Every finding on record at Carrington Place of Tappahannock

Based on staff interviews, clinical record reviews, and review of facility documents, the facility staff failed to ensure the activities program was directed by a qualified professional who could direct the provision of activities to the residents which resulted in substandard quality of care. The findings included: During the recertification survey conducted 7/9/2024 through 7/11/2024 and an extended survey conducted through 7/15/2024, residents were identified who could benefit from meaningful and individualized activity programs. For the Activities Director, the facility has hired an activities director who does not meet the qualifications set forth in the regulations. On 7/9/24 at approximately 2:00 PM an interview was conducted with Employee E the Activities Director who stated that she had been in that role since September 2023. When asked about her credentials she stated that she did not have any certification or attend a program or training course. She indicated that she would be willing to attend any training necessary to ensure her job security and further her career as she enjoyed the job and enjoys working with the Residents. On the morning of 7/12/24 an interview was conducted with the Administrator who acknowledged that the Employee E did not yet have the qualifications for the position of activities director. On 7/15/24 during the end of day meeting the Administrator was made aware that the Activities Director did not have the mandatory requirements for training to serve in that role. No further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with the potential to affect all residents in the facility. The Findings included: The facility staff failed to develop and implement a Legionnaire's water policy or program or Quality Assurance and Process Improvement (QAPI) program . During the entrance conference, the facility's Administrator stated the previous Maintenance Director had quit on 6/28/2024 and had not been replaced at the time of the survey on 7/9/2024. Surveyor C informed the Administrator that she would review the Legionnaires program with the person in charge of the program. The Administrator stated the Maintenance Director was in charge of the testing for Legionnaires. Review of the facility's documentation revealed no records of testing the water for Legionella. There was no documentation of the Facility's Legionnaires policy. Review of the QAPI records revealed no documentation of the issue of testing the water for Legionella . On 7/11/2024, Surveyor C conducted an interview with the Administrator who stated the facility had not established an effective program for the detection of Legionella. She also stated the issue had not been discussed in the QAPI meetings. During the end of day debriefing, the Administrator, Director of Nursing and Corporate Nurse Consultant were informed of the findings. No further information was provided.

Based on interview, clinical record review and facility documentation, the facility staff failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being, for 14 out of 14 Residents that attended the group meeting. The findings included: For Residents attending the group meeting, the facility staff failed to assign a shower aid during the time that CNA B (the shower aid) was on vacation, resulting in no showers being given to 14 out of 14 Residents attending the group meeting. On the afternoon of 7/10/24 during the group interview it was stated that there was no shower aid to give showers while Employee B (the shower aid) was on vacation. Fourteen out of 14 Residents representing both units agreed on this statement. The group agreed that CNA (Certified Nursing Assistant) G was the only one who gave showers, and she gave them only to residents on her assignment list. They stated the facility did not assign anyone to take over the shower aid assignments, therefore no showers were done by other staff. The group also stated that showers are given only during the time the shower aid is on duty 7-3 this meant Residents could not get showers in the evening or night shift. On the afternoon of 7/12/24 an interview was conducted with the DON and Administrator. The DON was asked if they had a CNA that was assigned to give showers, and she stated that there was, and she named CNA B. When asked who was assigned to take her place when she went on vacation. She stated that the CNA's can-do showers. When to what the resident council stated about no one getting showers except those on Employee G's assignment, she stated that the CNA's can do it when she is not here. A review of the assignment sheets for the week of 7-1-24 through 7-7-24 revealed that there was no one assigned to do showers, and there was no indication that all CNA's must do their own showers for the week CNA B was off. On 7/15/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to act promptly upon the grievances arising from Resident Council. The findings included: Resident council continues to have complaints of the same nature with no improvement month after month, the facility has not effectively addressed the concerns of the Residents regarding menus, timeliness of CNA rounding, cleanliness of the building and issues with patio and temperatures in the building. A review of the Resident Council minutes revealed the following: December 2023- Residents complained there was not enough housekeeping staff on weekends. January 2024 - Housekeeping - Dining room is dirty / filthy. February 2024 - meeting was rescheduled for March due to Covid outbreak. March 7, 2024 - Fixing up the patio putting the umbrellas back so they can enjoy the weather. March 20, 2024 (rescheduled from February) - Collective agreement about the dining room being unclean - as well as resident bathrooms. Fixing up the patio umbrellas for shade. April 2024 - Residents stated they would like someone to help the shower aid with showers. Deep cleanings are not being done like they should. Residents are getting tired of the same meals over and over again. May 2024 - No CNA rounding at night, Residents would like their wheelchairs cleaned and inspected. Food is horrible same repeated menus. June 2024 - Still having issues with cleanliness of resident bathrooms. Resident council expressed issue with repeated menus same meals, Dietary Mgr. explained the process of winter menus and summer menus. Residents complained there are no snacks available at night. CNA's should be making rounds every 2 hours. July 2024 - Air conditioning in the dining room. Administrator talked about process pertaining to fixing the issue. Dietary Mgr. is working on changing the menus changes to the meals adding fresh fruit and vegetables. Residents would like the patio tables and umbrellas back. CNA rounding is not happening on 3-11 shift. On the afternoon of 7/12/24 an interview was conducted with the Activities Director who stated that each department is given the feedback from Resident Council to address within their department. When asked if she saw the same issues keep arising month after month, she stated that she did see a pattern. On 7/12/24 during the end of day meeting the Administrator was made aware of the concerns and no further information as provided.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure a Residents right to a safe clean, comfortable homelike environment for Residents in a survey sample of 33 Residents. The findings included: The facility staff has failed to ensure the facility was in good repair, temperatures were comfortable, and failed to ensure the cleanliness of the dining room, and resident bathrooms. On 7/9/24 at approximately 12:30 PM the following observations were made in the dining room: The large table near the windows had puzzles, books, a plastic tub of markers and pens in the center while Residents were eating their meal. The dining room has shelves for activity supplies however they were not put on the shelves in preparation for noon meal. The dining room was warm there was one fan blowing in the front of the dining room and a portable a/c unit vented to the outside at the rear of the dining room however the temperature was still too warm for comfort. There was no thermostat / thermometer in the dining room. Staff did not have access to maintenance equipment to check the temps in the dining room at that time. ** Please note the Resident Rooms have individual PTAC wall units. Residents can stay cool if they remain in their rooms. The air conditioning that is broken is the main central air for the facility. This central air unit affects the halls, common areas, kitchen, laundry, lobby, and the second floor where the physical therapy gym is located. The Residents cannot access the second floor at this time due to the elevator also being out of service. *** The following observations were made in Resident Rooms: 7/9/24 at 11:35 Resident #9 complained that his bathroom light was not working, and he has to leave his door open to be able to see. Resident #9's bathroom smelled strongly of urine. Surveyor stepped into [NAME] and [NAME] style bathroom (that is a bathroom located between 2 resident rooms where occupants of both rooms share a bathroom.) When the door was closed the only light visible was the light shining in the crack at the bottom of the door. Resident #9 stated that if he closes the door, he cannot see but if he leaves it open anyone can see him. On 7/9/24 at approximately 