Every finding on record at Chelsea Rehabilitation and Healthcare Center

Based on staff interview, facility document review, and clinical record review, the facility staff failed to notify the provider of a resident's change in condition in a timely manner for one of seven residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to notify the physician in a timely manner of neurological status changes after a fall. A review of R1's clinical record revealed the following progress notes: 3/31/24 at 7:50 p.m. Falls/Trauma .Altered level of consciousness .Patient initial evaluation post fall stable VS (vital signs) WNL (within normal limits). Patient c/o (complained of) pain to left side of head in area of hematoma. Neuro (neurological check) #4 pupils unequal, non-reactive. Patient not following commands appropriately, c/o being nauseated. Recommend sending to ER (emergency room ). 3/31/24 at 10:15 p.m. Made aware by CNA (certified nursing assistant) at approximately 1950 (7:50 p.m.) that resident was found on the floor. Went to assess resident. Resident was observed laying (sic) on the floor on her left side. Resident noted to have large hematoma to the left forehead. Patient assessed. Vital signs and neuro checks WNL. Patient transferred back to bed by CNA and nurse. Neuro checks initiated. C/o pain only to forehead at location of hematoma. Patient stated that she was taking the 'boys' back to the house. Patient is unsure of where she is and can only state her name and birthday at this time. Of note she does have dementia .At approximately 2020 (8:20 p.m.) while completing the 4th neuro check, patient noted to be moaning and in pain. At this neuro check pupils were not equal. Left was larger than right. Neither pupil reacted to light. At this time .the patient was also noted to be rather drowsy, having a difficult time following directions and complaining of being nauseated. 911 was called and report given to EMS (emergency medical services). Patient was taken to [name of local hospital]. A review of the neuro check record for R1 dated 3/31/24 revealed entries for 7:35 p.m. and 7:50 p.m. indicating R1's pupils were equally reactive, but were sluggish reacting to light. The entry for 8:05 p.m. did not have documentation regarding whether the pupillary reactions were brisk or sluggish. The entries for 8:20 p.m. and 8:35 p.m. indicated R1's level of consciousness had declined from alert to drowsy, and that her pupils were not reactive at all to light. These entries also indicated the resident was no longer able to follow verbal commands. A review of R1's provider's orders revealed she was receiving Eliquis (1) and Aspirin at the time of her fall, both of these medications making her blood thinner and clotting more difficult. On 12/9/24 at 2:58 p.m., ASM (administrative staff member) #2, the director of clinical services, was interviewed. She stated neuro checks should include a resident's vital signs, pupil reactions to light, and level of consciousness. She stated the nurse should assess whether the resident's pupils react briskly or sluggishly or not reactive at all. When asked the next step to be taken if a nurse finds sluggish pupils, she stated: The would call the doctor or the NP (nurse practitioner) right away. She stated sluggish pupils are not typically within normal limits for any resident. ASM #2 was asked to find evidence the nurse who assessed R1 neurologically after the resident's fall (this nurse was not available for interview at the time of the survey) took timely action when the resident's pupils were both sluggish immediately after the fall. On 12/9/24 at 3:36 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated neuro checks include pupils, hand grasps, and mobility per a resident's baseline. She stated if a resident's pupils are sluggish on assessment, she would definitely call the provider, either the attending physician or NP, immediately. After reviewing R1's records, LPN #1 stated she would have called the doctor much sooner. On 12/9/24 at 4:06 p.m., ASM #1, the executive director, ASM #2, and ASM #3, the regional nurse consultant, were notified of these concerns. A review of the facility policy, Neurological Assessment (Routine), revealed, in part: Routine neurological assessment is conducted to evaluate the resident for small changes that may be indicative of neurological injury .Test pupillary reaction to light .Notify the physician of any change in a resident's neurological status. A review of the policy, Change in a Resident's Condition or Status, revealed, in part: Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental condition and/or status .The nurse will notify the resident's attending physician or physician on call when there has been a .significant change in the resident's physical .condition. No additional information was provided prior to exit. Reference (1) Apixaban (Eliquis) is used help prevent strokes or blood clots in people who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes) that is not caused by heart valve disease. Apixaban is also used to prevent deep vein thrombosis (DVT; a blood clot, usually in the leg) and pulmonary embolism (PE; a blood clot in the lung) in people who are having hip replacement or knee replacement surgery. Apixaban is also used to treat DVT and PE and may be continued to prevent DVT and PE from happening again after the initial treatment is completed. Apixaban is in a class of medications called factor Xa inhibitors. It works by blocking the action of a certain natural substance that helps blood clots to form. This information was taken from the website https://medlineplus.gov/druginfo/meds/a613032.html.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to develop an accurate baseline care plan for one of seven residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to include the risks of taking anticoagulants on the baseline care plan. A review of R1's clinical record revealed the following provider's orders on admission: 3/28/24 Aspirin Oral Tablet Chewable 81 MG (milligrams) (Aspirin) Give 1 tablet by mouth one time a day. 3/28/24 Apixaban (Eliquis) (1) 2.5 mg Give 1 tablet by mouth two times a day. On 12/9/24 at 2:39 p.m., RN (registered nurse) #1 was interviewed. She stated she believed the admission nursing assessment is the beginning of the resident's baseline care plan, but other information to complete the baseline care plan should probably be included. When asked if a resident's taking both Aspirin and Eliquis as blood thinners should be on a resident's baseline care plan, she stated that it should. She stated these two medications increase a resident's potential for bleeding. On 12/9/24 at 3:36 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the assessments that nurses perform when a resident is admitted to the facility contribute to the baseline care plan. She stated the baseline care plan contains the basic information needed to take care of a resident day to day. She stated anticoagulant use should be included on the baseline care plan. On 12/9/24 at 4:06 p.m., ASM #1, the executive director, ASM #2, and ASM #3, the regional nurse consultant, were notified of these concerns. A review of the policy, Care Plans - Baseline, revealed, in part: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission .The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following .physician orders. No additional information was provided prior to exit. Reference (1) Apixaban (Eliquis) is used help prevent strokes or blood clots in people who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes) that is not caused by heart valve disease. Apixaban is also used to prevent deep vein thrombosis (DVT; a blood clot, usually in the leg) and pulmonary embolism (PE; a blood clot in the lung) in people who are having hip replacement or knee replacement surgery. Apixaban is also used to treat DVT and PE and may be continued to prevent DVT and PE from happening again after the initial treatment is completed. Apixaban is in a class of medications called factor Xa inhibitors. It works by blocking the action of a certain natural substance that helps blood clots to form. This information was taken from the website https://medlineplus.gov/druginfo/meds/a613032.html.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to respond to a resident's change in condition in a timely manner for one of seven residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to respond to her neurological status changes after a fall. A review of R1's clinical record revealed the following progress notes: 3/31/24 at 7:50 p.m. Falls/Trauma .Altered level of consciousness .Patient initial evaluation post fall stable VS (vital signs) WNL (within normal limits). Patient c/o (complained of) pain to left side of head in area of hematoma. Neuro (neurological check) #4 pupils unequal, non-reactive. Patient not following commands appropriately, c/o being nauseated. Recommend sending to ER (emergency room ). 3/31/24 at 10:15 p.m. Made aware by CNA (certified nursing assistant) at approximately 1950 (7:50 p.m.) that resident was found on the floor. Went to assess resident. Resident was observed laying (sic) on the floor on her left side. Resident noted to have large hematoma to the left forehead. Patient assessed. Vital signs and neuro checks WNL. Patient transferred back to bed by CNA and nurse. Neuro checks initiated. C/o pain only to forehead at location of hematoma. Patient stated that she was taking the 'boys' back to the house. Patient is unsure of where she is and can only state her name and birthday at this time. Of note she does have dementia .At approximately 2020 (8:20 p.m.) while completing the 4th neuro check, patient noted to be moaning and in pain. At this neuro check pupils were not equal. Left was larger than right. Neither pupil reacted to light. At this time .the patient was also noted to be rather drowsy, having a difficult time following directions and complaining of being nauseated. 911 was called and report given to EMS (emergency medical services). Patient was taken to [name of local hospital]. A review of the neuro check record for R1 dated 3/31/24 revealed entries for 7:35 p.m. and 7:50 p.m. indicating R1's pupils were equally reactive, but were sluggish reacting to light. The entry for 8:05 p.m. did not have documentation regarding whether the pupillary reactions were brisk or sluggish. The entries for 8:20 p.m. and 8:35 p.m. indicated R1's level of consciousness had declined from alert to drowsy, and that her pupils were not reactive at all to light. These entries also indicated the resident was no longer able to follow verbal commands. A review of R1's provider's orders revealed she was receiving Eliquis (1) and Aspirin at the time of her fall, both of these medications making her blood thinner and clotting more difficult. On 12/9/24 at 2:58 p.m., ASM (administrative staff member) #2, the director of clinical services, was interviewed. She stated neuro checks should include a resident's vital signs, pupil reactions to light, and level of consciousness. She stated the nurse should assess whether the resident's pupils react briskly or sluggishly or not reactive at all. When asked the next step to be taken if a nurse finds sluggish pupils, she stated: The would call the doctor or the NP (nurse practitioner) right away. She stated sluggish pupils are not typically within normal limits for any resident. ASM #2 was asked to find evidence the nurse who assessed R1 neurologically after the resident's fall (this nurse was not available for interview at the time of the survey) took timely action when the resident's pupils were both sluggish immediately after the fall. On 12/9/24 at 3:36 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated neuro checks include pupils, hand grasps, and mobility per a resident's baseline. She stated if a resident's pupils are sluggish on assessment, she would definitely call the provider, either the attending physician or NP, immediately. On 12/9/24 at 4:06 p.m., ASM #1, the executive director, ASM #2, and ASM #3, the regional nurse consultant, were notified of these concerns. A review of the facility policy, Neurological Assessment (Routine), revealed, in part: Routine neurological assessment is conducted to evaluate the resident for small changes that may be indicative of neurological injury .Test pupillary reaction to light .Notify the physician of any change in a resident's neurological status. No additional information was provided prior to exit. Reference (1) Apixaban (Eliquis) is used help prevent strokes or blood clots in people who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes) that is not caused by heart valve disease. Apixaban is also used to prevent deep vein thrombosis (DVT; a blood clot, usually in the leg) and pulmonary embolism (PE; a blood clot in the lung) in people who are having hip replacement or knee replacement surgery. Apixaban is also used to treat DVT and PE and may be continued to prevent DVT and PE from happening again after the initial treatment is completed. Apixaban is in a class of medications called factor Xa inhibitors. It works by blocking the action of a certain natural substance that helps blood clots to form. This information was taken from the website https://medlineplus.gov/druginfo/meds/a613032.html.