Every finding on record at Deer Meadows Rehabilitation and Nursing

Based on interviews, clinical record review, and facility document review, the facility staff failed to ensure medical provider orders were signed by the ordering provider when the orders were entered into residents' clinical records by non-prescribing facility staff members for two (2) of 11 sampled residents (Resident #4 and Resident #6). The findings include: 1. Review of Resident #6's clinical record revealed multiple orders that had not been signed by the prescribing medical provider. Resident #6's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/27/24, was signed as completed on 9/2/24. Resident #6 was assessed as able to make self understood and as able to understand others. Resident #6's Brief Interview for Mental Status (BIMS) summary score was documented as a 10 out of 15; this indicated moderate cognitive impairment. The following orders were not signed by the ordering medical provider: - Resident #6's laboratory order for multiple blood tests dated 8/20/24. - Resident #6's medication order for Ferrous Sulfate Tablet 325 mg dated 8/21/24. - Resident #6's medication order for Eliquis 5mg dated 8/21/24. - Resident #6's order for Zinc to be applied to the coccyx dated 9/6/24. - Resident #6's wound care order dated 8/22/24 at 1:57 p.m. - Resident #6's left heel Deep Tissue Injury (DTI) care order dated 8/22/24 at 1:59 p.m. - Resident #6's wound care order dated 8/23/24 at 11:42 a.m. On 3/12/25 at 2:35 p.m., the Director of Nursing (DON) confirmed that some of Resident #6's wound orders had not been signed by the ordering medical provider. The following information was found in a facility document titled Verbal Orders (with a reviewed/revised date of 12/1/22): - Verbal Orders are those given to the nurse by the physician in person or by telephone, however, are not written by the physician in the medical record. - The physician should sign the order on his/her next visit to the facility or within the time frame required by the facility. On 3/12/25 at 3:08 p.m., the Director of Nursing (DON) reported that verbal orders should be signed by the medical provider at the next visit. The survey team met with the facility's Administrator, DON, Assistant DON, and Regional Director of Clinical Services on 3/14/25 at 4:12 p.m. During this meeting, the failure of the facility staff to ensure verbal orders were signed by the ordering medical provider was discussed. 2. For Resident #4, facility staff failed to ensure multiple orders for Invega (a medication that can treat schizophrenia and schizoaffective disorder) were signed by the prescribing provider. On 03/14/25, Resident #4's clinical record was reviewed. The following orders for Invega were not signed by the prescribing provider, a nurse practitioner (NP): 1. On 11/03/22, Invega Sustenna Suspension Prefilled Syringe 234 MG/1.5ML. Inject 1.5 ml intramuscularly one time only related to SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TYPE . The start and end date were 11/07/22. 2. On 11/03/22, Invega Sustenna Suspension Prefilled Syringe 234 MG/1.5ML. Inject 1.5 ml intramuscularly one time a day every 30 day(s) related to SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TYPE . The start date: 12/07/22 with no end date. 3. On 11/03/22, Invega Sustenna Suspension Prefilled Syringe 156 MG/ML. Inject 1 ml intramuscularly one time only related to SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TYPE. The start and end date were: 11/15/22. 4. On 11/23/22, Invega Sustenna Suspension Prefilled Syringe 156 MG/ML. Inject 156 mg intramuscularly one time a day every 30 day(s) for schizoaffective disorder. The start date: 11/24/22 with no end date. During an interview with the regional director of clinical services (RDCS) and director of nursing (DON) on 03/14/25 at 10:10 a.m., the RDCS acknowledged Resident #4's four (4) Invega orders were not signed by the NP who wrote the order. The DON provided printed copies of each of the Invega orders and pointed out where the provider signature should have been and acknowledged none of the four (4) orders were signed. The NP who wrote the order and the medical director at the time were no longer employed at the facility therefore neither were interviewed. During a summary meeting with the administrator, RDCS, DON, and assistant director of nursing on 03/14/25 at 4:12 p.m., the concern regarding Resident #4's unsigned medication orders was discussed. No further information was provided prior to the exit conference.

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to obtain laboratory tests as ordered by the medical provider for two (2) of 11 sampled residents (Resident #2 and Resident #7). The findings include: 1. The facility staff failed to obtain Resident #7's urinalysis laboratory test as ordered by a medical provider on 2/10/25. Resident #7's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/20/24, was signed as completed on 12/26/24. Resident #7 was assessed as able to make self understood and as able to understand others. Resident #7's Brief Interview for Mental Status (BIMS) summary score was documented as a 12 out of 15; this indicated moderate cognitive impairment. Review of Resident #7's clinical records failed to reveal results for a urinalysis (a laboratory test) ordered for 2/10/25. On 3/13/25 at 1:45 p.m., the surveyor asked the Director of Nursing (DON) and Assistant Director of Nursing (ADON) about the missing urinalysis results. The following information was found as part of a facility policy titled Laboratory Services and Reporting (with a reviewed/revised date of 12/1/22): - The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. - The facility must provide or obtain laboratory services to meet the needs of its residents. - The facility is responsible for the timeliness of the services. A document from the laboratory, dated as being reported on 2/15/25, indicated the 2/10/25 urinalysis was not completed due to a specimen issue. The issue with the specimen was documented as either (a) the age of this specimen or (b) required specimen for the test ordered was not received. Resident #7's medical provider signed this laboratory report on 2/18/25. On 3/14/25 at 10:27 a.m., the ADON confirmed that no results were found for the aforementioned urinalysis laboratory test; the ADON reported the medical provider signed the laboratory report and chose not to reorder the test. The survey team met with the facility's Administrator, DON, ADON, and Regional Director of Clinical services on 3/14/25 at 4:12 p.m. During this meeting, the failure of the facility staff to obtain Resident #7's 2/10/25 urinalysis laboratory test was discussed. 2. For Resident #2 the facility staff failed to obtain laboratory tests per the physician's order. Resident #2's face sheet listed diagnoses which included but not limited to schizoaffective disorder and type 2 diabetes mellitus. Resident #2's most recent minimum data set with an assessment reference date of 05/31/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #2's clinical record was reviewed and contained a physician's order summary which read in part, CBC (complete blood count), CMP (comprehensive metabolic panel), TSH (thyroid stimulating hormone), A1C (hemoglobin A1C), FLP (full lipid panel) on admission or next lab day every night shift for Z79.899 (long term drug therapy). Make lab sheet please. This order was written on 05/24/24 with a start date of 05/26/24. The order was discontinued on 06/12/24. Resident #2's electronic medication administration record (MAR) for the months of May 2024 and June 2024 were reviewed and contained an entry as above. The MAR for May indicated that the lab tests were obtained on 05/27/24, 05/29/24, 05/30/24, and 05/31/24. The MAR for June indicated that the lab tests were obtained on 06/01/24, 06/02/24, 06/04/24, 06/05/24, 06/06/24, 06/07/24, and 06/08/24. Resident #2's clinical record contained laboratory reports for the laboratory tests dated 05/30/24, 05/31/24, 06/05/24, 06/06/24, and 06/10/24. Surveyor spoke with the regional director of clinical services on 03/11/25 at 5:15 pm regarding Resident #2's lab tests. Regional director of clinical services stated that the lab orders should be entered for 3 days upon admission, and once obtained one time should be discontinued. Surveyor asked if the lab tests for Resident #2 should have been obtained multiple times and regional director of clinical services stated they should not. Surveyor requested and was provided with a facility policy entitled, Laboratory Services and Reporting which read in part, The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The concern of not following the physician's order for lab tests was discussed with the administrator, director of nursing, and regional director of clinical services on 03/14/25 at 12:25 pm. No further information provided prior to exit.

Based on staff interviews and facility document review, the facility staff failed to have evidence of attempting to resolve four (4) grievances. The findings include: A grievance dated 9/9/24 referenced Resident #6. This grievance was documented as being made by a member of the resident's family. This grievance included concerns related to urine appearance, wound care, and housekeeping. No evidence was found by or provided to the surveyor to indicate this grievance had been investigated. The form this grievance was documented on included areas for Investigation/Analysis of Concern and Actions Taken to Correct Concern; both of these areas were blank. The form had an area for facility staff to document the response to the individual lodging the grievance; this area was blank. On 3/11/25 at 3:10 p.m., the surveyor discussed the aforementioned grievance with the facility's Social Worker. The Social Worker reported that no additional information related to this grievance was available. On 3/11/25 at 3:48 p.m., the Regional Director of Clinical Services confirmed that no evidence was found to indicate a response was provided to the individual who lodged the aforementioned complaint. Review of the facility's grievance documentation revealed three (3) additional grievances which had the Investigation/Analysis of Concern and Actions Taken to Correct Concern sections not completed; two (2) of these grievances were dated 1/8/25 and one (1) grievance was dated 1/9/25. These three (3) additional grievances did not include evidence of the facility providing a response to the individuals lodging the grievances. These incomplete grievances were reviewed with the facility's Administrator on 3/14/25 at 3:55 p.m. The following information was found in a facility policy titled Resident and Family Grievances (with a reviewed/revised date of 12/1/22): - The resident has the right to, and the facility must make prompt efforts by the facility [sic] to resolve grievances the residents may have . - The resident will be provided a written summary of the resolution (excluding any information protected by HIPAA or labor laws). Every attempt will be made to provide this summary within 48 hours of receiving the grievance. An acknowledgement signed by the resident validating he or she has received a written response will be maintained with the grievance. - Grievances from any non-resident will receive a verbal, and if requested, written response within 5 (five) working days or will be notified if the investigation requires more time. - Investigation documents must include the following (as applicable): . Witness Statements and contact information . Grievance disposition . A Signed Communication of Grievance Resolution validating the resident (and/or responsible party) has received a written response. The survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, and Regional Director of Clinical Services on 3/14/25 at 4:12 p.m. During this meeting, the failure of the facility staff to follow their grievance process to address the aforementioned four (4) grievances was discussed.

Based on staff interviews and clinical record review, the facility staff failed to ensure a baseline/admission care plan addressed indwelling urinary catheter care for one (1) of 11 sampled residents (Resident #8). The findings include: Resident #8's baseline/admission care plan did not address personal hygiene related to indwelling urinary catheter care. Resident #8's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/24/25, was signed as completed on 2/5/25. Resident #8 was assessed as able to make self understood and as able to understand others. Resident #8's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact or borderline cognition. Resident #8 was admitted to the facility with orders for an indwelling urinary catheter due to a diagnosis of neurogenic bladder. Resident #8's baseline/admission care plan included the presence of an indwelling urinary catheter but did not include interventions for personal hygiene related to indwelling urinary catheter care. The following information was found in a facility policy titled Baseline Care Plan (with a reviewed/revised date of 12/1/22): - The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. - The baseline care plan will: . Include the minimum healthcare information necessary to properly care for a resident . On 3/14/25 at 9:15 a.m., the Director of Nursing (DON) reported Resident #8's baseline/admission care plan discussed personal hygiene but did not specifically address personal hygiene related to urinary catheter care. On 3/13/25 at 3:33 p.m., the Regional Director of Clinical Services (RDCS) reported the facility did not have a policy to address indwelling urinary catheter care. The RDCS reported they use a professional reference to guide indwelling urinary catheter care. The following information was found in a professional referenced provided to the survey team by the facility administrative staff: Clean around the area where the catheter enters urethral meatus (meatal-catheter junction) with soap and water during the daily bath to remove debris (Lippincott Manual of Nursing Practice, 11th edition, 2019). The survey team met with the facility's Administrator, DON, Assistant DON, and Regional Director of Clinical Services on 3/14/25 at 4:12 p.m. During this meeting, the failure of the facility staff to ensure Resident #8's baseline/admission care plan addressed urinary catheter care was discussed.

