulse oxygen was 85% on 10 LPM. The paramedic stated a pulse oxygen saturation level in the 80's is too low for someone who does not have an underlying chronic respiratory disease. The paramedic indicated that he was concerned with having answered other rescue calls at the facility and either the resident did not require emergency care services or the resident was in an acute condition that should have been acted upon much sooner. Agonal respirations are irregular, gasping breaths often seen during [MEDICAL CONDITION]. In most cases, rescuers will see victims take these gasping breaths no more than 10 to 12 times per minute; that's one every five to six seconds. Agonal respirations do not provide adequate oxygen to the body and should be considered the same as no breathing at all. Referenced from www.nih.gov (National Institute of Health). Upon arrival to the ER the resident was treated by the emergency room physician and transferred to the ICU and placed on a ventilator. Resident #1 subsequently expired two days later on [DATE]. The discharge summary primary [DIAGNOSES REDACTED]. Interviews with the nurse, the nursing supervisor, and the attending physician were conducted during the investigation. On [DATE] at 3:35 pm, LPN #1 was interviewed. The nurses notes for [DATE] were read back to the nurse to include the sequence and times of the event as described earlier. She concurred that the times and sequence were correct. She then stated that she had observed the resident wheeling himself around the dining room located on the unit when she arrived to work on the morning of [DATE]. When she administered the resident his morning medications she noted the resident had some difficulty swallowing the medications. She stated this was not normal for him. LPN #1 stated that she asked the resident to open his mouth so she could check to make sure the pills were swallowed, she did not see any pills remaining in the resident's mouth. LPN #1 stated she observed the resident was restless. LPN # 1 stated, earlier the CNA had attempted to assist the resident with transferring to the toilet from the wheelchair and the resident was not able to stand, LPN #1 stated this was not normal for the resident. She stated the resident was weak and she contributed that to the resident having had several diarrhea episodes earlier during the night shift. The nurse indicated she had attempted to obtain a set of vital signs but due to the resident's restlessness was unable to. After administering the medications she called the supervisor to notify her of a change in the resident's condition. The nurse was asked if a manual blood pressure cuff and a stethoscope were available for use. She stated "Yes, on the medication cart." She was asked why she did not utilize these and stated, "My concern was that he was responding to us...he looked like he wanted to rest...if he had that much loose stool then he is weak...my other concern was that he was going to have a [MEDICAL CONDITION] or try to get out of bed." The nurse indicated several minutes later she came back to check on the resident and asked him if he was okay, he responded, "yes." The nurse stated upon returning back into the room she noted the resident was "restless...moving side to side...I took the machine (vital sign machine) but because he was moving so much the machine would not register." LPN #1 stated, "All of a sudden he didn't look right...his facial expression...I called the nursing supervisor." Several minutes later the CNA attempted to obtain a set of vital signs using this same machine and was unable to due to the resident's restlessness. The CNA noted the resident's feet and hands felt cold and he notified the nurse. At this time the nurse and the supervisor were at the nurses station and went to the resident's bedside. The resident's pulse oxygen level was 80% and the nurse placed the resident on oxygen via a simple face mask at 5 LPM. Five minutes later the nurse rechecked the pulse oxygen level and it was still at 80%, she then increased the oxygen to 10 LPM. The nurse indicated the resident was not gasping for air and his respirations were at 23 minute. There is no documentation in the clinical record of the resident's respiratory rate during the change in respiratory status. The supervisor stated, "Let's call the doctor." The supervisor texted the attending physician. The attending physician responded with an order to send the resident out to the emergency room for evaluation. This call was documented at 9:50 am. At 10:14 am, the nursing supervisor called 911. Twenty four minutes had lapsed from the time the physician order [REDACTED]. The nurse was asked why was there a delay in calling 911. She stated the nursing supervisor was responsible for calling 911. She indicated she was getting the paperwork together for the paramedics. She indicated this was the first time she had sent a resident out 911 during a weekend. She indicated usually there is a unit secretary responsible for copying records for the 911 