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to protect a resident from abuse by another resident, resulting in harm, a fractured wrist, for one of 32 residents in the survey sample, Residents #32 and #16. The findings include: The facility synopsis of the event, dated, 3/22/24, documented, Resident to Resident, separated, abut policy initiated. Residents involved: (Resident #32 and Resident #16). The facility synopsis of the event, dated 3/29/24, documented in part, (R32) was in the dining room on the evening of March 22nd around 5:10 p.m. He was watching a program in the dining room, as he often does. When (R16) came into the dining room, he changed the TV channel without first, communicating with (R32). This upset (R32). (R32) stood and aggressively approached (R16), who then pushed (R32); (R32) lost his footing due to the push and fell to the ground attempting to catch himself with his right arm. Resident (R32) sent out for evaluation following complaints of pain in the right wrist and with bruising and swelling. Resident (R32) sent to (Name of hospital) ED (emergency department), returned the same night with diagnoses of right wrist fracture. Findings: Statements resident (R32) and (R16) were reviewed. This was an unwitnessed event that took place in the dining room. Immediately following resident to resident incident, both residents were separated, and room change initiated, before the incident residents were roommates. Skin assessments of (R32) and (R16) were completed, with swelling and bruising noted to (R32) right wrist, there were no new skin impairments for (R16). A pain evaluation was completed for (R32), resulting in him being sent to ER for an X-ray of his wrist, which revealed a fracture to the right wrist. Resident care plans were reviewed (and subsequently updated based on incident), care plan updated to reflect triggers and identification for staff for (R34) aggression. (R34) care plan was also updated to reflect the right wrist fracture. (R16) care plan was updated to reflect the potential for aggression towards other residents. Staff responded appropriately when notified of the incident, able to calm residents and assess the situation. The Nurse Practitioner has noted in resident file, that (R32) behaviors can pose a risk for others when he is unable to get his way, he has unpredictable triggers. Medications reviewed by the Medical Director and adjusted his (R32) Latuda in relation to his schizophrenia. Both residents have low BIM scores and a history of traumatic brain injury which can cause impaired decision making. Screening for potential PTSD completed by Director of Social Services, for (R32) and (R16) following incident, for three days, with no indications of both trauma due to incident. Referral to psych services through (name of company) was also sent for both residents, with (R16) seeing (name of mental health nurse practitioner) on 3/26/24, for an initial evaluation and (R16) had no recollection of the resident-to-resident incident. Resident #32 (R32) The MDS (minimum data set) assessment, closest to the time of the incident, a significant change assessment, with an assessment reference date (ARD) of 3/26/24, the resident scored a 5 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired for making daily decisions. In Section E - Behaviors, the resident was coded as having verbal behavioral symptoms directed towards others one to three days of the look back period. The comprehensive care plan dated, 2/21/2019, documented in part, Focus: (R32) can be resistive to care, refusal of showers, yells at staff/other residents, cursing at staff and can be aggressive to staff/residents. the resident is/has potential to be physically aggressive will posture towards staff when angry or upset, is non-compliant with diet, referring sandwiches. Resident has a fear that if he does not have Lomotil then he will have diarrhea again - demands med with angry posturing and foul language. Can demand any meds with angry posturing and foul language when not ready when he requests. Resident #16 (R16) The MDS assessment, closest to the time of the incident, a quarterly assessment, with an ARD of 3/22/24, the resident scored a 4 out of 15 on the BIMS score, indicating the resident was severely impaired for making daily decisions. In Section E - Behaviors, the resident was not coded as having any behavioral symptoms. The comprehensive care plan dated, 3/22/24, documented in part, Focus: I have behavior problem r/t (related to) TBI (traumatic brain injury), I will resist help with ADLs (activities of daily living) and mobility, I will refuse therapy services, I will push other resident in their wheelchair within the building and outside, I will refuse meds and lab draws, I will push other residents. The witness statements were reviewed. This was an unwitnessed incident. The staff stated there didn't notice anything between the two residents. They stated they were getting along like they normally do. An interview was conducted with RN (registered nurse) #2 on 9/10/24 at approximately 4:00 p.m. When asked what she would do if a resident pushes another resident causing the resident to go down to the floor, RN #2 stated she would immediately separate the residents, assess for injury, notify the administrator and the director of nursing. When asked if this is a reportable incident, RN #2 stated, yes. When asked if this was abuse, RN #2 stated, yes. RN #2 was asked if she had received education on abuse, she stated they have received it after the above incident. An interview was conducted with ASM administrative staff member) #1, the administrator, on 9/11/24 at 9:28 a.m. When asked what happens when a resident strikes another resident, ASM #1 stated they would separate the resident, evaluate each resident, try and figure out if there was a cause behind the incident. Start the abuse policy which entails re-education, will do screening of all residents for abuse. The residents answer five questions the social worker asks. ASM #1 further stated that the residents involved in the incident would receive a PTSD screening. When asked if anything was put in place at the time of the above incident, ASM #1 presented an action plan. The Action Plan dated 3/22/24 documented: Problem Statement: Area of opportunity identified o 3/29/24 due to resident-to-resident abuse. Goal: Resident will have necessary oversight to prevent abuse. Objective: The facility will establish a system to routinely evaluate residents and develop a plan of care to aid in the prevention of abuse and to ensure resident to resident altercations are minimized. Goals/Tasks - Resident involved in resident-to- resident altercations assessed. One resident sustained a fractured right wrist. Monitor resident for no other adverse effects. - Target date - 3/22/24. Statements obtained from residents involved. Target date - 3/24/24. Social Services will meet with the involved resident daily x 3 days to address psycho-social needs. - Target date - 3/27/24. The Medical Director was made aware of the allegations of abuse. Target date - 3/22/24. Department of Health was notified of the allegations of abuse. - Target date - 3/22/24. Current employees will receive education regarding prevention, recognizing, identifying triggers and deescalating abuse. Target date - 3/30/24. Newly hired employees will receive education regarding preventing, recognizing, and reporting abuse prior to assuming any assignment. Target date - 3/30/24. Ensure residents with possible aggression are intellectually and physically stimulated daily through group or 1:1 activities of interest to the resident. Target date - 3/30/24. Educate staff on residents involved updated care plan identifying triggers and de-escalation tactics. Target date - 3/29/24. Dining Room to be closed to residents in not in use for meals or for activities. When residents conjugate in the day room, staff will provide q 15 min checks. Target date - 3/29/24. The QAPI Committee will make recommendations based upon the results of the audits. Upon attaining consistent compliance, the QAPI committee will determine the continuation for the audits. Target date - 3/30/24. The credible evidence for the above action plan was reviewed. Resident and staff interviews were conducted to verify the educations and plan. No further concerns were found in the area of F600. This deficiency is being cited at past non-compliance. PAST NON-COMPLIANCE

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of care for one of 32 residents in the survey sample, Resident #19. The findings include: 1.a. For Resident #19 (R19), the facility staff failed to document progress notes in a timely manner A review of R19's clinical record revealed three progress notes related to R19 with an effective date between two to four days prior to when the note was actually written. These notes were: On 8/26/24, LPN (licensed practical nurse) #2 wrote a note about what she observed and assessed on 8/22/24. She documented this as a Late Entry. On 8/26/24, RN (registered nurse) #1 wrote a note about what she observed and assessed on 8/23/24. She documented this as a Late Entry. On 8/26/24 at 1:35 p.m., ASM (administrative staff member) #2, the director of nursing, wrote a note about R19 being sent to the emergency roiagnom on [DATE]. The effective date of this note was 8/24/24 at 9:00 p.m. She documented this as a Late Entry. On 9/10/24 at 9:53 a.m., LPN #2 was interviewed. When asked why she did not enter a note about R19's 8/22/24 fall until 8/26/24. She stated: At the time of the fall I did not put a note in. I don't know why I didn't. She added: Nobody asked me to put the note in. I did a witness statement on [R19's fall], and then realized I had not written the note. She stated she knows she had documented the fall and her assessment findings at the time of the resident's fall. On 9/10/24 at 11:20 a.m., RN #1 was interviewed. When asked why she assessed R19 on 9/23/24 but did not document any of her findings until 9/26/24, she stated she had 13 other residents receiving skilled nursing services who needed detailed charting from her on 9/23/24. She stated she habitually manually writes notes in her own notebook so I can remember, then comes in another day to document her findings in the resident's clinical record. She stated she lets the oncoming nurse know what has happened with the resident during her shift. She added: We have to chart on skilled residents and residents on antibiotics, and it takes time. On 9/10/24 at 12:32 p.m., ASM #2 was interviewed. When asked the facility policy about timely documentation by nursing staff, she stated she did not know if there was a policy dictating a specific amount of time that would be considered as timely. She stated some facility staff get overwhelmed by the end of a shift and have to return to the facility on another day to complete their documentation. She stated she would prefer that nurses finish all documentation before they leave the facility after a shift, but understands things get busy with resident care. She stated: Patient care comes first, as long as the documentation gets done. She stated a nurse's charting will likely be more accurate if it is completed as close as possible in time to when an actual event or assessment occurred. On 9/10/24 at 4:40 p.m., ASM #1, the administrator, ASM #2, and ASM #3, the regional director of operations were informed of these concerns. A review of the facility policy, Charting and Documentation, failed to reveal any information related to timeliness of documentation. No further information was provided prior to exit. High quality documentation is .Accurate, relevant, and consistent .Timely, contemporaneous, and sequential. This information is taken from the American Nurses Association website http://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf 1.b. For R19, the facility staff failed to perform complete neurological assessments by checking the resident's pupil response. A review of R19's clinical record revealed a Neurological Assessment Flow Sheet with the following dates and times: 8/22/24 at 1:30 p.m., 1:45 p.m., 2:00 p.m., 2:15 p.m., 3:15 p.m., 4:15 p.m., 5:15 p.m., 6:15 p.m., and 10:15 p.m.; and 8/23/24 at 2:15 a.m., 6:15 a.m., 10:15 a.m., 2:15 p.m., 6:15 p.m. and 10:15 p.m. The flow sheet included a column to report the assessment findings of the resident's pupil response. All boxes in this column were blank for the 15 neurological assessments performed by the facility staff following R19's fall on 8/22/24. On 9/10/24 at 10:12 a.m., ASM (administrative staff member) #4, a nurse practitioner, was interviewed. She stated a neurological assessment includes pupils, arm and leg strength, changes in mentation, and the resident's ability to talk. She stated it is important to check for changes in a resident's pupils for consistency and changes. When asked if a thorough neurological assessment has been performed if a nurse has not assessed a resident's pupils, she stated: It would appear not. On 9/10/24 at 11:20 a.m., RN (registered nurse) #1 was interviewed. She stated neurological assessments always included the level of consciousness and the pupil response. She stated an abnormal pupil might signal insufficient brain function, and might require further assessment. On 9/10/24 at 12:12 p.m., LPN (licensed practical nurse) #3, a unit manager, was interviewed. She stated pupils should always be checked because a change in function can signal some possible changes in the brain. On 9/10/24 at 1:21 p.m., ASM #5, the attending physician, was interviewed. He stated a thorough neurological assessment should include pupil response to light. On 9/10/24 at 4:40 p.m., ASM #1, the administrator, ASM #2, and ASM #3, the regional director of operations were informed of these concerns. A review of the facility policy, Indications for Neurological Assessment, failed to reveal any information related to elements of a thorough neurological assessment. No further information was provided prior to exit. Routine neurological exams performed by registered nurses during their daily clinical practice include assessing mental status and level of consciousness, pupillary response, motor strength, sensation, and gait. This information is taken from the National Institutes of Health website https://www.ncbi.nlm.nih.gov/books/NBK593206/.