11:45 Resident #3 was observed in bed dressed in hospital gown sheet covering body. Interview was conducted and Resident #3 was conducted and he stated he was hot and sweaty. There was a white sheet of notebook paper taped to the PTAC (Packaged Thermal Air Conditioner) unit that read, Do Not Turn On A/C Leaks. There were several dirty towels and a bath blanket shoved under the unit stained with yellowish stains and obviously wet. When asked how long the air conditioner had been broken Resident #3 stated that the Maintenance Man said he would fix it a week ago. **Please note Maintenance Director (who is the only maintenance person employed by the facility) has been gone since 6/28/24 quit without notice and has not been replaced as of the end of survey (7/15/24). ** On 7/10/24 at 9:45 AM Resident #3 was observed in his bed dressed in a hospital gown and covered with a sheet. Resident #3 expressed being hot and sweaty. On the morning of 7/11/24 the Administrator was asked about the repairs to the air conditioning unit in Resident #3's room and she stated that she was not aware of a problem with the air conditioning unit in his room. Administrator walked to the room with the surveyor and observed the sign on the unit and the felt how warm it was in the room. The Administrator stated that she would handle it immediately and stated that had she been aware of the issue she would have handled it sooner. When asked who put the signage up about the air conditioner being broken she stated that she did not know. When asked about the process for handling maintenance issues she stated that the nurses fill out a slip and put it in the box for maintenance director to handle. When asked who is doing maintenance now, she stated that the Maintenance Director was the only maintenance staff and he left on 6/28/24 without notice. She stated that she was conducting interviews this week to fill the position, however, currently there was no interim person filling in. On the afternoon of 7/10/24 during the Group Interview, Resident # 16 complained about the sink in his room being stopped up. On 7/10/2024 at 4:15 p.m., when the cold water was turned on, there was noted delay in the water draining from the sink. There was a slow drain time. When interviewed, Resident # 16 stated the sink had been stopped up for a while. Resident # 16 stated staff members were informed of the clogged sink previously. During the end of day debriefing on 7/10/2024, the administrator was informed of the issue with the sink in Resident # 16's room. The Administrator stated she was unaware of the sink being clogged. Resident # 16 also reported that there was a screw missing in the footboard of his bed and it was wobbly. The Administrator and Director of Nursing were informed of the complaint during the end of day debriefing. The Director of Nursing stated she would check into it. On 7/15/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public The findings included: For the residents, staff and the public the facility staff failed to maintain a working elevator, working air conditioning in the common areas (not Resident Rooms), dining area that clean and free of clutter, and Resident bathrooms that were clean. On 7/9/24 observations were made: 11:30 a.m. - Entrance to facility the lobby area was very warm apparent that there was an issue with the air conditioning. 11:45 a.m. - Sign on elevator in lobby Do not use elevator is broken. 11:55 p.m. - The large table near the windows had puzzles, books, a plastic tub of markers and pens in the center while Residents were eating their meal. The dining room has shelves for activity supplies however they were not put on the shelves in preparation for noon meal. The dining room was warm there was one fan blowing in the front of the dining room and a portable a/c unit vented to the outside at the rear of the dining room however the temperature was still too warm for comfort. There was no thermostat / thermometer in the dining room. On 07/09/2024, at approximately 12:30 p.m., during the initial tour of the facility, it was observed that the South Hall, nursing station and the resident dining room was very warm. The Hall thermostat was set at 63 degrees Fahrenheit and was reading a temperature of 79 degrees Fahrenheit. An interview was conducted with Residents #39 and #40. When asked about the temperatures Resident #40 stated that the main air condition unit for the facility has been broken for over a month and the facility staff is using the air-condition units in the residents room to cool the halls. On 7/9/24 at 1:35 p.m. Resident #9 complained that his bathroom light was not working, and he has to leave his door open to be able to see. Resident #9's bathroom smelled strongly of urine. Surveyor stepped into [NAME] and [NAME] style bathroom (that is a bathroom located between 2 resident rooms where occupants of both rooms share a bathroom.) When the door was closed the only light visible was the light shining in the crack at the bottom of the door. Resident #9 stated that if he closes the door, he cannot see but if he leaves it open anyone can see him. On 7/12/2024 at approximately 10:50 a.m., the Director of Nursing toured the hallways with surveyors. The hallways felt very hot. Residents were sitting in the hallway some were propelling their wheelchairs in the hallways, and some were just standing in the doorways. On the North Hall, the wall mounted fans at the end of the hall were not blowing. The cord to a motorized wheelchair was plugged in the outlet. The Director of Nursing stated the wheelchair could be unplugged. A review of the Resident Council minutes for the previous 6 months revealed the following: December 2023- Residents complained there was not enough housekeeping staff on weekends. January 2024 - Housekeeping - Dining room is dirty / filthy. March 7, 2024 - Fixing up the patio putting the umbrellas back so they can enjoy the weather. March 20, 2024 (rescheduled from February) - Collective agreement about the dining room being unclean - as well as resident bathrooms. Fixing up the patio umbrellas for shade. April 2024 - Deep cleanings are not being done like they should. May 2024 -Residents would like their wheelchairs cleaned and inspected. June 2024 - Still having issues with cleanliness of resident bathrooms. July 2024 - Air conditioning problems in the dining room. On the afternoon of 7/12/24 an interview was conducted with the Administrator who provided timelines for the air conditioning and elevator repairs. The timelines provided stated that the elevator had broken down 3 times. The first breakdown occurred on 5/9/24 and was running again 5/16/24 the second break down occurred on 5/30/24 and was repaired and running again on 6/6/24, the final break down of the elevator occurred on 6/14/24 as of the end of survey is still out of service. The Air Conditioning that is out of service is not in the Resident rooms it affects only the common areas, lobby, hallways, kitchen, dining area, second floor including physical therapy gym and the laundry and staff areas as well. The HVAC unit has been down since 5/24/24. On 7/12/24 during the end of day meeting the Administrator was made aware of the concerns and no further information as provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide an ongoing program to support residents in their choice of activities for 4 Residents (#'s 9, 16, 34, & 36) in a survey sample of 33 Residents. The findings included: For Resident #9 the facility staff failed to conduct an activity assessment to ensure Residents were receiving services from the activities dept that met their interest and personal preferences. Resident #9's most recent Activity Assessment was on 7/14/2023 it read as follows: Reason for Assessment: Initial assessment Orientation: Comments - No change in resident's level of participation since last assessment. Please see 06/26/2023. Progress Summary Note: Quarterly late entry for ARD 07/14/2023: No change in resident's level assessment. Please see assessment dated for ARD 06/26/2023. Proceed with POC. Will monitor. [Former Activities Director name redacted] Resident # 16 did not have an activity assessment. Resident # 34's Activity Assessment read as follows. Reason for Assessment: Initial assessment Orientation: Comments - Resident alert and oriented to person, disoriented to all other spheres. Please see last assessment dated for ARD 05/17/2023. Progress Summary Note: Quarterly for ARD 06/13/2023: No change in resident's level of participation since last assessment. Please see last assessment dated for ARD 05/17/2023. Proceed with POC. Will monitor and follow up on next review. [Former Activities Director name redacted]. Resident # 36 had an initial assessment on 2/15.2024, however, there was no quarterly assessment in the record. On the afternoon of 7/15/24 an interview was conducted with the DON and the Administrator, and they stated if the assessment was not in the electronic medical records, then there was none. When asked when the Assessments should be done and she stated that they should be done on admission, quarterly and yearly. On 7/15/24 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, Resident interview, clinical record review, and facility documentation review, the facility staff failed to measure the success, and track, performance in their Quality Assurance and Process Improvement (QAPI) program for the provision of showers to residents. The findings