Based on staff interviews and clinical record review, the facility staff failed to ensure a comprehensive care plan addressed indwelling urinary catheter care for one (1) of 11 sampled residents (Resident #8). The findings include: Resident #8's comprehensive care plan did not address personal hygiene related to indwelling urinary catheter care. Resident #8's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/24/25, was signed as completed on 2/5/25. Resident #8 was assessed as able to make self understood and as able to understand others. Resident #8's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact or borderline cognition. Resident #8 was admitted to the facility with orders for an indwelling urinary catheter due to a diagnosis of neurogenic bladder. Resident #8's admission MDS assessment had the resident documented as having an indwelling urinary catheter. Resident #8's comprehensive care plan included the presence of an indwelling urinary catheter but did not include interventions for personal hygiene related to indwelling urinary catheter care. The following information was found in a facility policy titled Comprehensive Care Plan (with a reviewed/revised date of 12/1/22): - It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. - The comprehensive care plan will describe, at a minimum, the following: . The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. On 3/14/25 at 9:15 a.m., the Director of Nursing (DON) confirmed that Resident #8's comprehensive care plan identified an indwelling urinary catheter but did not address personal hygiene related to urinary catheter care. The DON stated expectations for indwelling urinary catheter care was at least daily but reported the facility's order was for catheter care every shift. (The facility divides the workday into two (2) shifts.) On 3/13/25 at 3:33 p.m., the Regional Director of Clinical Services (RDCS) reported the facility did not have a policy to address indwelling urinary catheter care. The RDCS reported they use a professional reference to guide indwelling urinary catheter care. The following information was found in a professional referenced provided to the survey team by the facility administrative staff: Clean around the area where the catheter enters urethral meatus (meatal-catheter junction) with soap and water during the daily bath to remove debris (Lippincott Manual of Nursing Practice, 11th edition, 2019). The survey team met with the facility's Administrator, DON, Assistant DON, and Regional Director of Clinical Services on 3/14/25 at 4:12 p.m. During this meeting, the failure of the facility staff to ensure Resident #8's comprehensive care plan addressed urinary catheter care was discussed.

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to provide treatment and/or care to address the needs of one (1) of 11 sampled residents (Resident #6). The findings include: The facility staff failed to: (a) follow-up on Resident #6's 9/3/24 emergency department visit and (b) consistently document Resident #6's urine output as ordered by the medical provider. Resident #6's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/27/24, was signed as completed on 9/2/24. Resident #6 was assessed as able to make self understood and as able to understand others. Resident #6's Brief Interview for Mental Status (BIMS) summary score was documented as a 10 out of 15; this indicated moderate cognitive impairment. On the afternoon of 3/11/25, the surveyor was unable to find information in Resident #6's clinical record to detail the outcome of the resident's 9/3/24 emergency department visit. On 3/11/25 at 2:15 p.m., the Director of Nursing (DON) reported she was only able to find the EKG from Resident #6's 9/3/24 emergency department visit. The facility staff obtained Resident #6's 9/3/24 emergency department visit documentation on 3/11/25 at 1:10 p.m. This documentation indicated the resident was seen for fatigue and included instructions for the resident to see a nurse practitioner by 9/6/24 to follow-up on the resident's urine cultures. On 3/12/25 at 2:35 p.m., the DON reported there was no documentation to indicate the time Resident #6 returned to the facility after a 9/3/24 emergency department visit. (Resident #6 was sent to the emergency department from a post-op visit at a local surgical provider's office.) The DON reported a nursing note should have indicated when the resident returned to the facility. The DON reported facility staff should have attempted to obtain information from the local emergency department related to Resident #6's emergency department visit. The DON reported there was no evidence of the facility staff following up on Resident #6's urine cultures as directed in the emergency department discharge information. Resident #6's clinical record included orders for an indwelling urinary catheter with documentation of urine output every shift. Review of Resident #6's urine output documentation showed the facility staff failed to document the resident's urine output for at least nine (9) shifts between the dates of 8/28/24 through 9/13/24. (The following day shifts did not have the resident's urine output documented: 8/30/24, 8/31/24, 9/5/24, 9/7/24, 9/9/24, 9/10/24, and 9/11/24. The following night shifts did not have the resident's urine output documented: 9/1/24 and 9/7/24.) On 3/12/25 at 9:00 a.m., the surveyor reviewed the absence of documentation of urine output for multiple shifts with the facility's Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON). The survey team met with the facility's Administrator, DON, ADON, and Regional Director of Clinical Services on 3/14/25 at 4:12 p.m. During this meeting, the following was discussed: (a) the failure of the facility staff to follow-up on Resident #6's emergency department visit and (b) the failure of facility staff to monitor Resident #6's urinary output as ordered by the medical provider.

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to consistently provide treatment and/or services to address pressure areas for one (1) of 11 sampled residents (Resident #6). The findings include: The facility staff failed to assess and/or provide treatment for Resident #6's sacral wound which was identified as part of a skin assessment dated [DATE] at 9:07 p.m. The facility staff failed to consistently provide treatment to Resident #6's left heel deep tissue injury. Resident #6's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/27/24, was signed as completed on 9/2/24. Resident #6 was assessed as able to make self understood and as able to understand others. Resident #6's Brief Interview for Mental Status (BIMS) summary score was documented as a 10 out of 15; this indicated moderate cognitive impairment. Resident #6's clinical record included skin assessments dated 8/20/24 at 9:07 p.m. and 8/24/24 at 3:41 a.m. Both skin assessments stated Sacrum- wound covered (with) dressing. These skin assessments did not detail the condition of the skin and/or describe the appearance of the wound. The following information was found in a facility policy titled Skin Assessment (with a reviewed/revised date of 12/1/22): - It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. - A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. - Procedure: . Remove any dressings, using clean technique, and note findings. - Documentation of skin assessment: Weekly Skin Review in (electronic medical record name omitted) a. Include date and time of the assessment, your name, and position title. b. Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.). c. Document type of wound. d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain) (Pressure and Non-pressure Wound Log). e. Document if resident refused assessment and why. f. Document other information as indicated or appropriate. The following information was found in a facility policy titled Pressure Injury Prevention and Management (with a reviewed/revised date of 12/1/22): Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. On 3/14/25 at 10:33 a.m., the surveyor reviewed Resident #6's skin assessments and wound orders with the facility's Infection Preventionist (IP) and Regional Director of Clinical Services (RDCS). The facility's Infection Preventionist (IP) confirmed there was not a description of Resident #6's sacral wound documented as a part of the aforementioned 8/20/24 and 8/24/24 skin assessments. The IP reported there was no evidence to indicate the sacral dressing was removed and the skin under the dressing assessed. The RDCS reported that facility staff should have removed the dressing to assess the wound and obtain orders if the skin was open. Resident #6's clinical documentation indicated the resident had a sacrum wound and a coccyx wound; the IP and the RDCS reported they believed the sacrum wound and the coccyx wound was the same wound based on the clinical documentation. Resident #6's clinical record failed to include orders for care of a sacral skin area at the time of the resident's admission on [DATE]. Resident #6's clinical record included nursing documentation, dated 9/6/24 at 2:10 a.m., which indicated the resident experienced a change in condition. The resident was assessed as having an open skin area identified as a Skin wound or ulcer described as a white, open area to the coccyx. Resident #6 had an order to Apply Zinc to Coccyx (every) shift and (as needed) every day and night shift for Coccyx dated 9/6/24 at 11:44 a.m. The next documentation of the sacral wound was on a medical provider note dated 9/11/24. On 9/11/24, Resident #6's sacral wound was described as a Stage II wound measuring 4.0 cm x 1.5 cm with a clean, moist wound bed. The facility staff failed to promptly obtain orders to address Resident #6's left heel deep tissue injury that was present on admission. On 3/12/25 at 2:40 p.m., the Director of Nursing (DON) provided a copy of a spreadsheet that contained the skin assessment information of three (3) different residents. This spreadsheet was dated 8/21/24. This spreadsheet included assessment information for Resident #6's left heel DTI (deep tissue injury). This spreadsheet included the following treatment information for the left heel DTI: Apply betadine and cover with abd pad, secure with rolled gauze and tape. This order was entered into Resident #6's clinical record on 8/22/24 at 1:59 p.m. by a member of the facility's nursing staff for the order to be started on 8/23/24 at 7:00 a.m. Review of Resident #6's August 2024 Treatment Administration Record (TAR) indicated the facility staff failed to provide evidence that Resident #6 received care to the left heel area on 8/29/24. Review of Resident #6's September 2024 Treatment Administration Record (TAR) indicated the facility staff failed to provide evidence that Resident #6 received care to the left heel area and to the coccyx wound on 9/7/24. The survey team met with the facility's Administrator, DON, Assistant DON, and Regional Director of Clinical Services on 3/14/25 at 4:12 p.m. During this meeting, the failure of the facility staff to promptly and/or consistently provide treatment to Resident #6's pressure areas was discussed.

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to consistently provide treatment and/or services to address a surgical foot wound for one (1) of 11 sampled residents (Resident #6). The findings include: The facility staff failed to ensure Resident #6's left foot surgical wound care included orders and/or documentation to address the use of a wound vac dressing. (Wound Vacuum-Assisted Closure (VAC) is a wound treatment that uses pressure to remove fluid and/or bacteria.) Resident #6's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/27/24, was signed as completed on 9/2/24. Resident #6 was assessed as able to make self understood and as able to understand others. Resident #6's Brief Interview for Mental Status (BIMS) summary score was documented as a 10 out of 15; this indicated moderate cognitive impairment. Resident #6's admission CHECKLIST form, dated 8/20/24, indicated the resident had a wound with a wound vac. Resident #6's nursing documentation indicated the resident had a wound vac in use on 8/20/24 at 10:08 p.m. Resident #6's nursing note, dated 8/21/24 at 3:16 p.m., included the following statement: Wound vac applied by wound care to residents [sic] foot. Resident #6's nursing note, dated 8/22/24 at 1:33 a.m., included the following statement: Resident continues to have wound vac on left foot. The following statement was found in discharge paperwork (printed on 8/20/24 at 12:46 p.m.) provided to the facility by the local hospital: Plan: OK to discharge from surgical standpoint. Continue wound vac per orders. WOUND VAC IS TO BE ON AT ALL TIMES UNLESS DURING PACKING/DRESSING CHANGES. IF VAC IS TO BE OFF MORE THAN 2 HOURS, DRESSING IS TO BE REMOVED AND WET TO DRY DRESSING IS TO BE ADMINISTERED UNTIL VAC IS ABLE TO BE REAPPLIED. VAC DRESSING CHANGES EVERY 48-72 HOURS PER ORDERS. Follow up with (medical provider name omitted) in surgical office in 2 weeks. Resident #6's clinical record failed to include medical provider orders addressing the aforementioned use of a wound vac at the facility. No orders were found by or provided to the surveyor to address the removal of the wound vac that was documented as being used between the dates of 8/20/24 - 8/22/24. No provider documentation was found by or provided to the surveyor to evidence the facility's medical provider consulting with the surgeon related to Resident #6's wound vac decisions. On 3/12/25 at 9:00 a.m., the Director of Nursing (DON) confirmed no medical provider information was found to address Resident #6's wound vac. The following information was found in a facility policy titled Wound Treatment Management (with a reviewed/revised date of 12/1/22): - To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. - Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. - In the absence of treatment orders, the licensed nurse will notify physician [sic] to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. - Treatments will be documented on the Treatment Administration Record. Resident #6's clinical record included a medical provider order for clean with wound cleaner, pat dry, apply calcium alginate, cover with abd pad and secure with rolled gauze to be started on 8/22/24. Clinical documentation failed to indicate this wound care was provided on 8/22/24. Resident #6's clinical record included a medical provider order for Clean surgical wound to left foot with (normal saline), apply skin prep to periwound, apply collagen to wound bed, cover with ABD pads and secure with kerlix . This order was documented as being ordered to be started on 8/29/24. Clinical documentation failed to indicate this wound care was provided on 8/29/24. Review of Resident #6's September 2024 Treatment Administration Record (TAR) failed to provide evidence that Resident #6 received wound care to the left foot surgical wound on 9/7/24. The survey team met with the facility's Administrator, DON, Assistant DON, and Regional Director of Clinical Services on 3/14/25 at 4:12 p.m. During this meeting, the failure of the facility staff to address Resident #6's wound vac for the resident's left foot surgical wound was discussed.