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain a complete pain management program for one of 32 residents in the survey sample, Resident #32. The findings include: For Resident #32, the facility staff failed to clarify the physician order to obtain parameters for two PRN (as needed) pain medications and administered pain medication for a pain scale rating of zero. Resident #32 suffered a fracture of his wrist on 3/22/24. The physician order dated, 3/27/24, documented, Ibuprofen Oral Tablet 200 MG (milligrams); Give 3 tablets by mouth every 6 hours as needed for breakthrough pain. The physician order dated, 4/25/24, documented, Oxycodone HCL (hydrochloride) Tablet 10 MG; Give 1 tablet by mouth every 8 hours as needed for pain. The June 2024 MAR (medication administration record) documented the above orders. The Ibuprofen was administered on the following dates, time and pain scale. (Pain scale is rated 0 - 10; zero indicating no pain and 10 indicating the worse pain the resident has ever been in): 6/2/24 at 2:11 a.m. - pain scale of 6. 6/3/24 at 1:50 a.m. - pain scale of 8. 6/12/24 at 2:46 a.m. - pain scale of 0. 6/18/24 at 4:45 a.m. - pain scale of 6. 6/19/24 at 1:16 a.m. - pain scale of 7. 6/23/24 at 4:42 a.m. - pain scale of 6. 6/26/24 at 2:05 a.m. - pain scale of 6. 6/27/24 at 3:30 a.m. - pain scale of 6. 6/28/24 at 4:05 a.m. - pain scale of 8. The Oxycodone was documented as administered on the following dates, time and pain scale: 6/1/24 at 9:03 a.m. - pain scale of 7, at 10:09 p.m. for pain scale of 8. 6/2/24 at 6:19 a.m. - pain scale of 8. 6/3/24 at 6:09 a.m. - pain scale of 2; 2:00 p.m. - pain scale of 5; 10:00 p.m. - pain scale of 8. 6/4/24 at 6:00 a.m. - pain scale of 8; 2:00 p.m. - pain scale of 3. 6/5/24 at 12:47 a.m. - pain scale of 4; 12:22 p.m. - pain scale of 10; 10:16 p.m. - pain scale of 10. 6/6/24 at 12:47 a.m. - pain scale of 8; 10:02 p.m. - pain scale of 6. 6/7/24 at 6:48 a.m. - pain scale of 4. 6/8/24 at 12:15 a.m. - pain scale of 8; 10:18 a.m. - pain scale of 8. 6/9/24 at 4:30 p.m. - pain scale of 7. 6/10/24 at 5:01 p.m. - pain scale of 9. 6/11/24 at 9:12 a.m. - pain scale of 9; 5:23 p.m. - pain scale of 9. 6/12/24 at 2:45 a.m. - pain scale of 6; 9:25 a.m. - pain scale of 8; 5:26 p.m. - pain scale of 7. 6/13/24 at 6:18 a.m. - pain scale of 0, 4:30 p.m. - pain scale of 8. 6/14/24 at 1:14 p.m. - pain scale of 5; 11:03 p.m. - pain scale of 5. 6/15/24 at 7:31a.m. - pain scale of 4; 3:35 p.m. - pain scale of 5; 11:53 p.m. - pain scale of 10. 6/16/24 at 8:07 a.m. - pain scale of 5; 5:30 p.m. - pain scale of 5. 6/17/24 at 5:15 p.m. - pain scale of 7. 6/18/24 at 6:18 a.m. - pain scale of 0; 2:58 p.m. - pain scale of 7; 9:30 p.m. - pain scale of 7. 6/19/24 at 12:46 p.m. - pain scale of 10. 6/21/24 at 1:06 a.m. - pain scale of 5. 12:00 p.m. - pain scale of 7; 8:13 p.m. - pain scale of 8. 6/22/24 at 4:30 a.m. - pain scale of 6; 9:59 p.m. - pain scale of 8. 6/23/24 at 5:00 a.m. - pain scale of 0; 4:11 p.m. - pain scale of 8. 6/24/24 at 8:34 a.m. - pain scale of 5; 6:38 p.m. - pain scale of 5. 6/25/24 at 3:04 a.m. - pain scale of 5; 10:27 p.m. - pain scale of 4. 6/26/24 at 10:11 p.m. - pain scale of 0. 6/27/24 at 6:40 a.m. - pain scale of 0; 2:41 p.m. - pain scale of 5. 6/29/24 at 2:20 a.m. - pain scale of 9; 10:59 a.m. - pain scale of 5; 7:00 p.m. - pain scale of 7. 6/30/24 at 5:37 a.m. - pain scale of 9; 2:02 p.m. - pain scale of 5; 10:53 p.m. - pain scale of 9. The July 2024 MAR documented the order for Ibuprofen. The Ibuprofen was administered on the following dates, time and pain scale: 7/11/24 at 3:17 a.m. - pain level of 7. 7/13/24 at 4:06 a.m. - pain level of 5. 7/26/24 at 3:25 a.m. - pain level of 8. The July 2024 MAR documented the order for Oxycodone. The Oxycodone was administered on the following dates, times and pain scale: 7/1/24 at 11:30 a.m. - pain scale of 10. 7/3/24 at 10:38 p.m. - pain scale of 0. 7/4/24 at 11:18 a.m. - pain scale of 5; 11:21 p.m. - pain scale of 0. 7/5/24 at 11:16 a.m. - pain scale of 5; 10:03 p.m. - pain scale of 7. 7/8/24 at 10:51 a.m. - pain scale of 5; 9:45 p.m. - pain scale of 5. 7/12/24 at 10:11 p.m. - pain scale of 9. 7/13/24 at 9:52 p.m. - pain scale of 9. 7/14/24 at 12:01 p.m. - pain scale of 5; 11:41 p.m. - pain scale of 5. The physician order dated, 7/24/24, documented, Oxycodone HCL Tablet 10 MG; Give 1 tablet by mouth every 24 hours as needed for pain. The July 2024 MAR documented this order. The Oxycodone was administered on the following dates, time and pain scale: 7/24/24 at 12:36 p.m. - pain scale of 7. 7/25/24 at 7:55 p.m. - pain scale of 7. 7/26/24 at 8:53 a.m. - pain scale of 8. The August 2024 MAR documented the order for Ibuprofen. The Ibuprofen was administered on the following dates, time and pain scale: 8/4/24 at 13:35 a.m. - pain scale of 6. The August 2024 MAR documented the order for Oxycodone. The Oxycodone was administered on the following dates, time and pain scale: 8/1/24 at 5:07 p.m. - pain scale of 5. 8/4/24 at 5:40 p.m. - pain scale of 10. 8/7/24 at 9:06 a.m. - pain scale of 7. 8/8/24 at 4:51 p.m. - pain scale of 5. 8/11/24 at 9:10 a.m. - pain scale of 5. 8/12/24 at 5:04 p.m. - pain scale of 9. 8/13/24 at 5:50 p.m. - pain scale of 6. 8/17/24 at 12:39 p.m. - pain scale of 5. 8/18/24 at 1:30 p.m. - pain scale of 9. 8/25/24 at 1:23 p.m. - pain scale of 9. 8/26/24 at 3:44 p.m. - pain scale of 8. 8/27/24 at 5:17 p.m. - pain scale of 6. 8/31/24 at 6:07 p.m. - pain scale of 8. An interview was conducted with RN (registered nurse) #4 on 9/11/24 at 11:14 a.m. The above orders for Oxycodone and Ibuprofen were reviewed with RN #4. When asked how she would know which medication to give, RN #4 stated it depended on the pain level. RN #4 was asked if the orders documented which medication to give for pain levels, RN #4 stated, that would need to be clarified with the doctor. When asked if a pain mediation should be given for a pain level of zero, RN #4 stated, no. [NAME] interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 9/11/24 at 11:46 a.m. The above orders were reviewed with ASM #2. When asked how the nurse would know what to give, ASM #2 stated the Ibuprofen would be given for a milder pain. ASM #2 explained the resident had a fractured wrist in March 2024 and the emergency room prescribed Oxycodone. She further explained the resident has a history of drug abuse. When asked if the orders tell the nurse which medication to give, ASM #2 stated, no. When asked what should be done with these orders, ASM #2 stated, they should have parameters. The above MARS were reviewed with ASM #2. When asked if a pain medication should be given for a pain level of zero, ASM #2 stated, no, she doesn't think the pain levels are accurate but that is what is documented. The facility policy, Pain Assessment and Management documented in part, 5. The following are considered when establishing the medication regimen: a. Starting with lower doses and titrating upward as necessary; b. Administering medications around the clock rather than PRN. c. Combining long-acting medications with PRNs for breakthrough pain; d. Combining non-narcotic analgesics with narcotic (opioid) analgesics; and e. Reducing or preventing anticipated adverse consequences of medications (e.g., bowel regimen to preventing constipation related to opioid analgesics). 6. The medication regimen is implemented as ordered. Results of the interventions are documented and communicated directly to the provider when appropriate. Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications .Documentation: 1. Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program. ASM #1, the administrator, and ASM #2 were made aware of these findings on 9/11/24 at 1:09 p.m. No further information was obtained prior to exit.

2. For Resident #74, the facility staff failed to maintain dignity of the resident while doing a dressing change. Observation was made on 9/10/24 at 12:15 p.m. of LPN (licensed practical nurse) #2, the wound care nurse administering a treatment for Resident #74 on his buttock. The physician order dated, 8/22/24, documented, Right Buttock: Cleanse with wound cleanser, pat dry, apply silver alginate, border gauze, every day shift for wound care. LPN #2 performed the dressing change as ordered. At the end of the dressing change, LPN #2 took her black marker out of her pocket and wrote on the dressing after the dressing, border gauze, had been applied to the resident's buttock. An interview was conducted with LPN #2 on 9/10/24 at 3:53 p.m. The dressing change was discussed with LPN #2. LPN #2 stated immediately that she wrote her date and initials on the dressing while the dressing was on the resident's buttock. She stated she normally writes on the dressing before she begins her treatments but got distracted with the new wound care provider that morning. When asked why we don't write on a dressing while it's on the resident's bottom, LPN #2 stated, it doesn't feel good to them. The facility policy, Dressing - Dry/Clean, documented in part, 10. Label tape or dressing with date, time and initials. Place on clean field. ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing, were made aware of the above finding on 9/11/24/ at 1:09 p.m. No further information was provided prior to exit. 31753 Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to maintain dignity for two of 32 residents in the survey sample, Residents #72 and #74. The findings include: 1. For Resident #72 (R72), the facility staff failed to provide dignity for the resident's indwelling urinary Foley catheter bag (1). A review of R72's clinical record revealed a physician's order dated 8/26/24 for an indwelling Foley catheter for urinary retention. On 9/9/24 at 7:17 p.m., R72 was observed lying in bed. The resident's indwelling urinary Foley catheter bag was attached to the bed frame. There was no privacy cover on the bag, urine was observed in the bag, and the bag was visible from the hall. On 9/10/24 at 4:09 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated there should be a privacy bag on residents' indwelling urinary Foley catheter bags to maintain residents' dignity. On 9/10/24 at 4:39 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Catheter Care, Urinary documented, Dignity 1. Use a drainage bag cover when the resident is in common areas. The facility policy titled, Dignity documented, 1. Residents are treated with dignity and respect at all times. Reference: (1) A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm

Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to accommodate a resident's needs for one of 32 residents in the survey sample, Resident #72. The findings include: For Resident #72 (R72), the facility staff failed to maintain the resident's call bell within the resident's reach. On 9/9/24 at 7:11 p.m., an observation of R72 lying in bed was conducted. R72 asked where his call bell was and stated he needed it in case he needed something. R72's call bell was observed lying on the floor beside the resident's roommate's bed and was not within R72's reach. There was no clip on the cord so the call bell could not be attached to the resident's bed sheets. On 9/10/24 at 4:09 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated staff should clip call bells to residents' bed sheets and ensure call bells are within residents' reach when they round every hour or two hours. On 9/10/24 at 4:39 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Answering the Call Light failed to document information regarding maintaining the call bell within a resident's reach. No further information was presented prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence that written notification of a hospital transfer was provided to the resident representative for one of 32 residents in the survey sample; Resident #28. The findings include: For Resident #28, the facility staff failed to evidence written notification of a hospital transfer on 7/14/24 was provided to the resident representative. A review of the clinical record revealed a progress note dated 7/14/24 that documented, writer at bedside w/ (with)resident to give evening medication, resident unarousable to voice and touch, noted labored breathing which is a change of condition from baseline call placed to (name of physician) by (licensed practical nurse), recommendations from MD (medical doctor) to send resident to ED (emergency department) for evaluation, RP (responsible party) (name) notified of coc (change of condition) and transfer to hospital @ (at) 1650 (4:50 PM) , ADON (Assistant Director of Nursing) (name) made aware via telephone. Further review failed to reveal any evidence of a written notice of this hospital transfer being provided to the resident representative. On 9/11/24 at 11:58 AM, evidence of the written notice to the resident representative was requested from ASM #2 (Administrative Staff Member) the Director of Nursing. On 9/11/24 at 12:39 PM, ASM #2 stated they did not have evidence that a written notification was provided to the resident representative. She was only able to provide evidence of what documentation was sent to the hospital, which did not include any document that was identified as a written notice to the resident representative. The facility policy, Transfer or Discharge, Facility-Initiated documented, Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) (long term care) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content equirements) No further information was provided by the end of the survey.