included; The facility failed to implement their plan to ensure all residents received a shower as scheduled when the Shower Aide was out on leave. As part of the facility's plan to correct the problem regarding showers, the QAPI committee was tasked with monitoring, measuring, tracking data, and sustaining compliance performance. The facility staff failed to implement measures to ensure Residents received showers as evidenced by their failure to assign the task of Showers/bathing when the Shower Aide was off on leave during July 1- July 7, 2024. Surveyor D documented the following observations: On 7/10/24 at 9:45 AM Resident #3 was observed in his bed dressed in a hospital gown and covered with a sheet. Resident #3 expressed being sweaty. Resident appeared unkempt hair was greasy, and nails had not yet been cut. Resident had noticeable body odor. When asked if he had been washed up this morning he stated not yet. On the afternoon of 7/10/24 during the group interview it was stated that there was no shower aide to give showers while Employee B (the shower aid) was on vacation. Fourteen out of 14 Residents representing both units agreed on this statement. The group agreed that CNA G was the only one who gave showers, and she gave them only to residents on her assignment list. They stated the facility did not assign anyone to take over the shower aide assignments, therefore no showers were done by other staff. The group also stated that showers are given only during the time the shower aide is on duty 7-3 this meant Residents could not get showers in the evening or night. A review of the assignment sheets for the week of 7-1-24 through 7-7-24 revealed that there was no one assigned to give showers, and there was no indication that all CNA's must do their own showers for the week CNA B was off. During the end of day debriefing on 7/15/2024, the Administrator was made aware of the concerns. The Administrator stated residents should be able to receive showers when scheduled. No further information was provided

Based on staff interview and facility documentation review, the facility staff failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, having the potential to affect all 58 residents residing in the facility. The findings included: 1. The facility staff failed to maintain an effective QAPI program regarding the residents receiving showers at least twice per week. On 07/09/2024 during the initial tour, the survey team interviewed alert and oriented residents who stated they had did not receive baths or showers when the assigned Shower Aide was not on duty. During the Group Interview/Resident Council Meeting conducted on 07/10/2024, there were fourteen alert and oriented residents in attendance. The residents stated they only received showers when the Shower Aide (Certified Nursing Assistant -B) was on duty. But when she was off, they did not get showers. The residents stated one other Certified Nursing Assistant (Certified Nursing Assistant-G) did give showers to those residents on her assignment during the previous week when the Shower Aide was off. They stated the other staff members did not give showers to the residents on their assignments. Review of the facility's grievances revealed concerns expressed by Residents of showers not being provided. Review of the Resident Council minutes for 6 months (January 2024- June 2024) revealed complaints about showers not being provided. Review of the QAPI information revealed documentation of the concern being addressed in May 2024. Review of the Inservice Education Records revealed documentation of education being provided on January 5, 2024 about showers being provided as scheduled and the right of refusal. The facility staff failed to ensure showers were provided to the residents while the Shower Aide was off for a week. On 7/11/2024 at 1:20 p.m., an interview was conducted with the Director of Nursing who stated the facility did use a Shower Aide who worked 5 days a week and on the Day Shift. When asked if Residents could receive showers on the evening shifts, night shifts or weekends, the Director of Nursing stated other Certified Nursing Assistants could provide showers. She stated the showers were usually done by the Shower Aide who worked on day shift Monday through Friday. Review of the QAPI notes and in-services from January 5, 2024, May 5, 2024 and May 8, 2024 revealed documentation that facility staff members were educated on the importance of and expectation of showers to be provided to residents even when the Shower Aide was off or not available. Review of clinical records of residents in the survey sample revealed showers were not provided two times per week as scheduled. During the week that the Shower Aide was off on leave, there were no showers provided to most of the residents. On 07/12/2024 at 11:10 a.m., the Administrator was informed that the interview for QAPI would be conducted on Monday, 07/15/2024. Review of the Survey Ready Binder revealed a sheet of paper that stated QAPI Plan: Please see QAPI plan. On 07/15/2024 at 1:58 p.m., an interview was conducted with the facility Administrator. The QAPI program/plan was reviewed during the interview. The Administrator stated the purpose of the QAPI program was to identify anything from the previous month and implement system changes to bring the facility into compliance. She stated the QAPI Committee met monthly to identify issues and address them. The Administrator stated they were expected to monitor ongoing compliance. The Administrator stated she did not have the policies and procedures for QAPI. The Administrator stated the facility staff members should ensure residents receive showers when the Shower Aide was off and on whatever shift they desired. The Administrator stated clearly it's broken. We need to readdress this. We need to make sure someone is scheduled to provide showers. The facility's policy on QAPI was not presented to the survey team prior to the end of survey During the end of day debriefing on 07/15/2024, the Administrator, Director of Nursing and Corporate Nurse Consultant were informed of the findings that the facility staff failed to maintain an effective QAPI program regarding provision of showers to residents at least twice per week. It was noted the facility did not ensure a staff member was assigned to provide showers when the Shower Aide was off on leave. Also, Residents were not offered the option of showers on the other shifts or the weekends. They stated the facility should make sure all residents receive at least two showers per week and document any refusals. No further information was provided.

Based on facility staff interview, and facility documentation, the facility failed to ensure that the nurse aides had 12 hours of in-service training including dementia, abuse preventions and facility assessments, and special needs of residents in a year. The findings included: The facility failed to ensure that all Certified Nursing Assistants (CNA's) had performance evaluations, and regular in-service education every 12 months for 2 CNA's #B and #F, in a survey sample of 7 employees. The facility failed to ensure that the ensure Certified Nursing Assistants (CNA's) have a performance evaluation every 12 months and have regular in-service education. Review of the Medline University Training Transcripts and Staff Education files revealed that the CNA's, in the staff survey did not have the mandatory in-services education and training. On 07/12/2024 at 2:00 p.m. an interview was conducted with the Human Resource (HR) Manager, and the Director of Nursing (DON) who were asked about staff training regarding, the CNA's, mandatory in-services education and training. The DON stated that they provide some in-services for the CNA's and other Licensed staff but that the training and education program was revamped in January 2024, and mainly maintained and recorded by Medline University. The DON went on to say that they have no documentation of trainings completed prior to this January 2024. On 7/15/2024 during the end of day meeting, the Administrator and the Director of Nursing (DON) were made aware of the findings. No further information was provided.

Based on facility staff interview, and facility documentation, the facility failed to ensure that all staff members had completed the mandatory Ethics and Compliance Training. The findings included: The facility failed to ensure that all staff members had completed the mandatory Ethics and Compliance Training for 7 employees in a survey sample of 7 employees: 2 Certified Nursing Assistants (CNA's) #B and #F, 3 Licensed Practical Nurses (LPN's) #E, #F, and #G, 1 Registered Nurse, RN #D, and the Administrator. Review of the Medline University Training Transcripts and Staff Education files revealed that none of the direct care staff in the survey sample had completed the mandatory Ethics and Compliance Training. On 07/12/2024 at 2:00 p.m. an interview was conducted with the Human Resource (HR) Manager who was asked about staff training regarding, Ethics and Compliance Training, and she stated that training and education are recorded by Medline University and was initiated in January 2024. The HR Manager went on to say that they have no documentation of trainings completed prior to January 2024. On 07/15/2024 during the end of day meeting, the Administrator and the Director of Nursing (DON) were made aware of the findings. No further information was provided.