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to provide indwelling urinary catheter care for one (1) of 11 sampled residents (Resident #8). The findings include: Resident #8's clinical documentation indicated a delay in the facility providing personal hygiene care for an indwelling urinary catheter. Resident #8's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/24/25, was signed as completed on 2/5/25. Resident #8 was assessed as able to make self understood and as able to understand others. Resident #8's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact or borderline cognition. Resident #8 was admitted to the facility with orders for an indwelling urinary catheter due to a diagnosis of neurogenic bladder. Resident #8's admission MDS assessment had the resident documented as having an indwelling urinary catheter. Resident #8's care plan included the presence of an indwelling urinary catheter but did not include interventions for personal hygiene related to indwelling urinary catheter care. On 3/14/25 at 9:15 a.m., the Director of Nursing (DON) confirmed that Resident #8's care plan identified an indwelling urinary catheter but did not address personal hygiene related to urinary catheter care. The DON stated expectations for indwelling urinary catheter care was at least daily but reported the facility's order was for catheter care every shift. (The facility divides the workday into two (2) shifts.) On 3/13/25 at 3:33 p.m., the Regional Director of Clinical Services (RDCS) reported the facility did not have a policy to address indwelling urinary catheter care. The RDCS reported they use a professional reference to guide indwelling urinary catheter care. The following information was found in a professional referenced provided to the survey team by the facility's administrative staff: Clean around the area where the catheter enters urethral meatus (meatal-catheter junction) with soap and water during the daily bath to remove debris (Lippincott Manual of Nursing Practice, 11th edition, 2019). Resident #8's first order for an indwelling urinary catheter was dated 10/18/24. Resident #8's clinical record did not include an order for Foley care (every) shift every day and night shift until 1/16/25. Review of Resident #8's Treatment Administration Records (TARs) indicated indwelling urinary catheter care started on 1/16/25. The survey team met with the facility's Administrator, DON, Assistant DON, and Regional Director of Clinical Services on 3/14/25 at 4:12 p.m. During this meeting, the failure of the facility staff to ensure indwelling urinary catheter care was being provided to Resident #8 from the time of admission was discussed.

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to ensure a correct diagnosis prior to the use of an antipsychotic medication and failed to monitor for behaviors for one (1) of 11 sampled residents (Resident #4). The findings were: For Resident #4, facility staff failed to ensure a new diagnosis of schizoaffective disorder was appropriate prior to a new medication order for Invega (an atypical antipsychotic medication that can treat schizoaffective disorder) and failed to implement behavior monitoring for Resident #4. Resident #4's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/25/22 was signed as completed on 11/07/22. The resident's Brief Interview for Mental Status (BIMS) summary score was documented as a 09 out of 15 which indicated moderately impaired cognition. Section I (Active Diagnoses) coded the resident's primary medical condition category a 13. Medically Complex Conditions. The active diagnoses in the last 7 days included but were not limited to Anemia, Hyperlipidemia, Non-Alzheimer's Dementia, Anxiety Disorder, Depression, Psychotic Disorder (other than schizophrenia), and Asthma, Chronic Obstructive Pulmonary Disease or Chronic Lung Disease. The diagnosis of Schizophrenia (e.g. schizoaffective and schizophreniform disorders) was not marked. The resident's care plan included but was not limited to a focus area which read the resident had a potential for side effects related to use of psychotropic medication for schizoaffective disorder, anxiety, mood disorder and depression. In an interview with an MDS coordinator, a licensed practical nurse (Employee #8) on 3/14/25 at 10:40 a.m., the MDS coordinator reported schizoaffective disorder was added to Resident #4's care plan during a care plan revision on 11/03/22. Resident #4's clinical record contained a list of diagnoses that included (but was not limited to) schizoaffective disorder, depressive type with an onset date of 11/02/22, over three (3) months following Resident #4's admission to the facility. The nurse practitioner (NP) hand-written Medical Evaluation Form/Progress Note listed Schizoaffective D/O as a diagnosis for the first time on 11/02/22. That progress note showed hand-marked checks and X's next to items in the physical exam. For the psych area, there were X's beside psych, attention and affect with a check beside agitation/aggression. The legend for the physical exam indicated a check equaled normal, and X equaled abnormal with a blank box equaled not assessed. The clinical record failed to contain evidence of a psychologist, or a psychiatrist evaluation related to the diagnosis of schizoaffective disorder. The NP wrote orders for Invega as follows: 1. On 11/03/22, Invega Sustenna Suspension Prefilled Syringe 234 MG/1.5ML. Inject 1.5 ml intramuscularly one time only related to SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TYPE . The start and end date were 11/07/22. 2. On 11/03/22, Invega Sustenna Suspension Prefilled Syringe 234 MG/1.5ML. Inject 1.5 ml intramuscularly one time a day every 30 day(s) related to SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TYPE . The start date: 12/07/22 with no end date. 3. On 11/03/22, Invega Sustenna Suspension Prefilled Syringe 156 MG/ML. Inject 1 ml intramuscularly one time only related to SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TYPE. The start and end date were: 11/15/22. 4. On 11/23/22, Invega Sustenna Suspension Prefilled Syringe 156 MG/ML. Inject 156 mg intramuscularly one time a day every 30 day(s) for schizoaffective disorder. The start date: 11/24/22 with no end date. A review of Resident #4's Medication Administration Record for November 2022 noted Invega Sustenna 234 mg/1.5 ml was administered on 11/07/22. Resident #4 received Invega Sustenna 156 mg/ml on 11/24/22. Resident #4 was admitted to an acute care hospital for sepsis on 11/15/22 and therefore did not receive that scheduled dose. Resident #4's Order Summary Report included an order that read, PLEASE DOCUMENT APPROPRIATE NUMBER THAT BEST MATCHES BEHAVIOR OBSERVED 1= No Behaviors noted 2= Kicking/Hitting 3= Grabbing/Pushing 4= Sexually Inappropriate 5=Yelling/Screaming/Cursing 6= Refusing Care (ADL, Meds etc ) 7= Wandering/Pacing 8= Exit Seeking 9= OTHER (** Document in Notes **) every shift if you Code **OTHER** please make an entry in Progress notes to describe. The order date and start date was 11/23/22 with no end date documented. The MARs for November and December 2022 failed to contain evidence facility staff documented Resident #4's behaviors. When the surveyor requested a policy regarding anti-psychotic medication orders, the regional director of clinical services (RDCS) provided a policy titled, Medication Orders with an implementation order dated 11/01/2020 with a reviewed/revised date of 12/01/2022 which read in part, . 3. Elements of the Medication Order: .i. Diagnosis or indication for use . The RDCS reported there was no policy found which addressed antipsychotic medication orders specifically. During an interview with the RDCS and director of nursing (DON) on 03/14/25 at 10:20 a.m., the RDCS acknowledged there were no documented behaviors as ordered for Resident #4 and no evidence of a psychological evaluation, note, or referral. On 03/12/25 at 4:20 p.m., when asked about the NP's documentation on the hand-written progress note dated 11/02/22, specifically the checks versus the Xs for the physical exam under psych compared to the legend, the RDCS stated we don't know for sure what [NP's name omitted] meant with checks and Xs on the written progress notes. The NP who wrote the orders and the medical director at the time were no longer employed at the facility therefore neither were interviewed. During a summary meeting with the administrator, RDCS, DON, and assistant director of nursing on 03/14/25 at 4:12 p.m., the concerns regarding Resident #4's new schizoaffective disorder diagnosis with Invega medication ordered and administered, and behaviors not documented were discussed. No further information was provided prior to the exit conference.

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to ensure antibiotics were administered as order by the medical provider for one (1) of 11 sampled residents (Resident #6). The findings include: The facility staff failed to ensure that Resident #6's intravenous (IV) Ertapenem was administered as ordered by the medical provider. Resident #6's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/27/24, was signed as completed on 9/2/24. Resident #6 was assessed as able to make self understood and as able to understand others. Resident #6's Brief Interview for Mental Status (BIMS) summary score was documented as a 10 out of 15; this indicated moderate cognitive impairment. Resident #6's medical record included the following antibiotic orders: - Ertapenem 1 gram intravenously (IV) for the morning of 8/21/24. - Ertapenem 1 gram intravenously (IV) in the morning for six (6) weeks to start on 8/22/24. - Cubicin 700 mg intravenously (IV) at bedtime for six (6) weeks to start on 8/21/24. The following information was found in a facility policy titled Medication Administration (with a reviewed/revised date of 12/1/22): Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Resident #6's clinical record failed to indicate the 8/21/24 dose of Ertapenem had been administered as ordered by the provider. On 3/13/25 at 10:22 a.m., the surveyor met with the facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON); the surveyor discussed the absence of documentation indicating this medication had been administered. The following information was documented in a nursing note dated 8/22/24 at 2:57 p.m.: (PICC) line dressing intact without signs of infection however only flushes with firm but gentle pressure and scheduled antibiotics do not run through line, pending replacement at this time. Alternate order for IM (intramuscular) Ertapenem administered per (Nurse Practitioner) . No documentation was found to address the IV Cubicin order. (A PICC (peripherally inserted central catheter) is a thin tube inserted through a vein then advanced into larger veins near the heart. A PICC line allows for intravenous administration of fluids and/or medications.) A nursing note dated 8/22/24 at 2:18 p.m., indicated the nurse practitioner ordered the PICC line to be replaced. A nursing note dated 8/22/24 at 8:51 p.m., indicated the previous PICC line had been removed and a new PICC line had been inserted with an x-ray scheduled to verify correct placement. The facility staff documented the evening dose of IV Cubicin was held awaiting confirmation of correct PICC line placement. A nursing note documented 8/23/24 at 1:02 a.m. included the following statement: IV tech informed this nurse that chest x-ray to confirm placement must be completed before use. A nursing note dated 8/23/24 at 3:11 p.m. included the following statement: Xray resulted . states The [sic] needs to be pulled back about 3 cm. (Nurse practitioner name omitted) aware. (Vascular access provider name omitted) contacted and order placed for someone to come to this facility to adjust the picc line . Antibiotic currently on hold until picc line is adjusted. Documentation indicated the vascular access provider repositioned the PICC line on 8/23/24 at 5:40 p.m. A nursing note dated 8/23/24 at 10:12 p.m. indicated the chest x-ray confirmed placement of the PICC line and that (antibiotics) resumed as per protocol. The evening dose of IV Cubicin was documented as being administered on 8/23/24. Resident #6's medication administration records (MARS) indicated the IV Ertapenem was held on 8/22/24, 8/23/24, and 8/24/24. Nursing documentation indicated the medical provider provided orders for IM Ertapenem on 8/22/24. The 8/24/24 morning dose of IV Ertapenem was documented as being held although the PICC line had been documented as being okay to use with an IV antibiotic being documented as administered on the evening of 8/23/24. The survey team met with the facility's Administrator, DON, Assistant DON, and Regional Director of Clinical Services on 3/14/25 at 4:12 p.m. During this meeting, the failure of the facility staff to appropriately administer Resident #6's antibiotic medications was discussed.