Based on observation, resident interview, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide ADL (activities of daily living) care to a dependent resident for one of 32 residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility staff failed to maintain trimmed fingernails. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 8/23/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section GG documented R2 requiring substantial/maximal assistance for personal hygiene and having impairment on one side in the upper extremities. Section I documented R2 having diagnoses including but not limited to Diabetes Mellitus (1). On 9/9/24 at 7:45 p.m., an interview was conducted with R2 in their room. R2 was observed lying in bed with the left hand observed to be contracted with the fingers closed in towards the palm of their hand. R2 stated that they did not have use of their left arm and hand and limited use of the right hand. Observation of R2's fingernails revealed the free edge of the nail approximately three sixteenths of an inch long. When asked about nail care, R2 stated that their nails grew quickly, and they had to beg the staff to trim their nails. R2 stated that the CNA (certified nursing assistants) were not allowed to trim their nails because they were diabetic and only the RN (registered nurses) were allowed to trim their nails. R2 stated that the RN's were always passing medications and never had the time to trim their nails, so they just had to wait until someone had time. R2 stated that they had asked several nurses to trim their nails and they had not been trimmed yet. Additional observations of R2 on 9/10/24 at 9:00 a.m., revealed R2's fingernails remained untrimmed. The comprehensive care plan for R2 documented in part, I have an ADL Self Care Performance Deficit r/t (related to) weakness and debility. Date Initiated: 08/16/2023, On 9/10/24 at 4:23 p.m., an interview was conducted with RN #2. RN #2 stated that the CNA staff were responsible for trimming fingernails unless the resident was diabetic and then it was the responsibility of the licensed nurse. She stated that the CNA staff should be observing the fingernails with their daily care and reporting to the nurse when the nails needed trimming. On 9/10/24 at 4:31 p.m., RN #2 observed R2's fingernails. RN #2 stated that the fingernails were long and needed to be trimmed. RN #2 asked R2 if they would like to have the nails trimmed and R2 stated that they would. The facility policy, Fingernails/Toenails, Care of dated February 2018, documented in part, Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 3. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . On 9/10/24 at 4:40 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the concern. No further information was provided prior to exit. Reference: (1) Diabetes is a disease in which your blood glucose, or blood sugar, levels are too high. Glucose comes from the foods you eat. Insulin is a hormone that helps the glucose get into your cells to give them energy. With type 1 diabetes, your body does not make insulin. With type 2 diabetes, the more common type, your body does not make or use insulin well. Without enough insulin, the glucose stays in your blood. You can also have prediabetes. This means that your blood sugar is higher than normal but not high enough to be called diabetes. Having prediabetes puts you at a higher risk of getting type 2 diabetes. Over time, having too much glucose in your blood can cause serious problems. It can damage your eyes, kidneys, and nerves. Diabetes can also cause heart disease, stroke and even the need to remove a limb. This information was obtained from the website: https://medlineplus.gov/diabetes.html

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for an indwelling urinary catheter for one of 32 residents in the survey sample, Resident #72. The findings include: For Resident #72 (R72), the facility staff failed to maintain the resident's indwelling urinary Foley catheter bag (1) in a sanitary manner. A review of R72's clinical record revealed a physician's order dated 8/26/24 for an indwelling Foley catheter for urinary retention. On 9/9/24 at 7:17 p.m., R72 was observed lying in a low bed. The resident's indwelling urinary Foley catheter bag was attached to the bed frame and was lying on the floor. On 9/10/24 at 4:09 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated indwelling urinary Foley catheter bags should be kept off the floor for infection control. On 9/10/24 at 4:39 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Catheter Care, Urinary documented, Be sure the catheter tubing and drainage bag are kept off the floor. Reference: (1) A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm

Based on observation, staff interview, and clinical record review, the facility staff failed to implement a resident's comprehensive care plan for one of 32 residents in the survey sample, Resident #72. The findings include: For Resident #72 (R72), the facility staff failed to implement the resident's comprehensive care plan for the resident's indwelling urinary catheter (1). R72's comprehensive care plan dated 8/16/24 documented, I have an indwelling urinary catheter r/t (related to) urinary retention .Maintain dignity bag/privacy cover over urinary collection bag when in social settings and when visible to others. On 9/9/24 at 7:17 p.m., R72 was observed lying in bed. The resident's indwelling urinary catheter bag was attached to the bed frame. There was no privacy cover on the bag, urine was observed in the bag, and the bag was visible from the hall. On 9/10/24 at 4:09 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated the purpose of the care plan is to provide individualized care for each patient. RN #2 stated nurses have access to residents' care plans to review and ensure the care plans are being implemented. RN #2 stated there should be a privacy bag on indwelling urinary catheter bags to maintain dignity. On 9/10/24 at 4:39 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility staff did not provide a policy regarding care plans. Reference: (1) A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to receive the pharmacy recommendations, after the pharmacist completed the medication regimen review, for two of 32 residents in the survey sample, Residents #37 and #76. The findings include: 1. For Resident #37(R37), the pharmacy failed to provide the facility with the pharmacy recommendations, after the medication regimen review (MRR) was completed on 4/24/24 until 5/30/24. The Pharmacy Consultant note in the clinical record, dated 4/24/24 at 9:22 p.m. documented, See report for recommendations. A request was made on 9/11/24 at 10:55 a.m. for the Pharmacy Recommendation of 4/24/24. On 9/11/24 at 11:27 a.m. ASM (administrative staff member) #2, the director of nursing, presented the, Note to Attending Physician/Prescriber, dated 4/24/24, documented in part, This resident has been taking the antipsychotic, Paliperidone ER (extended release) (used to treat schizophrenia) (1) 3 mg (milligrams) daily, for bipolar disorder. IF CLINICALLY APPROPRIATE, please consider a dose reduction (GDR) (gradual dose reduction), perhaps decreasing the paliperidone ER to 1.5 mg daily. ASM #2 presented the email that the pharmacist sent on 4/25/24 that had no attachments to it. The email dated 5/30/24 at 4:04 p.m. from the pharmacist to ASM #2, documented six attachments. The attachments included the pharmacy review for R37 from 4/24/24. The doctor responded to the above recommendation on 6/5/24. An interview was conducted on 9/11/24 at 12:06 p.m. with ASM #7, the consulting pharmacist. When asked why the facility did not receive their pharmacy recommendations completed on 4/24/24 until 5/30/24, ASM #7 stated it was 100% user error on his part. He did not attach them to the email that he sent to the director of nursing and didn't go back to ensure that they were sent. The facility policy, Medication Regimen Review and Reporting documented in part, 7. The record for the consultant pharmacist's observation and recommendations is made available in an easily retrievable format to nurses, physicians and the care planning team within 48 hours of MRR completion. ASM #1, the administrator and ASM #2, the director of nursing, were made aware of the above findings on 9/11/24 at 1:09 p.m. No further information was provided prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a615032.html 29125 2. For Resident #76, the facility staff failed to obtain the recommendations from the pharmacy within 48 hours of the completion of the pharmacy monthly medication regimen review completed on 8/30/24. A review of the clinical record revealed that the pharmacy completed a monthly medication review on 8/30/24. A progress note dated 8/30 24 documented, This individual's medication regimen was reviewed on the date listed here - _____ See report for recommendation(s). _____ Based on information available in the medical record at the time of review, it is my professional judgment that this medication regimen contained no new irregularities as defined in (the regulation set for long term care facilities) at that time. The box for See report for recommendation(s) was marked with an X Further review of the clinical record failed to reveal any evidence of the recommendation report that was referenced as marked by an X in the above note. On 9/11/24 at 11:58 AM, a copy of the pharmacy recommendation was requested from ASM #2 (Administrative Staff Member) the Director of Nursing. On 9/11/24 at 12:19 PM, ASM #2 stated that she has not received the recommendation yet from the pharmacist. ASM #2 was asked what is the time frame that the pharmacy has to provide the recommendations. She stated she would have to check the policy. On 9/11/24 at 12:42 PM in an follow up interview, ASM #2 stated that the pharmacy was to provide the recommendations within 48 hours of the review. The recommendation was not provided from the pharmacy to the facility within 48 hours. As of this survey, it had been 12 days thus far. No further information was provided by the end of the survey.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for two of four residents in the survey sample, Residents #2 and #3. The findings include: 1. For Resident #2 (R2), the facility staff failed to document the resident's bowel movements. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 8/16/2023, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. In Section G - Functional Status the resident was coded as being dependent upon one staff member for his toileting needs. In Section H - Bowel and Bladder, the resident was coded as being always incontinent of bowel. In the facility computer system, the Dashboard, had documented on 9/26/2023 and 9/27/2023, No BM (bowel movement) X (for) 3 days. The ADL documentation for bowel movements for August 2023 was reviewed and revealed in part, there were blanks on the following days and shifts: 8/17/2023 - 7:00 a.m. to 7:00 p.m. 8/21/2023 - 7:00 a.m. to 7:00 p.m. 8/21/2023 - 7:00 p.m. to 7:00 a.m. - a RR was documented, indicating resident refused. 8/22.2023 - 7:00 a.m. to 7:00 p.m. 8/23/2023 - 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. 8/24/2023 - 7:00 a.m. to 7:00 p.m. 8/25/2023 - 7:00 a.m. to 7:00 p.m. - a RR was documented. A blank was on the 7:00 p.m. to 7:00 a.m. shift. 8/26/2023 - 7:00 p.m. to 7:00 a.m. 8/27/2023 - 7:00 p.m. to 7:00 a.m. 8/28/2023 - 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. 8/29/2023 - 7:00 a.m. to 7:00 p.m. 8/31/2023 - 7:00 a.m. to 7:00 p.m. The ADL documentation for bowel movements forSeptember 2023 documented in part, there were blanks on the following days and shifts: 9/1/2023 - 7:00 p.m. to 7:00 a.m. 9/2/2023 - 7:00 a.m. to 7:00 p.m. 9/3/2023 - 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. 9/4/2023 - 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. 9/5/2023 - 7:00 a.m. to 7:00 p.m. 9/6/2023 and 9/7/2023 - 7:00 p.m. to 7:00 a.m. 9/8/2023 and 9/9/2023 - 7:00 a.m. to 7:00 p.m. 9/10/2023 - 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. 9/11/2023 - 7:00 p.m. to 7:00 a.m. 9/12/2023 - 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. 9/13/2023, 9/14/2023 and 9/15/2023 - 7:00 p.m. to 7:00 a.m. 9/16/2023 and 9/17/2023 - 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. 9/18/2023 - 7:00 a.m. to 7:00 p.m. 9/19/2023 - 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. 9/20/2023 - 7:00 p.m. to 7:00 a.m. 9/21/2023 and 9/22/2023 - 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. 9/23/2023 - 7:00 a.m. to 7:00 p.m. 9/24/2023 - 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. 9/25/2023, 9/26/2023 and 9/27/2023 - 7:00 p.m. to 7:00 a.m. On 9/27/2023 for the 7:00 a.m. to 7:00 p.m. there was a 0 documented, indicating no bowel movement. An interview was conducted with R2 on 9/27/2023 at approximately 2:00 p.m. When asked how often he has a bowel movement, R2 stated he doesn't eat much but he usually goes after lunch. He stated it's something about eating lunch but that's his time of day to have a bowel movement. When asked if he had gone today, R2 stated, yes, but not very much. An interview was conducted with CNA (certified nursing assistant) #1 on 9/27/2023 at 2:39 p.m. When asked where she documents that a resident had a bowel movement during her shift, CNA #1 stated it is documented in PCC (facility computer program). CNA #1 was asked how often should it be documented if a resident had a bowel movement or no bowel movement, CNA #1 stated every shift. An interview was conducted with LPN (licensed practical nurse) #1 on 9/27/2023 at 3:15 p.m. When asked how are BMs documented, LPN #1 stated the CNAs document it in their charting. LPN #1 stated, the nurses get an alert if there is no BM in three days, it's a dashboard alert. When asked what the blanks on the ADL documentation indicated, LPN #1 stated, it wasn't documented on. When asked how often should it be documented on, LPN #1 stated every shift. The facility policy, Activities of Daily Living (ADLs), Supporting, failed to evidence documentation related to bowel movements. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of operations, were made aware of the above concern on 9/28/2023 at 10:41 a.m. No further information was provided prior to exit. 2. For Resident #3 (R3), the facility staff failed to document the resident's bowel movements. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/25/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as being independent for toileting. In the facility computer system, the Dashboard had documented on 9/26/2023, No BM (bowel movement) X (for) 3 days. The ADL (activities of daily living) documentation for bowel movements for August 2023 was reviewed and revealed in part, there were blanks on the following days and shifts: 8/6/2023 and 8/7/2023 - 7:00 p.m. to 7:00 a.m. 8/10/2023 - 7:00 a.m. to 7:00 p.m. 8/12/2023, 8/14/2023 and 8/16/2023 - 7:00 p.m. to 7:00 a.m. 8/19/2023 and 8/20/2023 - 7:00 p.m. to 7:00 a.m. 8/21/2023 - 7:00 a.m. to 7:00 p.m. 8/23/2023 - 7:00 p.m. to 7:00 a.m. 8/25/2023 and 8/26/2023 - 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. 8/27/2023 - 7:00 a.m. to 7:00 p.m. 8/29/2023 - 7:00 p.m. to 7:00 a.m. The ADL (activities of daily living) documentation for bowel movements for September 2023 documented in part, there were blanks on the following days and shifts: 9/2/2023 - 7:00 a.m. to 7:00 p.m. 9/3/2023 and 9/4/2023 - 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. 9/5/2023 - 7:00 p.m. to 7:00 a.m. 9/6/2023 - 7:00 a.m. to 7:00 p.m. 9/7/2023 and 9/8/2023 - 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. 9/9/2023 - 7:00 a.m. to 7:00 p.m. 9/10/2023 - 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. 9/11/2023 and 9/12/2023 - 7:00 p.m. to 7:00 a.m. 9/13/2023 and 9/14/2023 - 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. 9/15/2023 - 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. 9/16/2023 - 7:00 a.m. to 7:00 p.m., an NA was document for this shift indicating Not applicable. 9/17/2023 through 9/21/2023 - 7:00 p.m. to 7:00 a.m. 9/22/2023 through 9/25/2023 - 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. 9/26/2023 - 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. An interview was conducted with CNA (certified nursing assistant) #1 on 9/27/2023 at 2:39 p.m. When asked where she documents that a resident had a bowel movement during her shift, CNA #1 stated it is documented in PCC (facility computer program). CNA #1 was asked how often you should document a bowel movement or no bowel movement, CNA #1 stated every shift. An interview was conducted with LPN (licensed practical nurse) #1 on 9/27/2023 at 3:15 p.m. When asked how are BMs documented, LPN #1 stated the CNAs document it in their charting. LPN #1 stated, the nurses get an alert if there is no BM in three days, it's a dashboard alert. An interview was conducted with R3 on 9/28/2023 at 10:21 a.m. When asked if she needs assistance with toileting, R3 stated she toilets herself. R3 was asked if the staff ask her if she has had a bowel movement, R3 stated, No, but they did ask me today. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of operations, were made aware of the above concern on 9/28/2023 at 10:41 a.m. No further information was provided prior to exit.