Based on facility staff interview, and facility documentation, the facility failed to ensure that all direct care staff complete mandatory Effective Communication training. The findings included: The facility failed to ensure that all direct care staff complete mandatory Effective Communication training for 7 employees in a survey sample of 7 employees: 2 Certified Nursing Assistants (CNA's) #B and #F, 3 Licensed Practical Nurses (LPN's) #E, #F, and #G, 1 Registered Nurse, RN #D, and the Administrator. Review of the Medline University Training Transcripts and Staff Education files revealed that none of the direct care staff has documented completion of mandatory Effective Communication training. On 07/12/2024 at 2:00 p.m., an interview was conducted with the Human Resource (HR) Manager who was asked about, direct care staff having completed mandatory Effective Communication training, she stated that training and education are recorded by Medline University and was initiated in January 2024. The HR Manager went on to say that they have no documentation of trainings completed prior to this date. On 07/15/2024 during the end of day meeting, the Administrator and the Director of Nursing (DON) were made aware of the findings. No further information was provided.

Based on facility staff interview, and facility documentation, the facility failed to implement and maintain an effective training program for all new and existing staff. The findings included: The facility failed to maintain an effective training program for 7 employees in the survey sample of 7 employees: 2 Certified Nursing Assistants (CNA's) #B and #F, 3 Licensed Practical Nurses (LPN's) #E, #F, and #G, 1 Registered Nurse, RN #D, and the Administrator. Review of the Medline University Training Transcripts and Staff Education files revealed that none of the direct care staff employees in the survey sample had maintained an effective training program. On 07/12/2024 at 2:00 p.m. an interview was conducted with the Human Resource (HR) Manager who was asked about, an effective training program, she stated that training and education are recorded by Medline University and was initiated in January 2024. The HR Manager went on to say that they have no documentation of trainings completed prior to this date. On 07/15/2024 during the end of day meeting, the Administrator and the Director of Nursing (DON) were made aware of the findings. No further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents who use psychotropics receive gradual dose reduction and are free from unnecessary psychotropic medications for 1 Resident #9 in a survey sample of 33 Residents. The findings included: For Resident #9 the facility staff failed to act on a recommendation from the pharmacy to reduce one or both of the Resident's psychotropic medications. On 7/11/24 a clinical record review was conducted on Resident #9's electronic health record. The record showed that on a pharmacy recommendation dated over a year ago (5/29/23), had not been addressed until 7/18/23 and then was not acted on. The pharmacy recommendation read as follows: The resident receives the following medications that may significantly prolong QT interval and increase risk for arrhythmias and or torsade's (TdP): Citalopram 30 mg QHS and doxepin 50 mg Q PM. Rationale: QT intervals in apparently normal older individuals when combined with expected QT interval changes induced by medications is associated with significantly prolonged QT intervals. Women, older adults, those with heart failure or preexisting arrhythmias may be at increased risk. Please consider decreasing one or both of the above agents and / or consider changing to alternatives. The physician signed and checked the box that said Agree and wrote Resident is male on the form. Resident #9 has diagnoses that include but are not limited to morbid obesity, sleep apnea, type II diabetes, hypertension, high cholesterol, kidney failure and atrial fibrillation (an arrhythmia). A review of the clinical record revealed that Resident #9's dosages had not been decreased nor had medications been changed, in fact the Resident's dose of Citalopram was increased to 40 mg. per day and the Doxepin was still 50 mg. A review of the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/23/24 revealed that the facility had not attempted a GDR (Gradual Dose Reduction) since admission on 12/20/22. On the morning of 7/15/24 an interview was conducted with the DON (Director of Nursing) who was asked about the expectation for GDR's. The DON was able to verbalize understanding that Federal regulations require that a GDR of a psychotropic medication is attempted twice in the first year of admission or initiation of the medication, then annually, however she stated that she did not know why the GDR was not attempted, A review of the clinical record did not reveal any notes that said GDR is contraindicated in this Resident. The DON stated that she the doctor that signed the pharmacy recommendation is no longer working at this facility but that she would bring this to the attention of the Nurse Practitioner in house. On 7/15/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents received the necessary services to maintain good grooming, and personal hygiene for 4 Resident (#'s 3, 9, 56 & 44) in a survey sample of 33 Residents. The findings included: 1. For Resident #3 the facility staff failed to cut nails and wash Resident's hair. On 7/9/24 at approximately 11:45 Resident #3 was observed in bed dressed in hospital gown sheet covering body. Resident #3 has a dx of a traumatic brain injury and has a BIMS (Brief Interview of Mental Status) score of 7/15 indicating severe cognitive impairment. Resident #3 appeared unkempt hair uncombed and greasy looking, nails were not cut about 1/4 inch over tip of fingers and had debris visible under the nail. Interview with Resident #3 was conducted, and he stated he was hot and sweaty. When asked if he had a shower recently, he stated he does not like showers. When asked how he bathes he stated, They wash me up in bed. When asked about his hair being washed and nails being cut, he stated It's been a while since they did that. A review of the clinical record revealed hair and nail care done on 6/1/24 by DON. On 7/10/24 at 9:45 AM Resident #3 was observed in his bed dressed in a hospital gown and covered with a sheet. Resident #3 expressed being sweaty. Resident appeared unkempt hair was greasy, and nails had not yet been cut. Resident had noticeable body odor. When asked if he had been washed up this morning he stated not yet. On the afternoon of 7/10/24 during the group interview it was stated that there was no shower aide to give showers while Employee B (the shower aid) was on vacation. 14/14 Residents representing both units agreed on this statement. The group agreed that CNA G was the only one who gave showers, and she gave them only to residents on her assignment list. They stated the facility did not assign anyone to take over the shower aide assignments, therefore no showers were done by other staff. The group also stated that showers are given only during the time the shower aide is on duty 7-3 this meant Residents could not get showers in the evening or night. A review of the assignment sheets for the week of 7-1-24 through 7-7-24 revealed that there was no one assigned to give showers, and there was no indication that all CNA's must do their own showers for the week CNA B was off. On 7/15/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 2. For Resident #9 the facility staff failed to ensure showers were given twice a week as scheduled. On 7/11/29 at approximately 10:00 a.m. an interview was conducted with Resident #9 who was asked about receiving showers and or baths during the week of 6/30/24 - 7/6/24. Resident #9 stated that he did not receive a shower because that was the week the shower aide was on vacation. Resident #9 stated he washed as best he could at the sink. On 7/11/24 a review of the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/26/24 revealed that Resident #9 required a Maximum Assistance of 2-person physical assistance for showers. On the afternoon of 7/12/24 an interview was conducted with the DON and Administrator. The DON was asked if they had a CNA that was assigned to give showers, and