Based on staff interview, clinical record review and facility document review the facility staff failed to obtain a physician's order prior to obtaining a laboratory test for 1 of 11 residents, Resident #2. The findings included: For Resident #2 the facility staff failed to obtain a physician's order for a urinalysis. Resident #2's face sheet listed diagnoses which included but not limited to schizoaffective disorder and type 2 diabetes mellitus. Resident #2's most recent minimum data set with an assessment reference date of 93/31/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #2's clinical record was reviewed and contained a laboratory report dated 05/31/24 which read in part, Clinical Laboratory Results: Urinalysis: Urinalysis with Microscopic (Reflex Culture if indicated) .Comments: CULTURE TO FOLLOW. Surveyor reviewed Resident #2's physician's orders and could not locate an order to obtain a urinalysis. Surveyor spoke with the regional director of clinical services on 03/13/25 regarding Resident #2's urinalysis. Regional director of clinical stated that the expectation would be that a there would be a physician's order prior to obtaining a urinalysis. Surveyor requested and was provided with a facility policy entitled, Laboratory Services and Reporting which read in part, The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The concern obtaining a urinalysis without an order was discussed with administrator, director of nursing, and regional director of clinical services on 03/14/25 at 12:25 pm. No further information provided prior to exit.

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to maintain complete and/or accurate clinical records for one (1) of 11 sampled residents (Resident #6). The findings include: Resident #6's clinical record failed to include: (a) wound assessment details/documentation and (b) complete wound orders. Resident #6's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/27/24, was signed as completed on 9/2/24. Resident #6 was assessed as able to make self understood and as able to understand others. Resident #6's Brief Interview for Mental Status (BIMS) summary score was documented as a 10 out of 15; this indicated moderate cognitive impairment. Review of Resident #6's clinical documentation failed to provide evidence of an assessment of the resident's wounds which included wound measurements and a description of the wounds on admission. On 3/12/25 at 2:40 p.m., the Director of Nursing (DON) provided a copy of a spreadsheet that contained the wound assessments of three (3) different residents. This spreadsheet was dated 8/21/24. This spreadsheet included assessment information for Resident #6's left foot surgical wound and left heel DTI (deep tissue injury). The DON confirmed this documentation was not part of Resident #6's clinical record. The DON reported this spreadsheet was found in the MDS (minimum data set) staff's documents. Resident #6's clinical record contained two (2) orders for wound care which did not identify which wound the order was intended to address. An ordered dated 8/22/24 at 1:57 p.m. stating clean with wound cleaner, pat dry, apply calcium alginate, cover with abd pad and secure with rolled gauze every day shift AND as needed did not identify which wound was to be treated by this order. An ordered dated 8/23/24 at 11:42 a.m. stating clean with wound cleaner, pat dry, cover with abd pad and secure with rolled gauze every day shift AND as needed did not identify which wound was to be treated by this order. The following information was found in a facility policy titled Documentation in Medical Record (with a reviewed/revised date of 12/1/22): - Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. - Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. - Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. The survey team met with the facility's Administrator, DON, Assistant DON, and Regional Director of Clinical Services on 3/14/25 at 4:12 p.m. During this meeting, the failure of the facility staff to ensure Resident #6's wound orders addressed the specific wound for which the order was being given was discussed.

Based on staff interviews and facility document review, the facility staff failed to have documented evidence of dietary staff training related to safe food handling. The findings include: The surveyor and the Regional Food Service Director (RFSD) reviewed the training and education of 12 dietary staff members who were working independently. These 12 dietary staff members did not have documentation of orientation. Nine (9) of the 12 dietary staff members reviewed did not have documentation of training related to safe food handling. On 8/1/2 at 10:00 a.m., the surveyor discussed the facility's dietary staff training with the RFSD. The RFSD reported the facility did not have written policies related to the orientation of its dietary staff. The RFSD reported the facility did not have written policies related to the training of its dietary staff. The RFSD provided the surveyor with a blank copy of a form titled ORIENTATION. This form did not specifically address safe food handling. The RFSD stated the topics on this form related to the overview of state and federal regulations would address information related to safe food handling. As of Monday, 8/5/24, several staff members had been trained in safe food handling. The surveyor reviewed the dietary schedule with the RFSD and Dietary Manager on 8/1/24. The following full days were identified to not have a dietary staff member scheduled who had evidence of safe food handling training: 7/17/24, 7/21/24, 7/27/24, and 7/28/24. The following days were identified to not have a dietary staff member scheduled who had evidence of safe food handling training for part of the day: 7/14/24, 7/15/24, 7/16/24, 7/18/24, 7/19/24, 7/20/24, 7/25/24, 7/26/24, 7/29/24, and 7/30/24.

Based on observations, staff interviews, and facility document review, the facility staff failed to ensure proper disposal and/or containment of the facility's garbage/waste. The findings include: On 7/31/24 at 1:15 p.m., the surveyor and the Dietary Manager made observations of the garbage disposal area outside of the facility but located on the facility's campus. The following observations were noted: - One (1) of the two (2) facility dumpsters was noted to have its two (2) doors partially open. The right door was open approximately four (4) inches; the left door was open approximately eight (8) inches. The left door was observed to have a bag, containing garbage, hanging partially out of the door. - Ten (10) medical gloves were noted to be on the ground to the right of and/or behind the facility's dumpsters. - Six (6) foam bowls were noted to be on the ground to the right of the facility's dumpsters. - One (1) meal size foam clam shell container was noted to be on the ground to the right of the facility's dumpsters. - One (1) bag of garbage containing disposable adult briefs and disposable blue pads was noted in a dumpster that did not have a lid/door to prevent/limit animal access to the bag of garbage. - A barrel where the facility staff disposes of used cooking grease was noted outside the facility. The lid to this barrel was not completely closed. A piece of aluminum foil was noted to be hanging out of the opening of the barrel and the unclosed lid. The following information was found in a facility policy titled Disposal of Garbage and Refuse (with a reviewed/revised date of 12/1/22): - Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. - Dumpsters shall be emptied according to the facility contract. Garbage should not accumulate or be left outside the dumpster. On 7/31/24 at 4:47 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, Regional Director of Clinical Services, and Regional Food Services Director. During this meeting, the survey team discussed the aforementioned observations of the improper disposal of facility garbage/waste.