responders. The nurse indicated she was trying to gather the paper work needed and was having to copy each sheet separately. The nurse indicated in between making copies she was going back and forth to the resident's room. The nurse indicated she was at the resident's bedside when the paramedic arrived and stated the resident was alert. The nursing supervisor was interviewed on [DATE] at 11:30 am. She stated she assessed the resident by listening to his lungs with a stethoscope. The nursing supervisor stated the resident was breathing rapid "about" 22 breaths per minute. She stated the resident's face was "a little purple." The supervisor was asked to demonstrate how the resident was breathing. During this demonstration the supervisor breaths were short and rapid, by count the resident's respirations would have been approximately ,[DATE] minute. The supervisor stated she raised the resident's head of the bed, oxygen was placed on the resident and she asked the CNA to get a set of vital signs. The supervisor stated she left the room to text the physician. The physician texted her back to send the resident to the emergency room for evaluation. She stated the physician asked her "To call the family whether they want him to go to the hospital...I couldn't get a hold of them (family)...I finally got a hold of them." The supervisor stated, "He (Resident #1) needed an acute level of care..." The documentation evidenced the family was contacted at 10:10 am., and the 911 call was received by the dispatcher at 10:14 am. The supervisor was asked why the resident was not changed from a simple mask to a nonrebreather mask. She did not respond. When asked if she knew what the difference between a simple mask and a nonrebreather mask was she stated, "I guess education is needed." The physician order [REDACTED]. On [DATE] at 1:15 pm, the attending physician for Resident #1 was interviewed via the telephone. The physician stated he received a text message from the supervisor at approximately 9:40 am and responded with an order to send the resident out to the ER for evaluation at 9:50 am. The physician stated he informed the supervisor to make sure they inform the resident's family that the resident was going to be sent out, he did not indicate he instructed the nurse to notify the family first and then call 911. The physician stated, "They didn't say the patient was not breathing, I knew his oxygen was down." The physician was asked what his expectation is for the time he gives an order to send a resident out 911 to the time the nurses call 911. He responded, "I would expect for them to call immediately...within ,[DATE] minutes...each and every minute is valuable...I don't know why she (the supervisor) waited." The above findings was shared with the administrator and the director of nurses on [DATE] at 5:50 pm. The DON stated her expectation is that the nursing staff call 911 immediately after an order is obtained. She indicated a nonrebreather mask was available and she would have used this one instead of the simple face mask. The DON also indicated she would have expected the nurses to have obtained and monitored the resident's vital signs (i.e., blood pressure, respirations, pulse, temperature, pulse oxygen level) at least every 5 minutes to include the use of a manual blood pressure cuff if the electronic vital sign machine was not able to obtain the vital signs, until the first responders arrived. 2. The facility staff failed to ensure Resident #2 was provided the necessary care and services from Emergency Medical Services in a timely manner after an assessed acute medical change on [DATE]. Resident #2 was a [AGE] year old readmitted to the facility on [DATE] previous admission was [DATE]. The resident's [DIAGNOSES REDACTED]. Based on medical record review the resident was a full code status prior to being discharged on [DATE] per the signed physician orders [REDACTED]. *Hypertension: a common disorder that is a known cardiovascular disease risk factor, characterized by elevated blood pressure over normal values of ,[DATE] mm Hg (milligrams of mercury) in an adult. *[MEDICAL CONDITION]: an abnormal condition that may affect the heart's arteries and produces various pathologic effects, especially reduced flow of oxygen and nutrients to the myocardium. *Diabetes Mellitus: a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion by the beta cells of the pancreas or resistance to insulin. *[MEDICAL CONDITION] Fibrillation: a cardiac arrhythmia characterized by disorganized electrical activity in the atria accompanied by an irregular ventricular response that is usually rapid. The atria quiver instead of pumping in an organized fashion, resulting in compromised ventricular filing and reduced stroke volume. Stasis of left [MEDICAL CONDITION] flow increases the risk of stroke as a result of clot formation. 