she stated that there was, and she named CNA B. When asked who was assigned to take her place when she went on vacation? She stated that the CNA's can-do showers. When told what the resident council attendees stated about no one getting showers except those on Employee G's assignment, she stated that the CNA's can do it when the shower aide is not here. A review of the assignment sheets for the week of 7-1-24 through 7-7-24 revealed that there was no one assigned to do showers, and there was no indication that all CNA's must do their own showers for the week CNA B was off. On 7/15/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 3. For Resident #56 the facility staff failed to ensure bathing and nail care was provided while the shower aide was on vacation. On 7/11/24 during the group meeting Resident #56 stated that he did not get his nails cut and showed the surveyor that his nails were indeed at least 1/4 inch over the tips of his fingers. Resident #40 told Resident #56 the CNA's should do your nails on your shower day. Resident #56 stated, I didn't get a shower last week because the shower aid was on vacation. The group agreed that this was an issue. The 14 attendees all agreed that only 1 CNA gave showers last week while the shower aid was on vacation. That CNA only gave showers to the residents on her assignment. When asked if the CNA's assigned to them offered them showers they agreed collectively that they were not offered showers and when they were asked, they were told the shower aid is on vacation. On the afternoon of 7/12/24 an interview was conducted with the DON and Administrator. The DON was asked if they had a CNA that was assigned to give showers, and she stated that there was, and she named CNA B. When asked who was assigned to take her place when she went on vacation? She stated that the CNA's can-do showers. When told what the resident council attendees stated about no one getting showers except those on Employee G's assignment, she stated that the CNA's can do it when the shower aide is not here. A review of the assignment sheets for the week of 7-1-24 through 7-7-24 revealed that there was no one assigned to do showers, and there was no indication that all CNA's must do their own showers for the week CNA B was off. On 7/15/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 4. For Resident #44 the facility staff failed to ensure twice weekly showers while shower aide was on vacation. During the group meeting Resident #44 stated that she had not had a shower last week and stated that she usually gets her hair washed as well and that did not happen because the shower aide was on vacation. On the afternoon of 7/12/24 an interview was conducted with the DON and Administrator. The DON was asked if they had a CNA that was assigned to give showers, and she stated that there was, and she named CNA B. When asked who was assigned to take her place when she went on vacation? She stated that the CNA's can-do showers. When told what the resident council attendees stated about no one getting showers except those on Employee G's assignment, she stated that the CNA's can do it when the shower aide is not here. A review of the assignment sheets for the week of 7-1-24 through 7-7-24 revealed that there was no one assigned to do showers, and there was no indication that all CNA's must do their own showers for the week CNA B was off. On 7/15/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents receive services in the facility with reasonable accommodation of resident needs for 1 Resident (Resident #9) in a survey sample of 33 Residents. The findings included: For Resident # 9 the facility staff failed to ensure the Resident had a bed that was suitable for his size and weight, comfortable and allowed him enough space to turn safely. On 7/9/24 at approximately 1:00 PM Resident was observed in a regular hospital bed. Resident #9 was interviewed and stated that his bed was uncomfortable. When asked to elaborate he stated I can feel the bed frame digging into my hips in this bed and it is hard to turn over there isn't much room. When asked if he had told the staff he was uncomfortable he stated that he had. When asked what their response was, he stated that they don't have any different beds. When asked if he would like a bariatric bed and mattress, he stated that he would. On 7/9/24 a review of the clinical record revealed that Resident #9 weighed 450 lbs. and had a bariatric wheelchair, a bariatric raised commode seat but was put in a regular sized bed with a regular mattress. On 7/9/24 at 3:00 PM an interview was conducted with the Administrator who stated that if a resident requires bariatric equipment such as wheelchair and walker that is ordered through therapy. When asked about beds she stated that would have to come through the Administrator. The Administrator was asked for the manufacturer instructions for the bed and mattress. On 7/10/24 the corporate Nurse was asked to accompany surveyor to Resident #9's room and assess if the Resident was in an appropriate bed. The corporate nurse stated that he has room on either side he is not touching the rails when he is in the bed. The corporate nurse was asked if a resident qualifies for a bariatric wheelchair and commode seat would he not also qualify for the bed as well? She stated that he could probably use a bariatric bed. On 7/12/24 a review of the email from the manufacturer of the bed revealed that the max weight on that particular model is 450 lbs. and the max weight for the mattress he had was 350 lbs. On 7/12/24 an interview was conducted with the Resident who stated he has not gotten any pressure areas or sores from the bed or mattress however he is uncomfortable in the bed. A review of the weekly skin assessments revealed no pressure areas or injury on Resident #9. On 7/12/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on facility staff interview, and facility documentation, the facility failed to ensure that all staff members had completed the mandatory Behavioral Health Training. The findings included: The facility failed to ensure that all staff members had completed the mandatory Behavioral Health Training for 7 employees in a survey sample of 7 employees: 2 Certified Nursing Assistants (CNA's) #B and #F, 3 Licensed Practical Nurses (LPN's) #E, #F, and #G, 1 Registered Nurse, RN #D, and the Administrator. Review of the Medline University Training Transcripts and Staff Education files revealed that none of the direct care staff in the survey sample had completed the mandatory Behavioral Health Training. On 07/12/2024 at 2:00 p.m. an interview was conducted with the Human Resource (HR) Manager who was asked about staff training regarding mandatory Behavioral Health Training, she stated that training and education are maintained and recorded by Medline University and was initiated in January 2024. The HR Manager went on to say that the Behavioral Health Training is scheduled for later this year, but that they have no documentation of trainings completed prior to January 2024. On 07/15/2024 during the end of day meeting, the Administrator and the Director of Nursing (DON) were made aware of the findings. No further information was provided.