Based on resident and staff interview, clinical record review, and facility document review, the facility staff failed to provide evidence of a bed hold policy being given to 5 of 27 residents in the survey sample, residents #13, 68, 36, 98, and 56. The findings included: For resident # 13 the facility staff failed to provide evidence that the resident or their responsible party was notified of a bed hold policy when the resident was hospitalized in June 2024. Resident # 13's minimum data set (MDS) assessment with an assessment reference date of 6/6/24 assigned the resident a brief interview for mental status (BIMS) score of 3 indicating severe cognitive impairment. Resident was not interviewable. The electronic medical record was reviewed and a progress note dated 6/6/24 at 11:18 AM read, Mobile images in for Venous/Arterial Doppler, blood clot to left lower extremity noted. Family informed, family raised concern that respiratory issues may be caused from blood clot that has traveled, (name omitted) FNP contacted and received order to send resident out for further evaluation. Resident out via (name omitted) Ambulance at this time. Resident was admitted to the hospital. On 8/2/24 this surveyor met with the Director of Nursing (DON), Assistant Director of Nursing (ADON and Regional Director of Clinical Services (RDCS) to discuss this concern. Surveyor asked for evidence of a bed hold notice being provided to the resident or the resident representative. Surveyor requested and received a copy of the policy entitled, Bed Hold Notice Upon Transfer with a revised date of 12/1/22. The policy read in part, At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. The last paragraph of the document read, The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file. On 8/6/24 at 12:15 PM this concern was reviewed with the Administrator, DON, ADON, RDCS, Regional Director of Operations and Regional Director of Culinary Services. No further information was provided to the survey team prior to the exit conference. 2. For resident # 68, the facility staff failed to provide evidence that bed hold information was given to the resident or their representative for a hospitalization in June 2024. Resident # 68's MDS with an ARD of 6/25/24 assigned the resident a BIMS score of 12, indicating mild cognitive impairment. The electronic medical record was reviewed and a progress note dated 6/14/24 at 11:44 PM read, Went to Res. room to check vital signs, Res. noted to be unresponsive to verbal and physical stimuli. Res. noted to be clammy, checked blood sugar 194. Res. noted to be clammy. During checking pupils noted to have bloody white of right eye. VS97.8-131/77-70-16-92% sat pm RA. Notified on call (name omitted) NP with new order May send to JMH ER for evaluation and treatment. Res. transported by stretcher by (name omitted) Ambulance. Notified by phone Father RP and on call supervisor. Report called to JMH ER nurse. Surveyor requested and received a copy of the policy entitled, Bed Hold Notice Upon Transfer with a revised date of 12/1/22. The policy read in part, At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. The last paragraph of the document read, The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file. On 8/6/24 at 12:15 PM this concern was reviewed with the Administrator, DON, ADON, RDCS, Regional Director of Operations and Regional Director of Culinary Services. No further information was provided to the survey team prior to the exit conference. 21227 3. The facility staff failed to provide Resident #56 and/or the resident's representative with the facility's bed-hold policy for the 2/27/24 transfer. Resident #56's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/20/24, was signed as completed on 7/29/24. Resident #56 was assessed as able to make self understood and as able to understand others. Resident #56's Brief Interview for Mental Status (BIMS) summary score was documented as a 13 out of 15; this indicated intact and/or borderline cognition. Resident #56's clinical documentation indicated the resident was transferred to a local hospital on 2/27/24. No evidence of the facility's bed-hold policy being provided to the resident and/or the resident's representative was found by or provided to the surveyor. The following information was found in a facility policy titled Transfer and Discharge (including AMA) (with a reviewed/revised date of 12/1/22): Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours of the transfer. The following information was found in a facility policy titled Bed Hold Notice Upon Transfer (with a reviewed/revised date of 12/1/22): The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file. On 8/6/24 at 11:32 a.m., the facility's Assistant Director of Nursing (ADON) reported no evidence of the bed-hold policy being provided was found. On 8/6/24 at 12:16 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, Regional Director of Clinical Services, and Regional Director of Operations. During this meeting, the surveyor discussed the absence of evidence of the facility providing its bed-hold policy to Resident #56 and/or the resident's representative. 4. The facility staff failed to provide Resident #98 and/or the resident's representative with the facility's bed-hold policy for the 5/29/24 transfer. Resident #98's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/28/24, was signed as completed on 7/5/24. Resident #98 was assessed as able to make self understood and as able to understand others. Resident #98's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. Resident #98's clinical documentation indicated the resident was transferred to a local hospital on 5/29/24. No evidence of the facility's bed-hold policy being provided to the resident and/or the resident's representative was found by or provided to the surveyor. On 8/6/24 at 11:32 a.m., the facility's Assistant Director of Nursing (ADON) reported no evidence of the bed-hold policy being provided to Resident #98 and/or the resident representative was found. On 8/6/24 at 12:16 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), ADON, Regional Director of Clinical Services, and Regional Director of Operations. During this meeting, the surveyor discussed the absence of evidence of written transfer notification being provided to Resident #98 and/or the resident's representative. 5. The facility staff failed to provide Resident #36 and/or the resident's representative with the facility's bed-hold policy for the 5/16/24 transfer. Resident #36's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/3/24, was signed as completed on 5/14/24. Resident #36 was assessed as able to make self understood and as able to understand others. Resident #36's Brief Interview for Mental Status (BIMS) summary score was documented as an eight (8) out of 15; this indicated moderate cognitive impairment. Resident #36's clinical documentation indicated the resident was transferred to a local hospital on 5/16/24. No evidence of the facility's bed-hold policy being provided to the resident and/or the resident's representative was found by or provided to the surveyor. On 8/1/24 at 4:02 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, Regional Director of Clinical Services (RDCS), and Regional Food Services Director. During this meeting, the surveyor discussed the absence of evidence that the facility's bed-hold policy was provided at the time of Resident #36's 5/16/24 hospital transfer. The RDCS acknowledged no evidence of the facility staff providing the bed-hold information was found.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team, and/or failed to involve the resident or resident representative in planning care, for 5 of 27 sampled residents, Resident #88, #23, #73, #28, and #82. The findings included: 1. For Resident #88 (R88), the facility staff failed to reassess the effectiveness of the interventions and review and revise the resident's activity care plan to meet the resident's needs. R88's diagnosis list indicated diagnoses that included, but were not limited to, Bipolar Disorder, Personal History of Transient Ischemic Attack (TIA) and Cerebral Infarction, Depression, Peripheral Vascular Disease, Congestive Heart Failure, Chronic Kidney Disease-Stage 5, and Polyosteorarthritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 06/22/2024 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating Resident #88 was severely impaired in cognition. A review of the current care plan revealed a Focus of, . [name omitted] (R88) attends activities of interest/choice and engages in self-initiated leisure activities . with a Goal of, .will initiate leisure activities 1-2 x/day (one to two times per day) such as watching tv and people watching . A second goal read, .will participate in 2-3 (two to three) in or out of room activities a week x 90 days (for ninety days) such as music, sensory and special snacks . The interventions read in part, .Invite, encourage and assist as needed to activities of choice/interest {sic} as tolerated by the resident . The interventions were assigned to activity assistant and activity director. The care plan revealed an initiated date of 11/13/2023 with a revision date of the first goal of 04/03/2024 and the second goal with a revision date of 04/09/2024, no changes were identified for the Focus, Goal or Interventions during this revision. Surveyor could not locate any Activity Progress notes on the clinical record for R88. On 7/30/24 at 3:20 PM, surveyor interviewed activity director-other staff #10 (OS#10) about activity assessments and activity progress notes. OS#10 stated she only completes activity assessments on admission, annually and for a significant change and does them with the ARD date of the MDS. She stated she does not do an activity progress note every ninety days or a quarterly assessment and she is behind on assessments. On 7/31/24 at 3:12 PM, regional director of clinical services #4 (RDCS#4) informed surveyor she had spoken to OS#10, and she had informed her that she had not done any ninety-day progress notes for residents. This concern was discussed at the end of day meeting on 7/30/24 at 4:15 PM with the administrator, director of nursing, assistant director of nursing, regional director of clinical services, regional director of operations, and regional director of dietary services and again during the end of day meetings on 7/31/24 at 4:47 PM, 8/1/24 at 4:00 PM, 8/5/24 at 4:30 PM and again at the pre-exit meeting on 8/6/24 at 12:16 PM. Surveyor requested and received the facility policy titled Comprehensive Care Plans, which read in part, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and timeframes to meet a resident's .psychosocial needs .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment .The objectives will be utilized to monitor the resident's progress . No further information regarding this concern was presented to the survey team prior to the exit conference on 08/06/24. 2. For Resident #23 (R23), the facility staff failed to reassess the effectiveness of the interventions and review and revise the resident's activity care plan to meet the resident's needs and the facility staff failed to ensure the resident was provided the opportunity to participate in planning care in the facility. R23's diagnosis list indicated diagnoses that included, but were not limited to, Diabetes Mellitus Type 2, Atrial Fibrillation, Peripheral Vascular Disease, Chronic Kidney Disease Stage 4, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Morbid Obesity, and Major Depressive Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 06/29/2024 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating R23 was cognitively intact. On 7/29/24 at 2:50 PM, surveyor interviewed R23, and he stated he did not attend activity programs and he used to get one-to-one activities, but that has decreased. R23 also stated that he has never attended a care plan meeting. A review of the current care plan revealed an activity Focus of, . [name omitted] (R23) attends activities of interest/choice and engages in self-initiated leisure activities . with a Goal of, .will participate in 2-3 in or out of room activities a week x 90 days (for ninety days) such as online shopping via iPad, Art Cart, current events, music, sensory and accepting healthy snacks. A second goal read, .will initiate leisure activities 1-2 x/day (one to two times per day) such as talking on the phone, bird watching watching tv {sic} and DVDs. The interventions read in part, .Invite, encourage and assist as needed to activities of choice interest {sic} as tolerated by the resident . The interventions were assigned to activity assistant and activity director. The care plan revealed an initiated date of 12/14/2020 with a revision date of the first goal of 04/12/2024 and the second goal with a revision date of 07/10/2024, no changes were identified for the Focus, Goal or Interventions during this revision. Surveyor could not locate any Activity Progress notes on the clinical record for R23. On 7/30/24 at 3:20 PM, surveyor interviewed activity director-other staff #10 (OS#10) about activity assessments and activity progress notes. OS#10 stated she only completes activity assessments on admission, annually and for a significant change and does them with the ARD date of the MDS. She stated she does not do an activity progress note every ninety days or a quarterly assessment and she is behind on assessments. On 7/31/24 at 3:12 PM, regional director of clinical services #4 (RDCS#4) informed surveyor she had spoken to OS#10, and she had informed her that she had not done any ninety-day progress notes for residents. In addition to the above stated findings, surveyor could not locate any evidence R23 was invited to or had attended any care plan meetings since his baseline care plan meeting on 11/24/2020. On 8/1/24 at 10:17 AM, surveyor interviewed MDS nurses, registered nurse #1 (RN#1) and licensed practical nurse #6 (LPN#6) about R23 and care plan meeting attendance. Both nurses stated they did not have invitation letters but did keep logs of care plan attendance and they write if residents attended or not. At 10:40 AM LPN#6 informed surveyor she scanned through progress notes and could not locate any notes where residents declined or attended care plan meetings. She also informed surveyor the MDS office had taken over sending out care plan invitations since the former social worker was not doing them and RDCS#4 concurred with this statement and informed surveyor the facility had a different social worker who was not doing/sending out care plan meeting invitations and the MDS office has now taken over. Surveyor requested and received copies of the care plan sign-in sheets for R23, and they revealed resident had not attended any care plan meetings since 12/2/2020. Surveyor also received a care plan meeting invitation dated 7/15/24 for a care plan meeting scheduled 7/23/24 at 2:30 PM for R23 and the care plan sign in sheet revealed R23 did not attend the care plan meeting on 7/23/24. These concerns were discussed at the end of day meeting on 7/30/24 at 4:15 PM with the administrator, director of nursing, assistant director of nursing, regional director of clinical services, regional director of operations, and regional director of dietary services and again during the end of day meetings on 7/31/24 at 4:47 PM, 8/1/24 at 4:00 PM, 8/5/24 at 4:30 PM and again at the pre-exit meeting on 8/6/24 at 12:16 PM. Surveyor requested and received the facility policy titled Comprehensive Care Plans, which read in part, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and timeframes to meet a resident's .psychosocial needs .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment .The objectives will be utilized to monitor the resident's progress . Surveyor requested and received a facility policy titled, Care Planning-Resident and/or Resident Representative participation that read in part, .This facility supports the residents and/or resident's representative right to be informed of, and participate in, his or her care planning and treatment .4. The facility will encourage and assist the resident and/or resident representative to participate in choosing care and treatment .7. The facility will honor the resident's choice in individuals to be included in the care planning process .9. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes . No further information regarding this concern was presented to the survey team prior to the exit conference on 08/06/24. 3. For Resident #73 (R73), the facility staff failed to reassess the effectiveness of the interventions and review and revise the resident's activity care plan to meet the resident's needs and the facility staff failed to ensure the resident was provided the opportunity to participate in planning care in the facility. R73's diagnosis list indicated diagnoses that included, but were not limited to, Morbid (severe) obesity, Anemia, Tachycardia, Constipation, Edema, and Hypothyroidism. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 07/13/2024 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating R73 was cognitively intact. On 7/29/24 at 4:10 PM, surveyor interviewed R73, and he stated activities come to see him once in a while and he gets his in-room supplies from his family and he rarely gets out of bed. R73 also stated that he attended his first, initial care plan meeting and they came to his room, but he has not been invited or heard of any other care plan meetings since then. A review of the current care plan revealed an activity Focus of, .The resident has little or no activity involvement r/t resident wishes not to participate . with a Goal of, .resident will express satisfaction with type of activities and level of activity involvement when asked through the review date A second goal read, .The resident will participate in activities of choice 2-3 times per week by review date . The interventions read in part, .Establish and record the resident's prior level of activity involvement and interests . The interventions were assigned to activity assistant and activity director. The care plan revealed an initiated date of 08/01/2023 with a revision date of both goals of 07/16/2024, no changes were identified for the Focus, Goal or Interventions during this revision. Surveyor could not locate any Activity Progress notes on the clinical record for R73. On 7/30/24 at 3:20 PM, surveyor interviewed activity director-other staff #10 (OS#10) about activity assessments and activity progress notes. OS#10 stated she only completes activity assessments on admission, annually and for a significant change and does them with the ARD date of the MDS. She stated she does not do an activity progress note every ninety days or a quarterly assessment and she is behind on assessments. On 7/31/24 at 3:12 PM, regional director of clinical services #4 (RDCS#4) informed surveyor she had spoken to OS#10, and she had informed her that she had not done any ninety-day progress notes for residents. In addition to the above stated findings, surveyor could not locate any evidence R73 was invited to or had attended any care plan meetings since his baseline care plan meeting on 08/01/2023. On 8/1/24 at 10:17 AM, surveyor interviewed MDS nurses, registered nurse #1 (RN#1) and licensed practical nurse #6 (LPN#6) about R73 and care plan meeting attendance. Both nurses stated they did not have invitation letters but did keep logs of care plan attendance and they write if residents attended or not. At 10:40 AM LPN#6 informed surveyor she scanned through progress notes and could not locate any notes where residents declined or attended care plan meetings. She also informed surveyor the MDS office had taken over sending out care plan invitations since the former social worker was not doing them and RDCS#4 concurred with this statement and informed surveyor the facility had a different social worker who was not doing/sending out care plan meeting invitations and the MDS office has now taken over. Surveyor requested and received copies of the care plan sign-in sheets for R73, and they revealed resident had not attended any care plan meetings since 08/01/2023. Surveyor also received a care plan meeting invitation dated 7/26/24 for a care plan meeting scheduled 8/6/24 at 1:15 PM for R73. These concerns were discussed at the end of day meeting on 07/30/24 at 4:15 PM with the administrator, director of nursing, assistant director of nursing, regional director of clinical services, regional director of operations, and regional director of dietary services and again during the end of day meetings on 7/31/24 at 4:47 PM, 8/1/24 at 4:00 PM, 8/5/24 at 4:30 PM and again at the pre-exit meeting on 8/6/24 at 12:16 PM. Surveyor requested and received the facility policy titled Comprehensive Care Plans, which read in part, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and timeframes to meet a resident's .psychosocial needs .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment .The objectives will be utilized to monitor the resident's progress . Surveyor requested and received a facility policy titled, Care Planning-Resident and/or Resident Representative participation that read in part, .This facility supports the residents and/or resident's representative right to be informed of, and participate in, his or her care planning and treatment .4. The facility will encourage and assist the resident and/or resident representative to participate in choosing care and treatment .7. The facility will honor the resident's choice in individuals to be included in the care planning process .9. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes . No further information regarding this concern was presented to the survey team prior to the exit conference on 08/06/24. 4. For Resident #28 (R28), the facility staff failed to reassess the effectiveness of the interventions and review and revise the resident's activity care plan to meet the resident's needs and the facility staff failed to ensure the resident was provided the opportunity to participate in planning care in the facility. R28's diagnosis list indicated diagnoses that included, but were not limited to, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Congestive Heart Failure, Peripheral Vascular Disease, Major Depressive Disorder, and Anxiety Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 06/27/2024 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating R28 was cognitively intact. On 7/29/24 at 2:26 PM, surveyor interviewed R28, and resident stated she did not attend activities at the facility. R28 also stated that she has never attended a care plan meeting. A review of the current care plan revealed an activity Focus of, .(R28) attends activities of interest/choice and engages in self-initiated leisure activities. with a Goal of, .will participate in 2-3 (two to three) in or out of room activities a week x 90 days (for ninety days) such as accepting special snacks and exercise. A second goal read, .will initiate leisure activities 1-2 x/day such as using her smart phone, reading magazines and watching tv. The interventions read in part, .Invite, encourage and assist as needed to activities of choice/interest {sic} as tolerated by the resident . The interventions were assigned to activity assistant and activity director. The care plan revealed an initiated date of 12/20/2023 with a revision date of the first goal of 04/12/2024 and the second goal with a revision date of 07/04/2024, no changes were identified for the Focus, Goal or Interventions during this revision. Surveyor could not locate any Activity Progress notes on the clinical record for R28. On 7/30/24 at 3:20 PM, surveyor interviewed activity director-other staff #10 (OS#10) about activity assessments and activity progress notes. OS#10 stated she only completes activity assessments on admission, annually and for a significant change and does them with the ARD date of the MDS. She stated she does not do an activity progress note every ninety days or a quarterly assessment and she is behind on assessments. On 7/31/24 at 3:12 PM, regional director of clinical services #4 (RDCS#4) informed surveyor she had spoken to OS#10, and she had informed her that she had not done any ninety-day progress notes for residents. In addition to the above stated findings, surveyor could not locate any evidence R28 was invited to or had attended any care plan meetings since her baseline care plan meeting on 12/05/2023. On 8/1/24 at 10:17 AM, surveyor interviewed MDS nurses, registered nurse #1 (RN#1) and licensed practical nurse #6 (LPN#6) about R28 and care plan meeting attendance. Both nurses stated they did not have invitation letters but did keep logs of care plan attendance and they write if residents attended or not. At 10:40 AM LPN#6 informed surveyor she scanned through progress notes and could not locate any notes where residents declined or attended care plan meetings. She also informed surveyor the MDS office had taken over sending out care plan invitations since the former social worker was not doing them and RDCS#4 concurred with this statement and informed surveyor the facility had a different social worker who was not doing/sending out care plan meeting invitations and the MDS office has now taken over. Surveyor requested and received copies of the care plan sign-in sheets for R28, and they revealed resident had not attended any care plan meetings since 12/05/2023. Surveyor also received a care plan meeting invitation dated 7/08/24 for a care plan meeting scheduled 7/16/24 at 2:30 PM for R28 and the care plan sign in sheet revealed R28 did not attend the care plan meeting on 7/16/24. These concerns were discussed at the end of day meeting on 07/30/24 at 4:15 PM with the administrator, director of nursing, assistant director of nursing, regional director of clinical services, regional director of operations, and regional director of dietary services and again during the end of day meetings on 7/31/24 at 4:47 PM, 8/1/24 at 4:00 PM, 8/5/24 at 4:30 PM and again at the pre-exit meeting on 8/6/24 at 12:16 PM. Surveyor requested and received the facility policy titled Comprehensive Care Plans, which read in part, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and timeframes to meet a resident's .psychosocial needs .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment .The objectives will be utilized to monitor the resident's progress . Surveyor requested and received a facility policy titled, Care Planning-Resident and/or Resident Representative participation that read in part, .This facility supports the residents and/or resident's representative right to be informed of, and participate in, his or her care planning and treatment .4. The facility will encourage and assist the resident and/or resident representative to participate in choosing care and treatment .7. The facility will honor the resident's choice in individuals to be included in the care planning process .9. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes . No further information regarding this concern was presented to the survey team prior to the exit conference on 08/06/24. 21227 5. The staff failed to ensure Resident #82's comprehensive care plan addressed the resident's use of medications to prevent blood clot formation. The facility staff failed to ensure Resident #82 was included in the care plan meeting. Resident #82's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/29/24, was signed as completed on 7/8/24. Resident #82 was assessed as able to make self understood and as able to understand others. Resident #82's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. On 7/29/24 at 2:30 p.m., Resident #82 reported they did not remember being invited to a care plan meeting in the past. On 8/5/24 at 3:57 p.m., the Director of Nursing (DON) reported no evidence was available to indicate Resident #82 was involved in care plan meetings. The DON reported a letter for Resident #82's March 2024 meeting was found but it was not signed by the resident; the letter was addressed To whom it may concern: and provided the date and time for the March 2024 care plan meeting. Review of Resident #82's clinical record included medical provider orders for the following medications for blood clot prevention: clopidogrel and enoxaparin. (Clopidogrel is an antiplatelet medication. Enoxaparin is an anticoagulant medication.) Resident #82's enoxaparin order had a start date of 7/17/24 to be administered for 17 days. Resident #82's clopidogrel order had a start date of 6/29/24. Resident #82's comprehensive care plan did not address bleeding risk related to the administration of antiplatelet and anticoagulant medications. The following information was found in a facility policy titled Care Planning-Resident and/or Resident Representative participation [sic] (with the reviewed/revised date of 12/1/22): The facility will make an effort make every effort [sic] possible to schedule the conference at the best time of the day for the resident/resident's representative. The facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan. The following information was found in a facility policy titled Comprehensive Care Plan (with a revised/reviewed date of 12/1/22): - The comprehensive care plan will be prepared by an interdisciplinary team, that include, but is not limited to: . The resident and the resident's representative, to the extent practicable. - The comprehensive care plan will describe, at the minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. On 8/5/24 at 4:31 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, Regional Director of Clinical Services, and Regional Food Services Director. During this meeting, the surveyor discussed the failure of Resident #82's care plan to address the resident's anticoagulant use. The DON confirmed that the care plan did not address the use of anticoagulants.