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 a annual dated [DATE] with a Brief Interview for Mental Status (BIMS) of a 4 out of a possible 15 which indicated that Resident #2 had severely impaired cognitive skills needed for daily decision making. Resident #2 required one person extensive assist for transfers, bathing, dressing, and toileting. For eating the resident was supervision setup help only. The MDS also indicated that Resident #2 had upper extremity impairment on only one side, no lower extremity impairment was noted. The comprehensive plan of care dated [DATE] prior to the resident's discharge to the hospital on [DATE] due to an acute change of condition indicated that the resident was a Full Code. The goal stated that, "the resident's desire for full code/CPR (cardio-pulmonary resuscitation) status will be followed". The attending physicians progress noted dictated [DATE] stated that Resident #2, "has been doing okay and is pretty much active now and participating in activities and going to different places in his wheelchair, remains friendly and cheerful." Review of the medical record based on the nurses notes by Registered Nurse (RN) #1, indicated that on [DATE] at 9:30 a.m. Resident #10 was noted in his wheelchair in the dining area with an asymmetrical face and drooling from his mouth. The resident was also unable to move his right leg to propel his wheelchair and his vital signs were obtained. At 9:40 a.m. the attending physician was notified of the resident's change of condition and ordered the resident be sent to the local emergency room for further evaluation and treatment. At 9:42 a.m. Resident #2's daughter was called and a message left for her to call the facility. At 9:45 a.m. RN #1 called 911 to report the resident's condition and request transfer to the hospital. Then at 10:02 a.m. Resident #2's daughter was called again and informed of his condition and was in agreement to send the resident to the hospital for evaluation. At 10:30 a.m. Resident #2 left the facility via 911 enroute to the local hospital. The physician order [REDACTED]. and treat." An interview was conducted on [DATE] at 11:00 a.m. with RN #1 regarding Resident #2's change of condition on [DATE]. When she was asked to describe how she found the resident that morning she stated, "I noticed he was crying a lot, his face was asymmetrical, he was drooling from his mouth, and he was not moving his right leg." When RN #2 was asked if this was normal for Resident #2 she stated, "No, I knew something was wrong he usually moves all over the facility in his wheelchair. He looked like he was having a stroke." RN #2 was asked to read and review her nurses notes from [DATE] and verified her assessment of the resident, the times she notified the attending physician and family and also the time she call 911 were accurate as charted. This surveyor asked RN #2 if a possible stroke was a medical emergency she stated, "Yes it is, you only have a short time for intervention." *Stroke: also called [MEDICAL CONDITION] which is an abnormal condition of the brain characterized by occlusion by an [MEDICAL CONDITION], thrombus, or [MEDICAL CONDITION] hemorrhage or vasospasm, resulting in ischemia of the brain tissues normally perfused by the damaged vessels. The above definition was derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition. On [DATE] at 12:30 p.m. the 911 Emergency Medical Station that transported Resident #2 to the hospital on [DATE] was called. At this time paramedic #2 verified that they had transported Resident #2 and that they were dispatched to the facility at 10:06 a.m. on [DATE] approximately one minute after the facility called 911 dispatch. To recap, RN #1 received the order to send Resident #2 to the ER from the attending physician at 9:40 a.m. on [DATE]. The 911 Emergency Medical Station was dispatched to the facility at 10:06 a.m. Therefore it is noted that there was approximately 26 minutes from the time the order was received to the call being placed to 911 for emergency transport. On [DATE] at 1 p.m. an interview was conducted via phone with Resident #2's attending physician. During this interview the attending physician was asked what his time frame expectations would have been for obtaining 911 assistance for Resident #2's change of condition. The attending physician stated, "Immediately, 5 to 10 minutes after the order is given". The attending physician was then asked if he felt that 26 minutes after the order was received would be considered immediately, he stated, "No, it is not". Based on medical record review Resident #2 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Resident #2 was readmitted back to the facility on [DATE] under Hospice services with a DO Not Resuscitate Comfort Measures order. Resident #2 expired on [DATE] in the facility. During a pre-exit interview with the Administrator and the Director Nursing the above findings were shared. The Director of Nursing shared that they were planning on cutting back on the facilities certified nursing assistant classes this year so that more training could be provided to present in house staff members. No further information was provided.