Based on staff interview, facility document review and employee record review, it was determined that the facility staff failed to evidence maintenance of required certification for four of five CNA (certified nursing assistants), CNA #1, CNA #2, CNA #3 and CNA #4 The findings include: The facility staff failed to provide the evidence of required certification verification prior to expiration, for four CNAs that were employed for greater than on year. During the Sufficient and Competent Staffing facility task review conducted on [DATE] at 9:30 AM the following CNA employee records and certifications were reviewed and revealed the following: 1. CNA #1 with a date of hire of [DATE], had a previous certification that expired [DATE], however updated certification was not verified through the Department of Health Professions (DHP) until [DATE]. 2. CNA #2 with a date of hire of [DATE], had a previous certification that expired [DATE], however updated certification was not verified through DHP until [DATE]. 3. CNA #3 with a date of hire of [DATE], had a previous certification that expired [DATE], however updated certification was not verified through DHP unit [DATE]. 4. CNA #4 with a date of hire of [DATE], had a previous certification that expired [DATE], however updated certification was not verified through DHP until [DATE]. On [DATE] at 10:30 AM, OSM #4, the human resources director stated, Audits are done on the employee files and I have a book by month of when employee certifications expire. I help them with the on-line process for their certification, but I do not always go back in and print the certificate. On [DATE] at 11:30 AM, ASM #1, the executive director and ASM #2, the director of nursing was made aware of the findings. According to the facility's Licensure, Certification, and Registration of Personnel policy with no date, revealed A copy of recertifications (e.g., annual, bi-annual, etc., as applicable) must be presented to the human resources director/designee upon receipt of such recertifications and prior to the expiration of current licensure, certification, and/or registration. A copy of the recertification must be filed in the employee's personnel record. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plans for three of 33 residents in the survey sample, Residents #11 (R11), #29 (R29), #30 (R30). The findings include: 1. For R11, the facility staff failed to review and revised the comprehensive care plan when psychoactive medications were discontinued. On the most recent MDS (minimum data set) assessment, the resident scored a three out of 15 on the BIMS (brief interview for mental status) score, indicating the resident severely cognitively impaired for making daily decisions. In Section N - Medications, the resident was coded as receiving anti-depressants for seven days of the look back period. R11 was not coded as taking any anti-anxiety medications during the look back period. The comprehensive care plan dated, 3/5/2020 and revised on 11/3/2022, documented, Focus: (R11) uses anti-depressant medication r/t (related to) Depression. The Interventions documented, Administer ANTIDEPRESSANT medications a ordered by physician. Observe/document side effects and effectiveness Q-SHIFT (every shift). Observe/document/report PRN (as needed) adverse reactions to ANTIDEPRESSANT therapy. The care plan further documented, dated 3/6/2020 and revised on 11/3/2022, Focus: (R11) uses anti-anxiety medications r/t Anxiety disorder. The Interventions documented, Administer ANTI-ANXIETY mediations as ordered by physician. Observe for side effects and effectiveness Q-SHIFT. Observe/document/report PRN (as needed) adverse reactions to ANTI-ANXIETY therapy. Review of the physician orders reviewed last on, 11/22/2022, failed to evidence documentation of a physician order for an anti-anxiety medication, or an antidepressant medication. An interview was conducted with RN (registered nurse) #1, the MDS coordinator, on 12/13/2022 at 8:33 a.m. When asked who is responsible for updating the care plan, RN #1 stated it depends, she does it a lot of the time. RN #1 stated she did the majority of it but if something happens, then nursing should be doing it. When asked if the care plans are reviewed for accuracy, RN #1 stated she sets up the care plan meeting and read off the care plan, [name of the director of nursing] signs off on them. RN #1 was asked to review the clinical record to determine the last time R11 received an anti-anxiety medication and an anti-depressant medication. On 12/13/2022 at 9:24 a.m. RN #1 stated after she reviewed the clinical record, [R11] had last received a PRN (as needed) anti-anxiety medication on 1/21/2022. RN #1 stated, [R11] had last received an antidepressant, Remeron, on 11/8/2022. When asked if the care plan should have been updated, RN #1 stated, yes. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 12/13/2022 at 10:16 a.m. When asked the purpose of the care plan, ASM #2 stated it is to guide us in the care plan of the patient and it should be complete and accurate. When asked in the care plan meetings, how does she sign off on it, ASM #2 stated they are supposed to sit in the meeting with the IDT (interdisciplinary team) and review the care plan, once we all deem it is correct and accurate, we sign off on it. The facility policy, Care Plans, Comprehensive Person-Centered, documented in part, 11. Assessments of resident are ongoing and care plans are revised as information about the resident and the residents' condition change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition .d. at least quarterly, in conjunction with the required quarterly MDS assessment, ASM #1, the executive director, and ASM #2 were made aware of the above concern on 12/13/2022 at 11:03 a.m. No further information was obtained prior to exit. 2. For R29, the facility staff failed to review and revised the comprehensive care plan when psychoactive medications were discontinued. On the most recent MDS assessment, an annual assessment, with an assessment reference date (ARD) of 11/28/2022, the resident was coded as having both short- and long-term memory difficulties. The resident was coded as being severely impaired for making cognitive daily decisions. In Section N - Medications, the resident was coded as not taking any psychoactive medications. The comprehensive care plan dated, 3/26/2022, and revised on 11/3/2022, documented, Focus: (R29) has depression and uses antidepressant medication r/t (related to) depression. The Interventions documented, Administer ANTIDEPRESSANT medications as ordered by physician. Observe/document side effects and effectiveness Q-SHIFT. Observe/document/report PRN adverse reactions to ANTIDEPRESSANT therapy. Review of the physician orders reviewed last on, 11/23/2022, failed to evidence documentation of a physician order for an antidepressant medication. An interview was conducted with RN (registered nurse) #1, the MDS coordinator, on 12/13/2022 at 8:33 a.m. When asked who is responsible for updating the care plan, RN #1 stated it depends, she does it a lot of the time. RN #1 stated she did the majority of it but if something happens, then nursing should be doing it. When asked if the care plans are reviewed for accuracy, RN #1 stated she sets up the care plan meeting and read off the care plan, [name of the director of nursing] signs off on them. RN #1 was asked to review the clinical record to determine the last time R29 received anti-depressant medication. On 12/13/2022 at 9:24 a.m. RN #1 returned and stated after she reviewed the clinical record, the R29 had last received an antidepressant, Remeron, on 8/11/2022. When asked if the care plan should have been updated, RN #1 stated, yes. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 12/13/2022 at 10:16 a.m. When asked the purpose of the care plan, ASM #2 stated it is to guide us in the care plan of the patient and it should be complete and accurate. When asked in the care plan meetings, how does she sign off on it, ASM #2 stated they are supposed to sit in the meeting with the IDT (interdisciplinary team) and review the care plan, once we all deem it is correct and accurate, we sign off on it. ASM #1, the executive director, and ASM #2 were made aware of the above concern on 12/13/2022 at 11:03 a.m. No further information was obtained prior to exit. 3. For R30, the facility staff failed to review and revised the comprehensive care plan when psychoactive medications were discontinued. On the most recent MDS assessment, a quarterly assessment, with an ARD of 11/16/2022, the resident was coded as having both short- and long-term memory difficulties. The resident was coded as being severely impaired for making cognitive daily decisions. In Section N - Medications, the resident was not coded as receiving any psychoactive medications. Review of the physician orders, last reviewed on 11/23/2022 failed to evidence documentation of a physician order for an anti-anxiety medication. The comprehensive care plan dated 8/25/2022, and last revised on 10/31/2022, documented, Focus: The resident uses anti-anxiety medications r/t anxiety disorder and treatments. The Interventions documented, Administer ANTI-ANXIETY medications as ordered by physician. Observe for side effects and effectiveness Q-SHIFT. An interview was conducted with RN (registered nurse) #1, the MDS coordinator, on 12/13/2022 at 8:33 a.m. When asked who is responsible for updating the care plan, RN #1 stated it depends, she does it a lot of the time. RN #1 stated she did the majority of it but if something happens, then nursing should be doing it. When asked if the care plans are reviewed for accuracy, RN #1 stated she sets up the care plan meeting and read off the care plan, [name of the director of nursing] signs off on them. RN #1 was asked to review the clinical record to determine the last time R30 received anti-anxiety medication. On 12/13/2022 at 9:24 a.m. RN #1 stated after she reviewed the clinical record, the R30 had last received an anti-anxiety medication, was on 9/4/2022. When asked if the care plan should have been updated, RN #1 stated, yes. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 12/13/2022 at 10:16 a.m. When asked the purpose of the care plan, ASM #2 stated it is to guide us in the care plan of the patient and it should be complete and accurate. When asked in the care plan meetings, how does she sign off on it, ASM #2 stated they are supposed to sit in the meeting with the IDT (interdisciplinary team) and review the care plan, once we all deem it is correct and accurate, we sign off on it. ASM #1, the executive director, and ASM #2 were made aware of the above concern on 12/13/2022 at 11:03 a.m. No further information was obtained prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to prevent verbal abuse for two of 33 residents in the survey sample, Residents # 30 (R30) and Resident #119 (R119). The findings include: For R30 and R119, the facility staff failed to prevent verbal abuse towards the residents, by a facility staff member, on 4/8/2022. R30's most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/16/2022, coded R30 as having both short- and long-term memory difficulties. The resident was coded as being severely impaired for making cognitive daily decisions. R119 no longer resided in the facility. On the most recent MDS assessment, prior to the incident, an admission assessment, with an ARD of 3/23/2022, the resident was coded as scoring a 7 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired for making daily decisions. The Facility Reported Incident (FRI) dated 4/9/2022, documented in part, Incident Date: 4/8/2022. Residents involved: [name of R30] and [name of R119]. Incident type: allegation of abuse/mistreat. Possible verbal comments directed towards residents. Name of Employee(s) involved and their positions: [Name of LPN (licensed practical nurse) #5]. Employee action initiated or taken: Immediate suspension pending investigation, residents assessed. The final report to the Virginia Department of Health, Office of Licensure and Certification, dated 4/12/12022, documented in part, On April 10, 2022 it was reported to myself (name of former director of nursing) by staff that resident [name of Resident #54] and several staff had observed [LPN #5] being verbally abusive to [R30] and [R119]. RN (registered nurse)[name of RN #2] was acting as Weekend Supervisor, was immediately informed of accusations and instructed to get do skin assessment, get witness statements and ensure wellbeing of residents. [RN #2] interviewed [R30] and [R119] also performing skin assessments with no findings. Neither resident was able to recall above mentioned accusations. Both residents where (sic) in good spirits and had no complaints. [RN #2] interviewed [R54] and [R56]. Both gentleman occupy rooms on the hallway where reported alleged incident occurred, both confirm that [R30] was yelling out as the norm of his documented behaviors when [LPN #5] began yelling Shut the F++K up at him while in the hallway from her medication cart. [R54] and [R56] state that at no time did they witness [LPN #5] being physically abusive toward [R30], however [R54] does state witnessing [LPN #5] aggressively pulling Geri chair [R119] occupied. No other staff member can corroborate this accusation. Staff members were interviewed from that evening, several witnessed [LPN #5]'s verbal behavior, no one witnessed any physical behavior or aggression from [LPN #5]. Staff members and [R54[ report witnessing, [LPN #5] saying to [R119], You need to shut up and get your A++ in bed because I need you to sleep. Staff report [LPN #5] requesting them to lay [R119] in bed as she was tired. [R119] had been up for several hours in geri chair and had reported behaviors of attempting to roll out of the chair and yelling. [LPN #5] was