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to provide care and/or services for five (5) of 27 sampled residents (Resident #15, Resident #36, Resident #73, Resident #82, and Resident #258). The findings include: 1. The facility staff failed to have documented evidence of Resident #82 being assessed by a licensed nurse prior to facility staff assisting the resident back to their wheelchair after the resident experienced a fall on 7/11/24. Resident #82's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/29/24, was signed as completed on 7/8/24. Resident #82 was assessed as able to make self understood and as able to understand others. Resident #82's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. On the afternoon of 8/5/24, the surveyor interviewed the facility's Assistant Director of Nursing (ADON), Licensed Practical Nurse (LPN) #8, Certified Nurse Aide (CNA) #6, and CNA #7. These three (3) staff members were involved in the care of Resident #82 after the fall on 7/11/24. It was reported that a licensed nurse was notified of the fall and involved in the resident's post-fall care. On 8/5/24 at 4:00 p.m., the Director of Nursing (DON) confirmed that no immediate post-fall assessment of the resident was documented. The DON confirmed that an assessment by a licensed nurse should have been completed after the fall and prior to the resident being assisted from the floor back to the wheelchair. On 8/5/24 at 4:31 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, Regional Director of Clinical Services, and Regional Food Services Director. During this meeting, the surveyor discussed the failure of the facility staff to have documented evidence of a licensed nurse completing an assessment of Resident #82 after the resident experienced a fall on 7/11/24. 2. The facility staff failed have evidence of Resident #36 being assessed by a licensed nurse when the resident experienced a change in condition. Resident #36's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/3/24, was signed as completed on 5/14/24. Resident #36 was assessed as able to make self understood and as able to understand others. Resident #36's Brief Interview for Mental Status (BIMS) summary score was documented as an eight (8) out of 15; this indicated moderate cognitive impairment. Resident #36's clinical record indicated the resident experienced a change in condition which resulted in a transfer to a local hospital on the evening of 5/16/24. The following information was found on a medical provider note dated 5/16/24: Send to ED (emergency department) to evaluate and treat; (oxygen saturation levels) in low 80's when I entered the room, increased (oxygen) to 4 (liters per minute) . Continues to be (short of breath) at rest. She is dependent on hemodialysis and states she does not feel she can attend her session tomorrow (due to) her current condition. Hopefully she will be admitted and can receive dialysis inpatient as she needs it, concerned about (pneumonia) and volume overload. Review of Resident #36's clinical record failed to reveal an assessment by a licensed nurse. No vital signs to include an oxygen saturation level was documented by nursing staff for 5/16/24. On 8/1/24 at 3:41 p.m., the surveyor discussed the absence of an assessment by a licensed nurse, when Resident #36 experienced a change in condition on 5/16/24, with the facility's Regional Director of Clinical Services (RDCS). The RDCS confirmed a nurse assessment, to include a full set of vital signs, should have been completed. On 8/1/24 at 4:02 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, RDCS, and Regional Food Services Director. During this meeting, the surveyor discussed the absence of a nursing assessment when Resident #35 experienced a change in condition on 5/16/24 which resulted in a transfer to the local hospital. 3. The facility staff failed to follow Resident #15's medical provider's bowel protocol standing orders. Resident #15's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/16/24, was signed as completed on 5/30/24. Resident #15 was assessed as being able to sometimes make self understood and as being able to sometimes understand others. Resident #15 was assessed as having moderate impairment with making decisions regarding tasks of daily life. On 8/2/24 at 1:05 p.m., the Assistant Director of Nursing (ADON) provided the surveyor a copy of Resident #15's standing orders including the following bowel protocol instructions: . if no (bowel movement) in 3 days; give Milk of magnesia 30 ml by mouth/peg . If no BM (bowel movement) in 24 hours after Milk of magnesia, give Dulcolax 10 mg suppository rectally . Resident #15's medical record included documentation to indicate the resident did not have a bowel movement for the following five (5) days: 7/22/24, 7/23/24, 7/24/24, 7/25/24, and 7/26/24. No evidence of the implementation of the resident's bowel protocol was found until a Dulcolax suppository was administered on 7/26/24 at 6:49 p.m. No evidence was found by or provided to the surveyor to indicate Resident #15 had been provided/administered oral milk of magnesia after three (3) days without a BM. On 8/5/24 at 4:31 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, Regional Director of Clinical Services, and Regional Food Services Director. During this meeting, the surveyor discussed the facility staff not following the medical provider's bowel protocol for Resident #15. 47299 4. For resident # 258, the facility staff failed to follow a physician's order to remove staples from a surgical incision. Resident # 258's pertinent diagnoses included displaced intertrochanteric fracture of the right femur post surgical repair for which resident was admitted to the facility for rehabilitation. Review of the clinical record revealed a nurse progress note dated 5/16/24 that read, refused to go to f/up Ortho appointment scheduled this day x 4 attempts. MD notified. A physician's note dated 5/21/24 read under the heading Plan/Orders: Remove staples today. There was no note that discussed staples being removed. There was no order entered into the electronic medical record to remove staples. According to the electronic medical record, resident # 258 was rehosptialized on 5/27/24 and a document entitled ED Notes dated 5/27/24 was reviewed. The document read in part, Staples removed by this RN. Chart shows that staples should have been removed two weeks from the date of his surgery on 4/27/24. On 8/5/24 this nurse interviewed the Assistant Director of Nursing (ADON). They stated they did not remember if resident # 258's staples had been removed but I feel like if we had an order we did it. They called the wound nurse, Licensed Practical Nurse (LPN) # 4 and stated She would have been the one to take them out. LPN # 4 was interviewed. When asked if she recalled removing staples from resident # 258, she stated, No, I didn't take his staples out. When asked if she was aware that an order was written to do so she stated, No, I didn't know. On 8/5/24 at 12:13 PM this surveyor met with the Director of Nursing (DON), ADON, and Regional Director of Clinical Services (RDCS). When asked how the order to remove staples didn't get carried out the RDCS stated, It was just missed. This concern was reviewed with the Administrator, DON, ADON, RDCS, Regional Director of Operations and Regional Director of Culinary Services on 8/6/24 at 12:15 PM. No further information was provided to the survey team prior to the exit conference. 49622 5. For Resident #73 (R73), the facility staff failed to follow provider orders for bowel protocol for the administration of Milk of Magnesia and Dulcolax used to treat constipation. R73's diagnosis list indicated diagnoses that included, but were not limited to, Morbid (severe) obesity, Anemia, Tachycardia, Constipation, Edema, and Hypothyroidism. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 07/13/2024 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating R73 was cognitively intact. On 7/29/24 at 4:10 PM, surveyor interviewed R73, and he stated he has problems with constipation. R73's provider orders included an order dated 06/28/24 for Milk of Magnesia 30 ml (milliliters) by mouth on day three (3) without a bowel movement; then initiate Bowel Protocol: Step 3. The resident's orders also included an order dated 06/28/24 for Dulcolax 10 mg (milligrams) Suppository per rectum on day four (4) without a bowel movement and no result from Milk of Magnesia; then initiate Bowel Protocol: Step 4 and a provider's order dated 06/28/24 for Administer Fleet enema per rectum on day five (5) without a bowel movement and no result from Milk of Magnesia or Dulcolax suppository; then initiate Bowel Protocol: Step 4. Surveyor reviewed R73's July 2024 MAR (medication administration record) and was unable to locate evidence of staff administering Milk of Magnesia or Dulcolax prior to administering Fleet enemas on 07/01/24, 07/09/24, and 07/26/24. A review of R73's current care plan with a focus that read in part, .has potential for fluid deficit r/t (related to) recent constipation . and interventions that read in part, .Administer medications as ordered. Observe for side effects and effectiveness .Observe bowel sounds and frequency of BM (bowel movement): provide medication per order and notify MD (medical doctor) as necessary . A review of R73's Bowel Movement flow sheet revealed documentation of resident having bowel movements only on the following dates: 07/01/24, 07/09/24, 07/14/24, 07/15/24, 07/26/24, 07/27/24, and 07/31/24. Surveyor requested and received the facility document titled, Bowel Protocol which read in part, .if no bm in 3 days; give Milk of magnesia 30 ml by mouth .If no BM 24 (twenty-four) hours after Milk of magnesia, give Dulcolax 10 mg suppository rectally .If no BM in 24 hours after Dulcolax suppository, administer fleet enema rectally .If no BM 4 hours after Fleet enema, notify MD . On 08/02/24 at 11:20 AM, surveyor spoke with regional director of clinical services (RDCS#4), and she informed surveyor they could not locate any evidence where Milk of Magnesia or Dulcolax were given to resident in July 2024 per bowel protocol. She agreed there were no notes indicating anything was given prior to the enemas and there was no proof. These concerns were discussed at the end of day meeting on 8/1/24 at 4:00 PM with the administrator, director of nursing, assistant director of nursing, regional director of clinical services, regional director of operations, and regional director of dietary services and again during the end of day meeting on 8/5/24 at 4:30 PM and again at the pre-exit meeting on 8/6/24 at 12:16 PM. No further information regarding this concern was presented to the survey team prior to the exit conference on 08/06/24.