Based on observation, Resident and staff interviews, and facility documentation review, the facility staff failed to maintain an effective pest control program affecting 2 of 2 Resident care hallways. The findings included: The facility staff failed to ensure the Resident rooms and hallways were free of flies and gnats. On 7/18/23, during the survey entrance conference, the facility Administrator was asked to provide pest control logs. On 7/18/23 at 2:32 PM, Surveyors B and C made observations on both Resident care hallways. It was noted that in Resident rooms, flies and gnats were flying around Residents and were observed on the bed linen, of multiple Residents. On 7/18/23, the survey team was provided a document titled, weekly inspections for pest control. Maintenance filled out the forms and noted on 7/17/23, ok indicating all areas were free of pests. On 7/19/23 at 12:48 PM, Surveyors B and C made observations on the Resident care unit again. Observations were made of the lunch trays being distributed and it was noted that multiple flies were on the food cart. Flies and gnats were observed again in multiple Resident rooms on both hallways. Flies were seen flying around Resident's meal trays, on privacy curtains, on bed linen, and on Residents. On 7/19/23, during the morning, an interview was conducted with Resident #3. When asked about pests in the facility, Resident #3 indicated there is a problem with flies and gnats. Resident #3 indicated he had personally purchased items to help deter and catch flies and gnats that he had put in his room. On 7/19/23 at approximately 1PM, an interview was conducted with CNA D. When asked about pests, CNA D said, We have a problem with flies and gnats. We try to keep things bagged up and covered. On 7/19/23 at approximately 1:30 PM, an interview was conducted with CNA B. When asked about pests, CNA B stated, It has been a problem ever since I've been here. When asked how long she had been at the facility, CNA B said about a year. CNA B said, It is mostly gnats in every room. When asked about the flies, CNA B said, You should see when the meal trays come out. CNA B acknowledged that she is aware that the facility has someone come in and spray, but it isn't effective. On 7/19/23 at 3:23 PM, an interview was conducted with Employee F, the maintenance director. Employee F confirmed that he oversees the pest control within the facility. He went on to say that they have a contracted provider that comes monthly. In addition to the contracted pest control company, I [the maintenance director] can treat ants, gnats and flies. When asked about the flies and gnats in the facility, the maintenance director said, We have a lot of gnats and flies, the way the ventilation is, we don't have units that manage the halls. There is also a lot of food and fruit, they get into face creams and anything you leave open. Here, you can only treat the top of the problem because you can't stop the food, from coming in and we can only use certain chemicals. During the above conversation/interview, the maintenance director stated that they [the facility management], is not satisfied with the current pest control vendor and I have gotten approval to go with someone local for service. The maintenance director said this is something he is doing the leg work on and doesn't currently have a contract with a new company yet. The maintenance director provided pest control logs, which did not have any information with regards to any pest sightings and what treatments were applied. On 7/19/23, during an end of day meeting, the facility Administrator and Director of Nursing were made aware of the above concerns. On 7/20/23, the facility Administrator provided the survey team with a facility policy titled, Pest Control. This policy read, Our facility shall maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . No additional information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to inform the physician of a change in condition or need to alter treatment for 1 Resident (#11) in a survey sample of 20 Residents. The findings included: For Resident #11, the facility staff failed to notify the Physician about a double lumen PICC (Peripherally Inserted Central Catheter) having a clogged port. On 7/18/23 at approximately 12:15 PM an interview was conducted with Resident #11 who stated she was not happy about being in the facility but understood she needed to have IV antibiotics and therapy. A review of the clinical record revealed that Resident #11 was admitted to the facility with orders that included. NAFCILLIN 2 GRAM/100 ML IN DEXTROSE(ISO-OSMOTIC) INTRAVENOUS PIGGYBACK-: intravenously Every 4 Hours Daily. - infuse 100ml q4h. A review of the clinical record revealed that the Resident received her antibiotics as ordered however the following was entered into the progress notes: 7/18/23 at 4:43 PM -PICC blue port unable to flush red line patent right arm +3 pitted edema dsgs intact anxiety high T 98.1 ABX Role: NUR, Category: Nurses Notes, Significance: Medium. On 7/19/23 at 1:30 PM an interview was conducted with LPN D who stated that the purple port was clogged but that she was giving the antibiotics through the red port. When asked if that was typically used for lab draws, she indicated that it was however it was the only way to give the antibiotics since the other port was clogged. On 7/19/23 at 1:45 PM the DON was interviewed and asked if she was aware of Resident #11's clogged port in her PICC line and she stated that she was not aware. Surveyor accompanied the DON to speak with LPN D. The DON asked LPN D if there was a problem with the PICC line for Resident #11. LPN D stated, The purple lumen is not patent it looks like someone tried to draw blood from it. LPN D tried to flush it and met resistance. She stated, I was going to let LPN B know but haven't gotten to it yet. The DON was asked by Surveyor B asked the DON what the danger is with a clogged PICC line, and she stated well it can get pushed through if someone tries to flush the line and pushes too hard and cause a blood clot to enter the bloodstream. The DON was asked what protocol is for a clogged PICC line and she stated, My next step is I'm going to notify the nurse practitioner that the line is clogged then she can order the Activase and then I will contact pharmacy, so they contact IV team. On 7/20/23 at 11:00 AM, the DON was asked about an update on Resident's PICC line she stated that the Resident was doing fine, and the nurse practitioner had ordered the Activase, and the Pharmacy IV team would be in to unclog the port however they did not have an estimated time of arrival yet. On 7/20/23 the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to assess for appropriateness of self-administration of medications for 1 Resident (Resident #17) in a survey sample of 20 Residents. The findings included: For Resident #17, the facility allowed the Resident to have a 4 oz container of pain-relieving foot cream in her room, at the bedside, without first assessing the Resident's ability to self-medicate. On 7/18/23 at approximately 2:00 PM, Resident #17 was noted to have a container of pain-relieving foot cream at the bedside. On 7/19/23 at approximately 8:30 AM, Resident #17's room was observed and again the container of pain-relieving foot cream was noted on the bedside table. On the morning of 7/19/23, a clinical record review was conducted of Resident #17's chart. This chart revealed no physician order, no assessment of her ability to safely self-administer medications, nor any mention of the pain reliving foot cream. Resident #17's care plan did indicate Resident #17 was at risk for pain and discomfort. The interventions for this read, Administer analgesic pain medication as ordered and Evaluate and treat pain. The pain-relieving foot cream was not addressed on the care plan nor the Resident's ability to self-administer medications. On the afternoon of 7/19/23, the Director of Nursing (DON) accompanied Surveyor C to the room of Resident #17 and observed the pain-relieving foot cream at the bedside. The DON stated that the Resident had been on a leave of absence and staff would not have entered the room. Surveyor C explained that the staff would still have to enter to provide care to the roommate and with it being unsecured, it was very visible. During the above observation in Resident #17's room with the DON present, Resident #17 returned from leave of absence. The Resident was interviewed and stated her sister had brought her the cream a while ago and she puts it on her feet. The DON removed the item. On 7/19/23 at approximately 4:15 PM, the survey team was provided a Self-Administration of Medications assessment that had been completed on Resident #17 following the surveyor bringing it to the facility staff's attention. The assessment indicated that the recommendation was: Resident can assist with administration of cream with supervision of a licensed nurse. Cream to be stored in locked unit by nursing staff. Review of the facility policy titled; Self-Administration of Medications was conducted. This policy read, 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident . 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents . On 7/19/23, during the end of day meeting, the Administrator and Director of Nursing were made aware of the concern and no further information was provided.