suspended immediately pending this investigation and removed from the staff schedule. [RN #2] performed random skin assessments and interview of residents assigned to [LPN #5] during that schedule with no findings of suspected abuse. Psychosocial assessments where (sic) performed by [RN #2]. Findings: Based on facilities (sic) investigation I find no evidence of physical abuse however based on multiple statements the Allegation of Verbal abuse/mistreat is substantiated. Conclusion: [LPN #5] will be terminated with a status of not eligible for rehire with [name of facility]. Board of Nursing will be notified. The Witness statement dated 4/9/2022, documented, On Friday 4/8/22 around 9pm, I herd (sic) charge nurse [LPN #5] yelling at a resident, telling the resident to shut the F*** up and go to sleep then later that evening I herd (sic) nurse [LPN #5] tell another patient to shut the hell up and go to bed. This was signed by CNA (certified nursing assistant) #6, an agency CNA. The Witness Statement dated 4/9/2022, document, On the night of 4/8/22, Charge nurse [LPN #5] was yelling and screaming in the hallway on 100 hall. Charge nurse [LPN #5] yelled at a resident b/c (because) he was repeating the same thing, she yelled and said Shut the F*** Up and go to sleep to him .Charge nurse [LPN #5] also yelled at another resident and told her you need to shut up and get your ass in bed b/c I no (sic) you need sleep. this was signed by CNA #7, an agency CNA. The Witness Statement dated, 4/8/22, documented, Resident reported while in his bed he overheard nurse cussing at resident from hallway, Shut the f*** up. Happened late evening. This was statement for [R56]. The Witness Statement dated, 4-8-22, documented, Resident stated he observed charge nurse [LPN #5] aggressively pulling another residents broda chair with resident in it saying, You need to get your ass in the bed. At which time she slung the chair he witnessed her tell another resident to Shut the f*** up. This was statement for [R54]. The Witness Statement from LPN #5, dated, 4-9-22, documented in part, I didn't have any interactions with [R30] . [listed names of three staff members] and myself took turns watching [R119] all shift. I did not witness or was involved with any verbal abuse on this shift. The above three employees were unavailable for interview. R54, on the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD of 10/18/2022, scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. On the MDS assessment, prior to the incident, a quarterly assessment, with an ARD of 3/7/2022, the resident scored a 14 out of 15 on the BIMS score, indicating they were not cognitively impaired for making daily decisions. An interview was conducted with R54 on 12/12/2022 at 3:01 p.m. When asked if they recalled the incident above, R54 stated they only thing that isn't correct on the witness statement is that they didn't observe it. R54 stated they were in the bed and heard both conversations with the curse words in it. R54 stated they didn't know who the nurse was they just heard the words said to a resident. R56, on the most recent MDS assessment, an admission assessment, with an ARD of 11/15/2022, scored a 14 out of 15 on the BIMS score, indicating R56 was not cognitively impaired for making daily decisions. On the MDS assessment, prior to the incident, a quarterly assessment, with an ARD of 2-25-2022, R56 scored a 13 out of 15 on the BIMS score, indicating the resident was not cognitively impaired for making daily decisions. An interview was conducted with R56 on 12/12/2022 at 3:07 p.m. When asked if they recalled the incident above, R56 stated yes and verified their statement. R56 stated they were in room (number) at the time and heard the nurse curse at the two residents. The former director of nursing was not available for interview. An interview was conducted with RN (registered nurse) #2 on 12/13/2022 at 8:51 a.m. When asked her role in the incident above, RN #2 stated she was called by the director of nursing to go into the facility and assess the residents involved. She did assess each resident and there were no noted injuries, neither resident could recall the incident. RN #2 stated she initiated the FRI report and sent it off to the state. When asked if she obtained any witness statements, she stated she interviewed [R54] and [R56]. RN #2 stated the former director of nursing did the rest of the investigation. RN #2 stated the nurse was suspended and was terminated after the incident. The facility policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, documented in part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation by anyone including but not necessarily limited to: a. facility staff 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents. ASM #1, the executive director and ASM #2 were made aware of the above concern on 12/13/2022 at 11:03 a.m. No further information was obtained prior to exit.

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to implement a facility-initiated discharge requirement for one of 33 residents in the survey sample, Resident #218. The findings include: For Resident #218 (R218), the physician failed to document the basis for the resident's discharge, the specific resident needs that could not be met at the facility, the facility attempts to meet R218's needs, and the services available at the receiving facility to meet R218's needs, when R218 was discharged from the facility on 10/5/21. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/5/22, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. A review of R218's clinical record revealed a nurse's note dated 10/5/21 that documented R218 was transferred to a local emergency department for shortness of breath, chest pain, nausea and a headache. Another nurse's note dated 10/5/21 documented R218 called the facility and stated the resident was being admitted to a local hospital. A document dated 10/5/21 and titled, Virginia Involuntary Transfer/Discharge Notice documented, To: (R218). From: (Name of former Executive Director) - (name of facility). Re: Discharge Notice- This is to notify you that you, (R218), will be transferred/discharged from our facility to an alternate skilled nursing facility or healthcare setting that can meet your needs no later than the end of 30 days 11/4/2021. At the time of your discharge your transfer will be set up in accordance with industry standards. This plan has been reviewed with our Medical Director and meets with their approval. Should you choose an alternative location services will be set up to that alternate address. You are being discharged because: The facility can no longer meet the resident's medical needs; The health and safety of the resident, other residents or staff is endangered . Resident #218 never returned to the facility. Further review of R218's clinical record failed to reveal any physician documentation regarding the resident's discharge until 12/23/21. A physician's note dated 12/23/21 documented, To Whom It May Concern: (R218) was found guilty of assaulting a staff member attempting to provide care to (the resident). (R218) exhibited behaviors of refusing staff assistance, remaining in same position for long hours causing skin deterioration. Unable to meet (the resident's) needs for ADL's (activities of daily living) causing great concern for UTI's (urinary tract infections), pneumonia and sepsis and proving to be accurate as this was the reason for (the resident's) admission to the hospital. The psychological aspect of anger was being managed by (name of psychology services) until (R218) refused that service as well. On 12/13/22 at 12:49 p.m., an interview was conducted with ASM (administrative staff member) #4 (the physician). ASM #4 stated he usually writes a note when a resident is discharged so the physicians at the receiving facility have information regarding the resident. ASM #4 stated his discharge notes usually contain an admission history and physical, documentation regarding the resident's stay at the facility and documentation regarding the discharge. ASM #4 stated he could not recall why he did not document a note when R218 discharged from the facility. On 12/13/22 at 1:30 p.m., ASM #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Discharge of Residents failed to document information regarding physician documentation of discharge. No further information was presented prior to exit. Complaint deficiency.

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to provide a discharge notice containing all required contents for one of 33 residents in the survey sample, Resident #218. The findings include: For Resident #218 (R218), the facility staff issued an involuntary discharge notice on 10/5/21. The involuntary discharge notice failed to contain the specific location to which the resident was being discharged . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/5/22, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. A document dated 10/5/21 and titled, Virginia Involuntary Transfer/Discharge Notice documented, To: (R218). From: (Name of former Executive Director) - (name of facility). Re: Discharge Notice- This is to notify you that you, (R218), will be transferred/discharged from our facility to an alternate skilled nursing facility or healthcare setting that can meet your needs no later than the end of 30 days 11/4/2021. At the time of your discharge your transfer will be set up in accordance with industry standards. This plan has been reviewed with our Medical Director and meets with their approval. Should you choose an alternative location services will be set up to that alternate address. You are being discharged because: The facility can no longer meet the resident's medical needs; The health and safety of the resident, other residents or staff is endangered . The notice failed to document the specific location to which R218 was being discharged . On 12/13/22 at 1:23 p.m., an interview was conducted with ASM (administrative staff member) #1 (the executive director). ASM #1 stated an involuntary discharge notice should document a safe and specific discharge location. On 12/13/22 at 1:30 p.m., ASM #1 and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Discharge of Residents documented, 6. The date and reason for discharge or transfer, the destination of the resident, if known, shall be recorded in the resident's file. No further information was presented prior to exit.

Based on staff interview and clinical record review, it was determined that the facility staff failed to provide notice of Medicare non-coverage for two of three residents identified during the beneficiary protection notification resident reviews, Resident #6 and Resident #320. The findings include: 1. For Resident #6 (R6), the facility failed to provide a resident and/or the resident's representative with an ABN (Advance Beneficiary Notice of Non-coverage) waiver of liability when a change in coverage occurred. R6's last covered day of Medicare part A services was 10/20/2022. R6 remained in the facility at the time of the survey. On 12/13/2022 at 8:05 a.m., an interview was conducted with OSM (other staff member) #3, the social services director. OSM #3 stated that they were responsible for providing the ABN notices to residents now. OSM #3 stated that when a resident had Medicare Part A and were discontinued from services with days remaining they provided them the required notices. OSM #3 stated that often residents only used a certain amount of their allotted days and they were required to provide the notices to the residents in order to give them the choice to appeal or continue the services at a cost. OSM #3 stated that residents were given three options to choose from on the notice and the purpose of the notice was to inform the resident that there may be financial liability to them. OSM #3 stated that R6 remained in the facility at the end of service and should have received an ABN notice but they did not have evidence that it was provided. The facility policy Medicare Advanced Beneficiary Notices dated October 2022 documented in part, .The SNFABN (skilled nursing facility advanced beneficiary notice of non-coverage) provides information to beneficiaries in advance of changes so that beneficiaries can decide if they wish to continue receiving the skilled service(s) that may not be paid for by Medicare and assume financial responsibility On 12/13/2022 at 11:11 a.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit. 2. For Resident #320 (R320), the facility failed to provide a resident and/or the resident's representative with an ABN (Advance Beneficiary Notice of Non-coverage) waiver of liability when a change in coverage occurred. R320's last covered day of Medicare part A services was 8/27/2022. R320 was discharged from the facility on 10/10/2022. On 12/13/2022 at 8:05 a.m., an interview was conducted with OSM (other staff member) #3, the social services director. OSM #3 stated that they were responsible for providing the ABN notices to residents now. OSM #3 stated that when a resident had Medicare Part A and were discontinued from services with days remaining they provided them the required notices. OSM #3 stated that often residents only used a certain amount of their allotted days and they were required to provide the notices to the residents in order to give them the choice to appeal or continue the services at a cost. OSM #3 stated that residents were given three options to choose from on the notice and the purpose of the notice was to inform the resident that there may be financial liability to them. OSM #3 stated that R320 remained in the facility at the end of service and should have received an ABN notice but they did not have evidence that it was provided. On 12/13/2022 at 11:11 a.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit.