Based on staff interview, clinical record review and facility document review the facility staff failed to act on pharmacy recommendations for 4 of 27 residents in the survey sample residents # 83, 8, 56, 28. The findings included: 1. For resident # 83 the facility staff failed to provided evidence of completed pharmacy recommendations for the months of September 2023 and May 2024. Resident # 83's diagnoses included but were not limited to, unspecified dementia with unspecified severity and anxiety, epilepsy, generalized anxiety disorder, and psychotic disorder with delusions due to unknown physiological condition. Resident # 83's minimum data set (MDS) assessment with an assessment reference date of 6/22/24 assigned the resident a brief interview for mental status (BIMS) score of 3 out of 15 indicating severe cognitive impairment. During a review of the electronic medical record a pharmacist note dated 9/13/23 at 11:00 AM read, MRR complete-see report. A note dated 5/28/24 at 2:29 PM read, MRR complete-see report. On 08/05/24 10:21 AM this surveyor asked the Assistant Director of Nursing (ADON) for resident # 83's pharmacist recommendations for 5/28/24 and 9/13/23. The ADON stated they were not able to locate either one. This surveyor requested and received the policy entitled, Medication Regimen Review with a revised date of 12/1/22. The policy read in part, 5. The pharmacist shall communicate any irregularities to the facility in the following ways: a. Verbal communication to the attending physician, Director of Nursing, and/or staff of any urgent needs. b. Written communication to the attending physician, the facility's Medical Director, and the Director of Nursing. 6. Written communications from the pharmacist shall become a permanent part of the resident's medical record. This concern was reviewed with the Administrator, Director of Nursing, ADON, Regional Director of Clinical Services, Regional Director of Operations and Regional Director of Culinary Services on 8/6/24 at 12:15 PM. No further information was provided to the survey team prior to the exit conference. 49622 2. For Resident #8 (R8), the facility staff failed to provide evidence of the 5/28/24 drug regimen review being reported to and acted upon by the medical provider. R8's diagnosis list indicated diagnoses, which included, but not limited to Dementia, Anxiety Disorder, Depression, Mood Affective Disorder, and Hypertensive Heart Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 5/8/24 assigned the resident a brief interview for mental status (BIMS) summary score of 5 out of 15 indicating the resident was severely cognitively impaired. Progress notes within R8's clinical record indicated a drug regimen review was completed on 5/28/24 with recommendations. Surveyor was unable to locate the recommendation reports in the resident's clinical record. Surveyor requested and received the drug regimen review recommendation reports completed by the pharmacist for R8 from the assistant director of nursing (ADON) on 8/2/24 at 10:26 AM and she stated some were missing and she was not sure what happened. The 5/28/24 Consultant Pharmacist Recommendation to Physician report had not been signed by the medical provider indicating review. The 5/28/24 Consultant Pharmacist Recommendations to Physician read in part .This resident has been taking Divalproex 250 mg (milligrams) Q8 (every eight hours) since 5/17/2023 without a GDR (gradual dose reduction). Could we attempt a dose reduction at this time to perhaps Divalproex 125 mg Q8 to verify this resident is on the lowest possible dose . A review of the active provider orders indicated the recommendation was not addressed, as the medication was active on the order with a start date of 5/17/23. This concern was discussed at the end of day meeting on 8/5/24 4:30 PM with the administrator, director of nursing, assistant director of nursing, regional director of clinical services, regional director of operations, and regional director of dietary services and again during the pre-exit meeting on 8/6/24 at 12:16 PM. Surveyor requested and received the facility policy titled Medication Regimen Review which read in part The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart .f. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities . No further information regarding this concern was presented to the survey team prior to the exit conference on 08/06/24. 3. For Resident #28 (R28), the facility staff failed to provide evidence of the 12/28/23, 2/23/24, 3/27/24, and 4/28/24 drug regimen reviews being reported to and acted upon by the medical provider. R28's diagnosis list indicated diagnoses that included, but were not limited to, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Congestive Heart Failure, Peripheral Vascular Disease, Major Depressive Disorder, and Anxiety Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 06/27/2024 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating R28 was cognitively intact. Progress notes within R28's clinical record indicated drug regimen reviews were completed on 12/28/23, 2/23/24, 3/27/24, and 4/28/24 with recommendations. Surveyor was unable to locate the recommendation reports in the resident's clinical record. Surveyor requested and received the drug regimen review recommendation reports completed by the pharmacist for R28 from the regional director of clinical services on 7/31/24 at 4:24 PM and she stated the drug regimen reviews were not signed. A review of the reports indicated the 2/23/24, 3/27/24, and 4/28/24 Consultant Pharmacist Recommendation to Physician reports had not been signed by the medical provider indicating review. The 12/28/23 Consultant Pharmacist Recommendations to Nursing Staff read in part .The resident is receiving the corticosteroid inhaler Symbicort. Reminder that the resident's mouth should be rinsed out after use to avoid oral thrush from developing . A review of the active provider orders, medication administration record and treatment administration records, indicated the recommendation was not addressed. On 7/31/24 at 4:24 PM, the regional director of clinical services informed surveyor the rinse had not been added after use. The 2/23/24 and 3/27/24 Consultant Pharmacist Recommendations to Physician read in part .The resident is receiving two drugs with very similar therapeutic activity: 1. Advair 2. Budesonide-Formoterol .PLEASE VERIFY THIS DRUG REGIMEN IS REQUIRED, if not, adjust therapy as needed . The reports had not been signed by the medical provider indicating review. The Budesonide-Formoterol was discontinued indicating the February recommendation was not addressed until 4/17/24. The 4/28/24 Consultant Pharmacist Recommendations to Physician read in part, .This resident has been taking Duloxetine 40 mg (milligrams) since 3/18/2024 without a GDR (gradual dose reduction). Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? If not, please indicate response below . The report had not been signed by the medical provider indicating review. The dose of Duloxetine was reduced to 20 mg indicating the April recommendation was not addressed until 6/26/24. These concerns were discussed at the end of day meeting on 8/1/24 at 4:00 PM with the administrator, director of nursing, assistant director of nursing, regional director of clinical services, regional director of operations, and regional director of dietary services and again during the end of day meeting on 8/5/24 at 4:30 PM and at the pre-exit meeting on 8/6/24 at 12:16 PM. Surveyor requested and received the facility policy titled Medication Regimen Review which read in part The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart .f. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities . No further information regarding this concern was presented to the survey team prior to the exit conference on 08/06/24. 21227 4. The facility staff failed ensure Resident #56's medication regimen review recommendation was addressed by a medical provider. Resident #56's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/20/24, was signed as completed on 7/29/24. Resident #56 was assessed as able to make self understood and as able to understand others. Resident #56's Brief Interview for Mental Status (BIMS) summary score was documented as a 13 out of 15; this indicated intact and/or borderline cognition. Resident #56 had a consultant pharmacist recommendation dated 5/28/24. This document included the following recommendation: This resident is on an antipsychotic medication and a current AIMS could not be located in the chart (in (electronic medical record company's name omitted)). AIMS should be done within the first 30 days of either admission or initiating therapy, then at least every 6 months after that. Please evaluate if applicable. Thank you. (Abnormal Involuntary Movement Scale (AIMS) is used to identify certain adverse reactions to antipsychotic medications.) The section of this pharmacist recommendation document where the medical provider addresses the recommendation was blank. Review of Resident #56's clinical record indicated the resident continued to receive an antipsychotic medication. No evidence that an AIMS assessment had been completed was found by or provided to the surveyor. On 8/5/24 at 4:31 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, Regional Director of Clinical Services, and Regional Food Services Director. During this meeting, the surveyor discussed the failure of a medical provider to address the 5/28/24 pharmacy recommendation for Resident #56 to have an AIMS completed.