Based on Resident interview, staff interview, clinical record review and facility documentation review, the facility staff neglected to provide care and services for 1 Resident (Resident #4) in a survey sample of 10 Residents. This negligence resulted in mental anguish and emotional distress which constituted harm for Resident #4. The findings included: 1. For Resident #4 the facility staff neglected to obtain and provide his IV antibiotic medications upon admission, as agreed upon, which resulted in Resident #4 being in fear of his life. This resulted in mental anguish and emotional distress which constituted harm for Resident #4. On 5/30/23 at 12:13 PM, Resident #4 was visited in his room. Resident #4 said that he was not doing well because my meds have not been available for 24 hours, I had a prior problem at another facility, this is very serious to me, I had an infection in the pig valve in my heart and I got here, and they didn't have my IV antibiotics. My understanding is the hospital gave me a dose before I left there and then this place would have it in time for my next dose. That didn't happen. They said if I had brought it with me, they could have given the next dose, I asked what happened to the next two doses. They have replaced that artificial valve in my heart once and can't do it again, if it gets infected, I will die. On 5/31/23 at approximately 1:40 PM, Resident #4 was visited in his room again. Resident #4's wife was at the bedside and said, I've been worried to death, the danger of infection scares us. He has a pig valve in his heart that got infected and failed and they had to replace it. They have told us they can't go in again and they guaranteed us that he would get his medicines here. If that valve gets infected, he will die. I am so glad you are looking into this. It happened at another facility, and he had to be sent back to the hospital because they didn't have his medicine but here, they told him to go back to the hospital he would have to sign out against medical advice. On 5/30/23-5/31/23, a clinical record review was conducted. The review included the records from the hospital prior to Resident #4's admission on 5/25/23 to this facility. The Discharge SNF/Rehab Instructions form read, . [Resident #4's name redacted] . recent hospitalization for Osteomyelitis of left great toe who presented to the ED [emergency department] on 5/18 after discharge to a SNF [skilled nursing facility], due to the facility not having the appropriate antibiotics at their facility. He was previously admitted from 5/1-5/16 for osteomyelitis of left great toe, and septic arthritis for left first interphalangeal joint, and is s/p [status post] I and D [incision and drainage]. He was discharged with instructions to continue IV unasyn [antibiotic] and daptomycin [antibiotic] via PICC [peripherally inserted central catheter] through 6/13, with ID [infectious disease] and podiatry follow-up outpatient, but accepting facility did not have the antibiotics required upon arrival so immediately sent to [hospital name redacted] ED [emergency department] for IV antibiotic administration. Case management found a facility [this facility] that can accommodate his both IV abx [antibiotic] therapy (Unasyn and daptomycin) for the pt [patient]. Pt will be discharged to SNF to complete the IV abx therapy. Physician orders dated 5/25/23, read, Unasyn 3-gram solution for injection: intravenous four times daily and Daptomycin 500 mg intravenous solution: intravenously evening shift daily give 8mg/kg . Review of the medication administration record (MAR) for May 2023, Resident #4 did not receive the Unasyn until the 5 PM dose on 5/26/23 and didn't receive the Daptomycin until 5/28/23. Review of the clinical record revealed no communication with the attending physician at the facility nor the infectious disease doctor who ordered the IV antibiotics to notify of the missed doses of treatment so that alternate orders could be obtained. On 6/1/23 at 8:40 AM, an interview was conducted with Employee D, the admissions director. Employee D was asked about Resident #4 being accepted for admission and the discussion of his needs. Employee D said it was discussed prior to admission that Resident #4 would need the IV antibiotics available to start immediately. Employee D said she called the pharmacy and was told the medications were available. Employee D went on to say, I asked them [the hospital] to send a dose with him and she said she didn't think they could do it, but when the nurse called [LPN B's name redacted] to give report they told her they were sending the next dose and it didn't come with him. On 6/1/23 at 11:17 am, an interview was conducted with LPN B. LPN B said, I started doing his [Resident #4] pre-admit orders, I was in report when he arrived. I did get report from the hospital on him, and they said they were going to send IV antibiotics with him. We needed the rate on one of his medications, I passed on to [LPN F's name redacted] that the rate was to come in his orders. LPN B said that when [Employee D's name redacted] got paperwork she said they wanted to make sure his IV antibiotics were here. On 6/1/23, LPN B and LPN C confirmed that the pharmacy makes two deliveries to the facility daily. On 6/1/23 at 5:25 PM, an interview was conducted with Employee F, the nurse practitioner (NP). The NP was asked about the process for obtaining medications for a new admission. The NP said, typically the nurses enter the orders and contact the pharmacy and the meds come on the next run. When asked if Residents who are on IV antibiotics are supposed to miss doses, the NP said, Is it acceptable, no, does it occur, yes. For IV's it is going to be hard to get upon arrival unless the hospital would send with the patient. During the above interview, the NP was asked to explain the risks to a patient who misses doses of IV antibiotics. The NP said, It delays the treatment of the infection, may have to extend the treatment. Usually those folks are followed by infectious disease. When asked if she would expect there to be communication with the doctor or nurse practitioner when doses are missed, the NP said, Yes, they should reach out to infectious disease or myself. Review of the facility's abuse policy titled, Abuse and Neglect- Clinical Protocol was conducted. This policy read, Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. The Recognizing Signs and Symptoms of Abuse/Neglect policy read the same with regards to the definition of neglect. Additionally this policy went on to read, . b. signs of actual physical neglect: . 5. Improper use/administration of medication; 6. Inadequate provision of care . On 6/1/23, prior to lunch, the facility's corporate staff, facility administrator and director of nursing were made aware of the above. On 6/1/23, the Corporate Clinical Support Consultant provided Surveyor B with a progress note that she had written on 6/1/23 at 1:12 PM, that read, Spoke with [Nurse Practitioner's name redacted] regarding missed doses of IV abt. Inquired about extending the dose and she stated she would evaluate him on her upcoming visit. Resident has had no s/s [signs and symptoms] of infection, foot incision clean dry and without signs of infection. Resident has been afebrile . No further information was provided.

Based on Resident interviews, staff interviews, clinical record documentation and facility documentation review, the facility staff failed to provide adequate supervision, failed to implement fall precautions and failed to ensure a Resident received assistance in a manner to prevent accidents/injury for 1 Residents (Resident #1) in a survey sample of 10 Residents. Resident #1 sustained a fractured tibia this constituted harm for Resident #1. The findings included: 1. For Resident #1 the facility staff failed to ensure the Resident was assisted by facility staff in a manner to prevent injury, which resulted in a fractured tibia/resulting in harm. On 5/30/23 at 1:24 PM, an interview was conducted with Resident #1. Resident #1 stated, [On 5/12/23] one of the employees was with maintenance, he was trying to be funny and grabbed my wheelchair and told my friend [Resident #8] he was kidnapping me. He turned around in fast speed and this leg [left leg] was hurt, from me having broke it several years ago. Anyway he turned it around at a high speed and it got caught underneath the w/c and it broke my tibia. I've been in the bed ever since. Resident #1 went on to say, He [Employee K] teased me and my boyfriend. When Surveyor B asked, has he pushed you in your wheelchair before? Resident #1 said, No he isn't authorized to do that. He [Resident #8] turned to close the door behind us and that is when he [Employee K] pulled the back of my chair and took off and said 'kidnapping.' Both of my shoes came off .Everything happened so fast this leg got bent back and I couldn't get it out of the way. On 5/31/23 at 11 AM, an interview was conducted with CNA B. CNA B stated she was working the day of Resident #1's incident but was not assigned to care for Resident #1 that day. CNA B's accounting of the events of that day were as follows, The housekeeping guy [Employee K's name redacted] came and took her wheelchair and said they were going for a joy ride and that is when it happened. CNA B had no further details of the incident. On 5/31/23 at approximately 11:15 AM, an interview was conducted with LPN C. LPN C said, I was at the nurses' station and a Resident [Resident #8] pushed her in, she said she was in pain. They said they were pushing her inside from outside and her foot got twisted up. On 5/31/23 at 12 noon, an interview was conducted with Resident #8. Resident #8 gave the following accounting of the events on 5/12/23 involving Resident #1. Resident #8 said, We were coming in the door, I turned around to close the door and [Employee K's name redacted] started pushing her chair real fast and her [Resident #1] leg went under the chair. I pushed her to her room. Resident #8 stated, He didn't mean to do it. On 6/1/23 at 3:30 PM, an interview was conducted with Employee K, the housekeeping supervisor. When asked to describe what happened, Employee K said, I remember that very clearly, we were in the dining room I remember she was stuck on the entrance going into the patio and she was trying to get off, I asked if she needed my help, I went over pulled her in and asked if she would like me to take her to her room, I started rolling her to her room, she put her foot down and jammed her foot on the floor, She said ow my leg I immediately took her to the nurses station, the nurses tended to her. That was pretty much it. When asked if anyone else was around Employee K said, Resident #8 was present because he was trying to help Resident #1 get unhooked [across the door threshold]. Employee K denied that there was any joking/playfulness, or any ill intent. On 5/30/23-5/31/23, a clinical record review was conducted. This review revealed an entry by LPN C dated 5/12/23 at 2:49 PM, that read, Resident c/o [complained of] of pain 10/10 [pain rating of 10 out of 10] in left knee and ankle, staff member advised this writer that resident twisted foot while being pushed in wheel chair, [Nurse practitioner name redacted] ordered Stat XRAY of left knee/Tib/Fib [tibia and fibula] and ankle, [mobile x-ray company name redacted] claim #39196429. There were no further details in the clinical record regarding the details of the incident. On 5/30/23 and again on 5/31/23, Surveyor B requested for the facility to provide any documentation/investigation, etc. that had been conducted regarding the incident involving Resident #1 which resulted in the fractured tibia. On 5/30/23 the facility staff provided an incident report, which read, Patient was sitting in her wheelchair and she usually propels herself in her wheelchair. She asked the housekeeping manager to push her to her room. He began to push her, and she said ouch my leg. It appeared that she jammed her left foot on the floor. They also provided an in-service education sheet where Employee K/the housekeeping manager was educated. It read, F/u [follow-up] to incident re: fx [fracture] on Resident after being moved by housekeeping director. Monitor location of resident's legs/feet during transport if there are no pedals on wheelchair it is meant that they self-propel and should do so. Safety guidelines with moving of residents. The facility staff also provided a copy of an email from Employee K, the housekeeping supervisor, to the Administrator dated 5/15/23. The email read, On 5/12/23, I noticed that [Resident #8's name redacted] was trying to pull [Resident #1's name redacted] wheelchair into the dining room by way of the patio door and was having trouble doing so. I assisted with helping by pulling the wheel chair in the dining room and did so successfully. She stated that she was going to her room, as I began pushing her to her room she screamed out 'ouch my leg' it appeared that she jammed her left foot into the floor. She stated that she was in a lot of pain. I immediately too her to the Nurses station [sic]. Surveyor B obtained and reviewed the hospital emergency room records regarding Resident #1's visit. The hospital records read, Comments: . with obvious external rotation of the left leg and deformity and questionable swelling of the proximal thigh . Inspection of her left lower extremity reveal shortening of the left leg with external rotation and questionable swelling of the proximal thigh . The notes with regards to x-ray results read, x-ray of the foot, tib-fib and knee reveal nondisplaced fracture of the proximal tibia . On 5/31/23, during an end of day meeting, the corporate staff and facility administration were made aware of the above findings and that it resulted in harm for Resident #1. No further information was provided.

Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed for 1 resident (Resident #6) of the survey sample of 16 residents, to identify pressure ulcers on the left and right heel prior to it developing eschar (unable to stage), resulting in harm. The resident was wearing inappropriately fitting shoes which had caused friction and breakdown. For Resident #6, the facility staff failed to identify a pressure ulcer prior to it developing to eschar on both heels. Definitions of pressure ulcers provided by NPUAP (National Pressure Ulcer Advisory Panel): The goal for revising the definition of unstageable ulcers was to reduce the tendency to classify an ulcer with any necrotic tissue as unstageable, when the depth of the ulcer can be seen. The new definition is Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Note the phrase the base of the ulcer is used to denote the inability to determine the depth. If necrotic tissue is present, for example, on the edge of the ulcer, but the base is bone, the ulcer should be staged as a Stage IV. Further description of Stage IV ulcers include these phrases: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as ' the body's natural (biological) cover' and should not be removed. The Findings included: Resident #6 was admitted to the facility on [DATE] . Resident #6 's [DIAGNOSES REDACTED]. The Minimum Data Set (prior to the heel wounds), which was a Quarterly Assessment, had an Assessment Reference Date of 1/19/16. Resident #6 was coded as having a Brief Interview of Mental Status Score of 6 out of a possible 15, indicating moderate impaired cognition. In addition, she was coded as extensive care of two staff members for transferring and one person for dressing. The resident's pressure ulcer risk potential dated 1/19/16 gave the following score: 10 indicating the resident was at risk of developing a pressure ulcer. (7-39 indicates at risk - the higher the number, the greater the risk). On 9/8/16, at 10:00 AM, review of the clinical record revealed a nurse's note dated 2/23/16 which read, Resident with areas to right outer heel and left inner heel. New order- skin prep to bilateral heels every shift. Heels up when in bed. A nurse's note dated 2/24/16 read: Pressure ulcer right heel Resident observed with an eschar area to right and left heel measuring 3 cm (centimeters) by 3 cm by 0 cm to both heels. Consistent with resident wearing her shoes with only the front half of her feet in them resulting in the shoes rubbing on her heels. MD in facility to assess areas. Continue skin prep as ordered. Shoes removed from room. According to the clinical record, the resident did not have pedal [MEDICAL CONDITION]. The wound assessment report dated 2/24/16, done by the wound nurse LPN (licensed practical nurse) B, contained the following: Right and left heel unstageable due to slough/eschar. 100 % eschar. Review of weekly skin assessments by nursing revealed for the following dates: 2/4/16 skin intact. 2/11/16 skin intact. 2/18/16 skin intact. 2/25/16 eschar to bilateral heels. The heel wounds healed on 4/13/16. Review of the bath records for February regarding skin condition, for the following dates: 2/20/16, 2/22/16, 2/23/16, 2/24/16 and 2/25/16 all documented no skin issues, even the day of and the day following the discovery of the heel wounds. Review of the care plan dated 12/10/15 revealed the following: Potential for skin breakdown r/t (related to) [MEDICAL CONDITIONS], diabetes, decreased mobility, urinary incontinence. The goal was to maintain intact skin integrity through next review. The following interventions were in place: Medications and treatments as ordered. Encourage adequate fluid and food intake Keep skin clean and dry. Alert MD to any significant changes in skin integrity. Turn and reposition as needed. Check for incontinence. Pressure relieving devices/equipment as needed. Weekly skin audit by nurse. Perform abbreviated nutritional assessment every three months. There was nothing in the care plan or nurses notes about the shoes until after the wounds developed. On 9/8/16 at 1:25 PM, Resident #6 was observed sitting near the nurse's station. She was wearing tennis shoes appropriately on both feet. On 9/8/16 at 1:05 PM, an interview was conducted with the LPN (B), who tracks the facility's wounds. When asked about Resident #6, LPN (B) stated, The areas to the heels were blackened. It was consistent with her shoes' and that the back of the heels were pushed down. She also stated, They came from her shoe rubbing. On 9/8/16 at approximately 4:30 PM, the DON (director of nursing) stated that wounds are not usually found at eschar. She stated that the resident's shoes had a ridge on the back of the shoe, and that the shoes were taken from the room. The Administrator and DON were notified of possible harm level deficiency. On 9/9/16 at 9:35 AM, a skin assessment was completed for Resident #6. The DON and unit manager were present. The buttocks, sacrum and hips were clear without redness or discoloration. She did have multiple old scarring on buttocks. The heels were intact and were very dry and flaky. On 9/9/16 at 9:35 AM, the Medical Director was questioned about the wound. He stated, She was wearing plastic shoes, worn on the back part of her shoes, causing friction. The Medical Director also stated that it would be unusual for eschar to develop quickly, i.e., in two days. On 9/9/16 at 9:55 AM, an interview was conducted with CNA (certified nursing assistant) C. CNA (C) stated, I found the heel wound. It was a black, soft area, I am not sure which heel. She went on to state the resident was wearing clog shoes. Review of the facility policy and procedure for the prevention and treatment of [REDACTED]. If any skin concerns are noted, they are to be reported immediately to the designated nurse. On 9/9/16 at 12:00 PM, the DON and Administrator were notified of above findings at harm level.