Based on observation, resident interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, it was determined that the facility staff failed to provide care and services in a manner to prevent accidents and injuries for three of 31 residents in the survey sample, Residents #29, #9 and #7; and failed to maintain seven of nine smoking aprons in an intact manner. 1. On [DATE], Resident #29 sustained a fall resulting in a cervical fracture and a scalp laceration requiring staples. An [DATE] nurses note documented the resident was reviewed at the weekly falls meeting, however there was no documentation on the care plan of the [DATE], fall with injury, or any new interventions to prevent further falls. On [DATE], Resident #29 was observed by staff wandering with an unsteady gait, restless and would jump up from the wheel chair and wander. The Resident was administered an as needed 1 mg (milligram) dose of Ativan (**a benzodiazepine antianxiety medication) and placed in the wheelchair without direct staff supervision. During an interview with staff (registered nurse #3)that cared for Resident #29 on [DATE], the staff said Resident #29 needed 1:1 supervision, but she could not provide it since she was passing medications. RN (registered nurse) #3 said the CNAs (certified nursing assistant) couldn't do 1:1 supervision at that time. Resident #29 fell and sustained a left forehead laceration that required four sutures and a blood blister on his upper lip. 2. Resident #9, the facility staff failed to address or implement interventions to prevent further falls on multiple occasions between [DATE] and [DATE]. 3. Seven smoking aprons were observed to be in disrepair with torn areas. 4. Resident #7, the facility staff failed to implement interventions to prevent further falls after the resident sustained [REDACTED]. The findings include: 1. On [DATE], Resident #29 sustained a fall resulting in a cervical fracture and a scalp laceration requiring staples. An [DATE] nurses note documented the resident was reviewed at the weekly falls meeting, however there was no documentation on the care plan of the [DATE], fall with injury, or any new interventions to prevent further falls. On [DATE], Resident #29 was observed by staff wandering with an unsteady gait, restless and would jump up from the wheel chair and wander. The Resident was administered an as needed 1 mg (milligram) dose of Ativan (**a benzodiazepine antianxiety medication) and placed in the wheelchair without direct staff supervision. During an interview with staff that cared for Resident #29 on [DATE], the staff said Resident #29 needed 1:1 supervision, but she could not provide it since she was passing medications. She continued and said the CNAs (certified nursing assistant) couldn't do 1:1 supervision at that time, since they were providing care for other residents. Resident #29 fell and sustained a left forehead laceration that required four sutures and a blood blister on his upper lip. "Ativan: Use- Oral: Management of anxiety disorders or short term relief of the symptoms of anxiety or anxiety associated with depressive symptoms...Warnings/Precautions: Cause CNS (central nervous system) depression (dose-related) which may impair physical and mental capabilities. Use with caution in patients receiving other CNS depressants or psychoactive agents. Benzodiazepines have been associated with falls and traumatic injury and should be used with extreme caution in patients who are at risk of these events (especially the elderly)..." ** Resident #29 was originally admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #29's annual MDS (minimum data set) with an ARD (assessment reference date) of [DATE], coded the resident's cognitive skills for daily decision making as severely impaired. Section G documented Resident #29 required limited assistance of one staff with bed mobility and transfers, and required supervision/set up help only for walking and locomotion. Section J documented the resident had not sustained any falls since the prior assessment. Resident #29 expired on [DATE]. Review of Resident #29's closed clinical record revealed the following physician's orders [REDACTED]. [DATE]- Trazodone (used to treat depression or insomnia)* 50 mg at bedtime. [DATE]- Ativan (an anti-anxiety medication) ** 0.5 mg (milligrams) twice a day and Ativan 1mg twice a day as needed. [DATE]- Seroquel (an antipsychotic medication used to treat schizophrenia, bipolar disorder or along with other medication to treat depression) *** 12.5 mg twice a day. Review of Resident #29's [DATE] MAR (medication administration record) revealed the resident was administered Seroquel 12.5 mg on [DATE] at 6:00 p.m., Ativan 0.5 mg on [DATE] at 6:00 p.m., Ativan 1 mg on [DATE] at 7:30 p.m. and Trazodone 50 mg on [DATE] at 9:00 p.m. Resident #29's insomnia care plan dated [DATE] documented, "Problem: Insomnia. Disturbance in sleep pattern. Goal: Resident will have at least 6 hours of sleep each night thru next review. Approaches & Interventions: Determine normal sleep pattern and assess need for intervention. Provide comfortable bedding and relaxed environment. Reduce noise and light. Discourage intake of caffeine products in evening - sodas, coffee, Tea, chocolate. Administer medications as ordered and monitor for affectiveness (sic). Notify MD (medical doctor) as needed. MD to review meds (medications) per policy and for potential changes. Began Trazodone 50 mg 1 QHS (every hour of sleep)." Resident #29's psychoactive medication use care plan dated [DATE] documented, "Anti-Depressant medication for DX (diagnosis) of Insomnia. Goal: Medication side effects will not impede daily function. Approaches & Interventions: Medication as ordered (see Mar (medication administration record))...Antidepressants: Report residual signs and symptoms of depression or symptomatic relief as needed. (i.e. safety measures for ataxia {Ataxia is sudden, uncoordinated muscle movement due to disease or injury to the cerebellum in the brain.^}, fluids for constipation). Monitor effectiveness and side effects such as: ataxia, abnormal dreams, confusion, constipation, hangover effect. If side effects present report to practitioner and provide symptomatic relief as needed. (i.e. safety measures for ataxia, fluids for constipation.)" Resident #29's comprehensive care plan failed to address the use of Ativan and Seroquel. Resident #29's fall risk evaluation dated ,[DATE] (no year) documented the resident was disoriented times three at all times, ambulatory and incontinent; the resident's vision status was poor (with or without glasses) and the resident had decreased muscular coordination. The fall risk total score was documented as 14; the form documented a total score of 10 or above deemed the resident at risk. Resident #29's safety care plan dated [DATE] documented, "Focus: The resident has the potential for injury..." No goal was documented. The "Approaches & Interventions" documented, ",[DATE]- Follow facility fall protocol. ,[DATE]- Medication as ordered. ,[DATE]- Every 15 minute safety checks. 4/ (26 or 28- date illegible)/14- B/C (bed/chair) alarm. ,[DATE]- Family request bed against wall for safety." Resident #29's safety care plan dated [DATE] documented, "Focus: The resident has the potential for injury. Goal: The resident will not injure themselves in a fall through next review. Approaches & Interventions: Follow facility fall protocol. Be sure the resident's call light in within reach and encourage the resident to use it for assistance as needed. Chair alarm- Check placement every shift and function." On [DATE] at 11:50 a.m., ASM (administrative staff member) #2, the director of nursing was asked which safety care plan was supposed to be in practice during [DATE] when Resident #29 sustained falls. ASM #2 stated, "I can't accurately tell you which care plan was in use if there are two of them." A nurse's note dated [DATE] at 5:00 a.m. documented, "Pt (patient) (an arrow pointing up indicating the word 'up') in w/c (wheelchair) med (medicated) x (times) 1 (a 'c' with a line over it indicating the word 'with') Ativan* x (times) 1 put in bed @ (at) 4A (4:00 a.m.). Called to room @ 410A (4:10 a.m.) pt on floor, laceration to R (right) occipital area & hematoma to R (right) eye; skin tear to R elbow, 911 called. Pt sent to (name of hospital) for eval (evaluation) & Tx (treatment)." The hospital records dated [DATE] revealed Resident #29 sustained a cervical fracture and a scalp laceration that required surgical staples. Resident #29's "After Care Instructions" dated [DATE], documented in part, "Instructions Fracture - Cervical (Name of Resident) has a broken C2 (second cervical vertebra) fracture. His neck fracture can be life-threatening or permanently disabling if reinjured.." A nurse's note dated [DATE] documented, "LE (late entry) for [DATE]: Reviewed at weekly falls meeting. Recent fall w/ (with) injury and increased behaviors." However despite this review, there was no documentation addressing the fall with injury on [DATE] or new interventions to prevent further falls documented on the [DATE] or [DATE] safety care plans. A nurse's note dated [DATE] at 10:20 p.m. documented, "Pt (patient) had been restless this evening. Scheduled Ativan 0.5 mg (milligrams) po (by mouth) given & Seroquel. Pt readied for bed but started wandering (unsteady), so given Ativan 1.0 mg po & assisted onto w/c (wheelchair). Attempted by staff & peers to keep pt distracted, but he kept trying to walk & get into wall panels. Had pt in hall at nurse's station for safety. Cervical collar remained on. Pt kept trying to remove it. Tried distractions. Nurse heard pt fall at 2115 (9:15 p.m.). Lips & L (left) fore-head were lacerated. VS (vital signs) taken. Neuro (neurological) (a check mark beside an s indicating the word 'checks') done. Dr (doctor) and Rescue squad called. Assistant DON (director of nursing) notified. Pt taken via Rescue Squad to (name of hospital) on board w/ (with) cerv. (cervical) collar still on. Informed wife of above when she awoke at 2200 (10:00 p.m.)." The hospital records dated [DATE] revealed Resident #29 sustained a left forehead laceration that required four sutures and a blood blister on his upper lip. On [DATE] at 7:30 a.m., an interview was conducted with ASM #2, the director of nursing, regarding safety monitoring. ASM #2, the director of nursing, stated safety monitoring was frequent checks- every 15 minutes, 30 minutes, hour or two hours, depending of what is appropriate for the resident. ASM #2, stated staff tries to monitor residents and keep them in eye sight when they are agitated or exit seeking. ASM #2 was asked what was implemented to prevent future falls after Resident #29 fell on [DATE]. ASM #2 stated the staff sent him to the emergency room where a cervical collar was placed, neurological checks, and continued 1:1 supervision. Review of Resident #29's clinical record only revealed documentation of 1:1 supervision on [DATE] at 11:30 pm.- "Pt (patient) has had 1:1 coverage" and [DATE] at 11:30 p.m.- "1:1 all shift." ASM #2 was asked to show evidence that safety checks had been completed since ,[DATE] as documented on the care plan. ASM #2, the director of nursing, stated, "Let me see. They shred them." On [DATE] at 7:55 a.m., an interview was conducted with CNA (certified nursing assistant) #10. When asked to explain the facility fall protocol, CNA #10 stated she would have to ask because she had just started in [DATE]. On [DATE] at 8:00 a.m., an interview was conducted with CNA #11 regarding the facility fall policy. CNA #11 stated the staff implements 15 minutes checks (then signs off), fall mats, alarms and a sign. CNA #11 stated a resident at high risk for falls is put on the protocol. CNA #11 was asked if she remembered Resident #29 and what interventions were in place for him to prevent falls. CNA #11 stated the resident had an alarm, fall mat, low bed and 15 minute checks. CNA #11 stated she didn't remember when and for how long Resident #29 had those interventions. On [DATE] at 8:30 a.m., an interview was conducted with LPN (licensed practical nurse) #3 regarding the facility fall protocol. LPN #3 stated, "As far as I know, we identify a person who is a possible fall risk and we have different levels of interventions." LPN #3 stated newly admitted residents are placed on safety checks for three days and the "Adopt a Resident" for ten days. When asked about long term residents who have previous falls, LPN #3 stated, "We have steps of interventions." LPN #3 stated a therapy evaluation, neurological checks and safety checks (for three days) are initiated after a fall. LPN #3 stated as the falls progress, bed/chair alarms, fall mats and low beds are implemented. LPN #3 was asked what should be done if a resident who is at high risk for falls begins to wander while the nurse is completing the medication pass and the CNAs are providing care to others; LPN #3 stated someone would have to watch that resident 1:1, if the resident is up moving then that person should be up moving with the resident. When asked if staff should be doing anything else when they are providing 1:1 supervision, LPN #3 stated the staff should be focused on that resident. When asked if a nurse could complete 1:1 supervision while on medication pass, LPN #3 stated, "My opinion is no. She would have to leave the resident to give meds (medications) and you never know if you are going to get tied up." LPN #3 was asked if she remembered Resident #29. LPN #3 stated she believed the resident was at risk for falls but couldn't remember what interventions were in place. On [DATE] at 9:30 a.m., this surveyor requested facility policies regarding falls and the facility fall protocol. ASM #4, the regional director of clinical services, stated the fall committee meets along with the fall investigation. ASM #4 presented a "Fall Risk" policy and stated this was the policy for the facility fall protocol. The policy documented, "Policy: To identify risk factors which place the resident at risk for falls and to facilitate the development of interventions to minimize or prevent falls to the extent possible, resident will have a fall risk evaluation completed on admission/readmission and quarterly. Procedure: Fall risk evaluation will be completed by a licensed nurses (sic) on admission/readmission, quarterly, with significant change, and as needed. Complete all sections of the fall risk evaluation using the coding as indicated on the fall risk evaluation form. A resident with a fall risk score of ten or more should be considered at risk for falls. Residents identified at risk for falls will have individualized prevention interventions added to the resident's plan of care. Initiate appropriate intervention to reduce risk. Document identified risk and intervention(s) in the resident's plan of care." At this time, ASM #2, the director of nursing, was asked who decides what type of safety monitoring is appropriate for each resident. ASM #2 stated, "It's a nursing intervention. We expect the nurse or staff to determine what level of monitoring they need." On [DATE] at 10:25 a.m., a telephone interview was conducted with RN (registered nurse) #3, the nurse responsible for documenting the note regarding Resident #29's fall on [DATE]. RN #3 stated Resident #29 was getting worse with falling and he could fall easily. RN #3 stated the staff tried to prevent falls, tried to have someone with the resident and tried to encourage him to use a wheelchair. RN #3 stated staff would assist Resident #29 to bed and a half hour later he would be walking down the hall with an unsteady gait. RN #3 was asked about Resident #29's behaviors. RN #3 stated the resident would sometimes get aggressive. RN #3 stated Resident #29 would sometimes become angry if you tried to encourage him to stay in the wheelchair. RN #3 stated the resident would wrench your wrists and say, "I want to stand up. I don't want anyone touching me." RN #3 stated Resident #29 was becoming worse and worse so staff would try to hold onto him when he wanted to walk. RN #3 stated some other residents and Resident #29's wife would distract him and try to get him to stay in his wheelchair. RN #3 stated she tried to have an employee with the resident. RN #3 was asked to explain what occurred on [DATE] when Resident #29 fell . RN #3 stated the resident wanted to get into things and walk and tried to take his cervical collar off. RN #3 stated Resident #29 was restless and would jump up, even with staff present. RN #3 stated she took the resident to her medication cart while she was passing medication to other residents. RN #3 stated something distracted her for one to two seconds and Resident #29 had fallen. When asked what type of safety monitoring was appropriate for Resident #29, RN #3 stated the staff was trying to keep someone with him all the time but that wasn't possible. RN #3 stated the CNAs (certified nursing assistants) had to conduct incontinence care rounds and she had to pass medications. RN #3 stated 1:1 supervision may be helpful to prevent another future fall but the CNAs couldn't do 1:1 supervision at that time. On [DATE] at 12:00 p.m., the administrator, director of nursing and regional director of clinical services were made aware of the above findings and the concern for harm. On [DATE] at 1:40 p.m., an interview was conducted with ASM #4, the regional director of clinical services. ASM #4 presented the [DATE] fall investigation and stated Resident #29 had a bed and chair alarm in place, the bed against the wall, and a scoop mattress. ASM #4 stated Resident #29 also had floor mats and a low bed. ASM #4 stated the documentation in the nurse's notes for ,[DATE] and ,[DATE] looked to her as if 1:1 supervision was completed for 24 hours. Review of Resident #29's clinical record and care plan revealed the following: Resident #29's alarm had been implemented since [DATE] and was not a new intervention. The [DATE] TAR (treatment administration record) documented, "[DATE]- Safety Alarm At All Times- Check Function and Place Every Shift." Nurses' initials were signed for each shift from [DATE] through [DATE]. Resident #29's bed against the wall had been implemented since [DATE] and was not a new intervention. Resident #29's safety care plan dated [DATE] documented, "Focus: The resident has the potential for injury..XXX,[DATE]- Family request bed against wall for safety." Resident #29's clinical record failed to evidence a scoop mattress was in place from [DATE] through [DATE]. The [DATE] TAR documented, "[DATE]- Check Mattress for Proper Positioning." Nurses' initials were signed for each shift from [DATE] through [DATE]. Resident #29's clinical record failed to evidence floor mats and a low bed were implemented from [DATE] through [DATE]. The care plans dated [DATE] and [DATE] did not document either of these interventions. Review of Resident #29's clinical record only revealed documentation of 1:1 supervision on [DATE] at 11:30 pm.- "Pt (patient) has had 1:1 coverage" and [DATE] at 11:30 p.m.- "1:1 all shift." The care plans dated [DATE] and [DATE] failed to document updates for the residents falls. There were no new interventions were document on any of Resident #29's care plans after his falls and his increased documentation of wandering. On [DATE] at 1:40 p.m., ASM #4 the regional director of clinical services, provided multiple "Safety Check" forms. Review of Resident #29's "Resident Safety Check" forms revealed no safety checks for: [DATE], [DATE], [DATE], [DATE], [DATE] or [DATE] (from 11:00 p.m. until 7:00 a.m. or 3:15 p.m. through 10:45 p.m.) There were no safety checks completed on [DATE] at the time of Resident #29's fall at 10:20 p.m. At this time, ASM #4 was asked to provide a copy of the [DATE] fall investigation (the investigation was not part of the clinical record). The copy was not provided prior to exit and no further information was provided documenting the facilty had evaluated and implmented new interventions to prevent further falls for Resident #29. According to "Handbook of Nursing Procedures Springhouse Corporation 2006 pages 323 through 328- Fall Prevention and Management: Falls are a major cause of injury and death among elderly people.... " In "Fundamentals of Nursing" 7th edition, 2009; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 5. "Client safety is a priority in health care. You need to protect clients from physical and emotional injury by continually assessing for and eliminating safety hazards. Clients fall due to many factors, such as improper transfer techniques, client age, side effects of medications, impaired mobility, or confusion. Learn your agency's fall prevention program for reducing client falls. Programs that use a multidimensional approach in designing fall prevention strategies have the greatest reduction in fall rates." According to Mosby's Textbook for Long-Term Care Assistants, fourth edition, 2003. Page 144, "Safety is a basic need. Nursing center residents are at great risk for falls and other accidents....You need to know the factors that increase a person's risk of accidents and injury. You also need to follow the person's care plan." *This information was obtained from the website: <http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 8.html> **This information was obtained from: Lexi-Comp's Drug Information Handbook for Nursing, 8th Edition; 2007; page 753 ***This information was obtained from the website: <http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 9.html> <http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_ guidelines_recommendations/2012 <http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_%20guidelines_recommendations/2012>>) states that benzodiazepine medications (the family of medications that include Ativan) should only rarely be used in older adults because "(Older adults) have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents. In general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults .... Avoid benzodiazepines (any type) for treatment of [REDACTED]." ^ This information was obtained from the wesite: <http://www.nlm.nih.gov/medlineplus/ency/article/ 7.htm> 2. For Resident #9, the facility staff failed to address or implement interventions to prevent further falls on multiple occasions between [DATE] and [DATE]. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded the resident's cognition as being severely impaired. Section G coded Resident #9 as requiring extensive assistance of one staff with bed mobility, transfers and walking. Section J documented Resident #9 sustained two falls with no injury since the prior assessment and two falls with injury (except major) since the prior assessment. On [DATE] at 9:30 a.m., this surveyor and ASM (administrative staff member) #2, the director of nursing reviewed Resident #9's clinical record and fall investigations. The following was noted: [DATE]- Resident #9 was reaching for a can of soda and fell on the floor. No injury was noted. Fall investigations documented the resident was encouraged to ask staff for help when getting items off the floor. The investigations further documented Fall Committee Review/Recommendations as: "Resident with behaviors. Packs clothing often during the day becomes combative at times when attempting to re-direct." The care plan revisions documented on the investigation were documented as a physician evaluation and medication review. The facility was unable to provide documentation to evidence a physician evaluation or medication review. In regards to this fall, ASM #2, the director of nursing confirmed there was no physician evaluation related to that fall. When asked to show evidence of a medication review, ASM #2, stated that was documented on the care plan. [DATE]- Resident #9 was observed sitting on the floor at the foot of the bed. He stated he was at his closet. No injury was noted. The clinical record and investigations failed to reveal any new interventions and failed to reveal the care plan was reviewed and revised. In regards to this fall, ASM #2, the director of nursing, stated she did not see any documentation of an intervention in the nurse's notes for that day, in the investigations or on the care plan. [DATE]- A nurse's note documented Resident #9 was reviewed at the weekly falls and behavior meeting with recent medication changes and a physician evaluation. The facility was unable to provide documentation to evidence a physician evaluation at this time. [DATE]- Resident #9 was "found" sitting on the floor in the bedroom. No injury was noted. The fall investigations documented the resident was assisted into the wheelchair after the fall. The Fall Committee Review/Recommendations was blank. The care plan revision documented on the investigation was, "Add to Adopt." The facility staff could not provide documentation to evidence "Adopt" was implemented. ASM #2 was asked to explain the "Adopt" program. ASM #2, the director of nursing, stated the program was another monitoring tool. On [DATE] at 9:50 a.m., ASM #2, the director of nursing, stated the facility staff does not keep Adopt forms past two weeks. [DATE]- Resident #9 was "found" on the floor. No injury was noted. The fall investigations documented to continue on 15 minute safety checks and engage in activities as the interventions implemented after the fall. The Fall Committee Review/Recommendations and care plan revisions documented on the investigations was blank. The care plan failed to document a check mark beside "Every 15 minute safety checks." The facility staff could not provide documentation to evidence the 15 minute safety checks were being implemented. ASM #2, the director of nursing, was asked if it was accurate to state there was no intervention or care plan update for this fall. ASM #2, the director of nursing, stated, "There's no dated intervention for this fall." [DATE]- Resident #9 was noted on the floor. No injury was noted. The nurse's note documented, "Resident cont (continues) on 15 min. (minute) safety (a check mark indicating the word 'check'). Will cont to monitor. The investigations documented, "What intervention was implemented after fall? Cont on 15 min safety (a check mark indicating the word 'check') engaging in activities." The fall committee Review/Recommendations and care plan revisions documented on the investigation was blank. The care plan failed to document a check mark beside "Every 15 minute safety checks." The facility staff could not provide documentation to evidence the 15 minute safety checks were being implemented. [DATE]- A nurse's note documented the resident was non-compliant with using the call bell for assistance and non-compliant with his alarm. [DATE]- Resident #9 urinated on the floor and slipped on his buttocks. The resident removed his alarm. The investigation failed to reveal any interventions were implemented after the fall and failed to reveal the care plan was reviewed and revised. [DATE]- A nurse's note documented Resident #9 had removed the bed alarm but it was replaced while the resident was sleeping. [DATE] (9:15 a.m.)- Resident #9 was "found" sitting on the floor in the bedroom. No injury was noted. The nurse's note documented the resident continued to try to ambulate unassisted after numerous redirecting. The investigation failed to reveal any interventions were implemented after the fall and failed to reveal the care plan was reviewed and revised. In regards to this fall, ASM #2, the director of nursing, stated that the resident required ADL (activities of daily living) assistance and this was on the ADL care plan. Resident #9's ADL care plan documented interventions for bathing, bed mobility, dressing, eating, grooming, and transfers (requiring two person assist). The ADL care plan was dated [DATE] at the top of the form. The implementation date was blank. The target dates were ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. There was no documentation to evidence any new interventions or that this care plan had been reviewed and revised in relation to the [DATE] fall. [DATE]- Resident #9 rolled out of bed and onto the floor. The resident complained of right sided pain. X-rays were negative for fractures. The investigation and clinical record review failed to reveal any interventions were implemented after the fall and failed to reveal the fall was addressed by the fall committee and care plan revisions were made. Care plan revisions were not reflected on the fall care plan. [DATE]- Resident #9 was observed on the floor in the bedroom. The resident sustained [REDACTED]. A nurse's note documented the resident continued to try to get out of the chair unassisted and removes the bed/chair alarms. The investigations and clinical record failed to reveal new interventions were addressed/implemented and failed to reveal the care plan was reviewed and revised. [DATE]- No documentation of a fall in the clinical record. The investigations documented Resident #9 sat himself on the floor. The investigation failed to reveal any interventions were implemented after the fall and failed to reveal the care plan was reviewed and revised. On [DATE] at 9:50 a.m., ASM #2, the director of nursing, stated she could not provide documentation of the actual fall nor could she provide evidence of an intervention or care plan update. [DATE] (2:00 p.m.)- Resident #9 sustained a fall at 1:15 p.m. per the nurse's notes. No injury was noted. The investigations and clinical record failed to reveal new interventions were addressed/implemented and failed to reveal the care plan was reviewed and revised. [DATE]- (8:00 p.m.)- Resident #9 sustained a fall at 4:15 p.m. per the nurse's notes. No injury was noted. The investigations and clinical record failed to reveal new interventions were addressed/implemented and failed to reveal the care plan was reviewed and revised. [DATE]- Resident #9 slid out of the wheelchair. No injury was noted. The wheelchair cushion was adjusted. The fall investigations documented, "Resolution/Intervention for minimizing future occurrences: Adjusting padding in w/c (wheelchair). Dycem added to w/c." The fall investigations further documented care plan revisions as dycem. Resident #9's safety care plan documented a check mark beside, "Pad equipment (specify type and device to pad." No specification (including dycem) was documented. On [DATE] at 9:45 a.m., Resident #9 was observed in a wheelchair in the hall across from the nurse's station. No dycem was observed in the wheelchair. On [DATE] at 11:10 a.m., an interview was conducted with LPN (licensed practical nurse) #3 regarding falls. LPN #3 stated after a resident falls, the nurse assesses the resident, returns the resident to the wheelchair or bed, calls the physician to see if there is a need for any new orders, call the family and implement 15 minute safety checks for three days. When asked what is done if the resident has had previous falls, LPN #3 stated there are steps of interventions that the facility staff put into place and the interventions may include 15 minute checks, low beds or alarms. When asked if new interventions are attempted after each fall, LPN #3 stated if the resident is on every intervention they have in place then the staff obtain physician's orders [REDACTED]. LPN #3 stated that resident is reviewed at the