Based on observation, staff interview, and facility document review, the facility staff failed to store all medications and biologicals in a locked storage compartment on 1 of 2 nursing units, unit 1 hall C. The findings included: On 8/5/24 at 9:18 AM, this surveyor observed a medication cart in the hallway. The cart was unattended and unlocked. There was a staff member observed in room [ROOM NUMBER] interacting with a resident in the bed by the window. The staff member was not in the line of sight to the medication cart. At 9:24 AM Licensed Practical Nurse (LPN) # 2 exited room [ROOM NUMBER]. When asked if they were assigned to that medication cart they stated, Yes, that's me today. When surveyor pointed out that the cart was unlocked they stated, I never do that. Surveyor asked if the cart should have been locked while unattended and unobserved and they stated, Yes, I should have locked it before I went in there. This surveyor met with the Assistant Director of Nursing at 9:30 AM and discussed the concern. A copy of the policy entitled, Medication Storage with a revised date of 12/1/22 was received. The policy, under the heading 1. General Guidelines, read in part a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under the proper temperature controls, and c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. The survey team met with the Administrator, Director of Nursing, Assistant Director of Nursing, Regional Director of Clinical Services, Regional Director of Operations and Regional Director of Culinary Services on 8/6/24 at 12:15 PM and this concern was discussed. No further information was provided to the survey team prior to the exit conference.

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation the facility staff failed to provide treatment for [REDACTED].#19, #10, #16, #23, #3, #25, #5 and #14. The findings included: 1. For Resident #19 the facility staff failed to accurately assess and diagnose the communicable disease, scabies, resulting in a delay of treatment. Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of [DATE] coded the Resident as 2 out of 15 in section C, cognitive patterns. This is a quarterly MDS. Resident's CCP (comprehensive care plan) reviewed at this time. Resident #19's clinical record was reviewed on [DATE]. It contained the following nurse's notes which read in part: [DATE] 4:00AM On [DATE] at 11:00pm Resident came to nurses med cart crying. Resident c/o (complained of) itching all over. States 'it wont stop itching and its driving me crazy'. States 'It feels like something crawling under my skin'. Res (sic) has a few small raised like areas noted on her left back. No rash noted on rest of Residents body. Called on call Dr .(name omitted). New order noted for [MEDICATION NAME] 25mg every 6 hours prn (as needed). RP (responsible party) notified. [DATE] 6:58 AM Resident continues to complain of severe itching and is requesting to be seen by MD. Given [MEDICATION NAME] per prn order. Res (sic) states 'It helps but doesn't make it stop'. [DATE] 6:31 AM Medication follow-up-([MEDICATION NAME] 25 MG CAPSULE 1 cap by mouth ev) Medication was effective. [DATE] 7:53 AM Resident continues to c/o of itching all over. Resident has several small red spots on right thigh and back of neck. Given [MEDICATION NAME] per prn order. MD made aware. [DATE] 5:35 PM NO (new order): .CHANGE [MEDICATION NAME] TO 50MG PO (by mouth) Q6HRS (every 6 hours) PRN. [DATE] 9:45 PM Continues [MEDICATION NAME] UTI. No adverse reactions noted. Skin warm and dry. Continues to c/o itching at times. No acute distress noted. Call light and PO fluids within reach. [DATE] 9:53 PM Medication Follow-up - ([MEDICATION NAME] 50 MG CAPSULE BY MOUTH EVERY 6) Medication was effective. [DATE] 9:33 PM Medication Follow-up - ([MEDICATION NAME] 50 MG CAPSULE BY MOUTH EVERY 6) Medication was effective. [DATE] 2:50 AM visteral (sic) for complaint of nervousness. Res. slept til this time, complaint of itching. had visteral (sic) earlier at 1am . [DATE] 6:26 AM 4am Res. was up in wheelchair complaint of itching and sharp pain in upper Lt. chest . [DATE] NEW ORDER: [MEDICATION NAME] 0.1% APPLY TO AFFECTED THIGH BID X 7 DAYS. DERMATOLOGY EVAL . [DATE] 12:12 AM Resident had complained with itching and this nurse administered Vistril (sic) @ approx. 8 pm . [DATE] 2:04 AM Resident complaining of itching and Resident was saw by staff her stratching (sic) herself. This nurse administered vistril (sic) as ordered . [DATE] 7:11 AM VISTRARIL 50 MG CAPSULE BY MOUTH EVERY 6 complaints of itching. [DATE] 10:37 PM Medication Follow-up - ([MEDICATION NAME] 50 MG CAPSULE BY MOUTH EVERY 6) Medication was effective. [DATE] 12:20 AM Medication Follow-up - ([MEDICATION NAME] 50 MG CAPSULE BY MOUTH EVERY 6) Medication was effective. [DATE] 9:37 PM New order for [MEDICATION NAME] 5% external cream apply to skin from neck to soles of feet. and wash off after 8 hours. Daughter notified of this order. [DATE] 8:14 AM At 2:00am Given shower and premethrin (sic) cream applied to entire body per orders. Reported to oncoming shift. Resident #19's clinical record contained the following physician's progress notes which read in part: [DATE] Cc (chief complaint): Acute UTI (urinary tract infection). Pt stated she dropped her spoon, was sent to ER for S/S (signs/symptoms) of 'stroke'. Yesterday she was sent back to facility s (without) any new orders. Resident's complaints of itching were not addressed. [DATE] Cc: Recert. Resident's complaints of itching were not addressed. [DATE] Cc: Readmitt to (name omitted) s/p (status [REDACTED]. Complaints of itching not addressed. [DATE] Cc: Burn No sig (sic) rash noted scant petechiae which appear age related. [DATE] Cc: Pt c (with) rash B (bilaterally) (writing illegible). Has had x > (greater than) 30 d, had (writing illegible) has grandchild c rect (recent) Dx (diagnosis) of scabies. -scant 0 [DIAGNOSES REDACTED]tic rash trunk, LE (lowere extrimities) B (bilaterlly), 0 raised, flat, no (writing illegible). Assessment: Rash-does not appear to be scabies 0 classic . (illegible) Re (Red raised rash c tunneling) Rec. derm eval. [DATE] Cc: fu (follow up) rash. Flat light rash B LE trunk 0 red, 0 rash 0 raised 0 .(illegible). Assessment: Rash- No .(illegible) c (with) scabies 0 red, 0 raised, 0 tunnelling. Although I may not be correct. Therefore given Hx (history) of family c scabies, will ask for derm. eval + scraping to see what is cause. If it is scabies certainly not classic presentation. [DATE] Cc: Pt c derm evl today, scraping + scabies Resident #19's clinical record contained a Report of Consultation dated [DATE] which read in part Chief complaint: 1) Itching all over-2 months. History of Present Illness: Patient presents today for evaluaton of a severely pruritic rash that has been occurring on her wrists and ankles and upper back for the past 2 months. Multiple family members have been diagnosed and treated for [REDACTED]. Patient lives at (name omitted). Physical exam: Burrows on wrists bilaterally. Few excoriations on the upper back. Assessment: Scabies. According to the Virginia Department of Health epidemiology fact sheet, scabies is a disease of the skin caused by a mite. Scabies mites burrow into the skin, producing pimple-like irritations or burrows. Symptom of scabies include intense itching, especially at night with areas affected to include wrists, elbows, armpits, waist, thighs . Surveyor spoke with the administrative team on [DATE] at approximately 1515 regarding Resident #19. Surveyor asked administrative team how soon after a request is made by a Resident to see the physician should the Resident be seen. The interim DON (director of nursing) stated when a Resident requests to be seen by the physician, they should be seen with 24 hours or as soon as is reasonably possible if request is made on weekend. Surveyor requested and was provided with a copy of facility policy entitled Residents Right which read as follows: A. Residents Rights: It is our belief that you as a Resident have the right to expect certain standards of care and considerations while at our facility. You have the right to: 1. Expect reasonable responses to requests to services within our capacity, our stated mission and applicable law and regulation. Surveyor spoke with the FNP (family nurse practitioner) on ,[DATE] at approximately 1730 regarding Resident #19. FNP stated the he initially saw Resident due to complaints of itching and rash on trunk. FNP stated that Resident had some small petechiae on both thighs. FNP stated that CNA (certified nurse's aide) told him that the rash became more prominent when Resident showered. FNP stated that Resident was initially treated with [MEDICATION NAME] for the itching. After 1 week, Resident had a little more rash. FNP stated that over the next few weeks, the Resident's rash appeared no better, but no worse. FNP stated some success with [MEDICATION NAME] and [MEDICATION NAME] cream. FNP stated that Resident had grandchild that had tested positive for scabies. FNP stated that Resident's rash did not look like scabies and that the facility medical director agreed, but sent for dermatology consult to be sure. Surveyor asked FNP why Resident had not been seen by dermatology sooner, and FNP stated that since Resident has dementia, he did not want to send her out and disrupt her regular routine. FNP stated that at times the rash seemed better with treatment. The concern of the delay in treatment was discussed with the administrative staff during a meeting on [DATE] at approximately 1515. Prior to exit conference, the interim DON provided the surveyor with copies of physician's progress notes which were not included in Resident's clinical record at time of surveyor review. These progress notes read in part: [DATE] Pt c rash R anterior thighs, tx (treatment) with [MEDICATION NAME] for itching Plan: Observe, fu (follow up) 1 week. [DATE] Pt c fu rash (writing illegible) Assessment: Rash .(illegible) Plan: .(illegible) ? need for scraping. No further information was provided prior to exit. 2. For Resident #10 the facility staff failed to follow facility established bowel protocol. Resident #10 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of [DATE] coded the Resident as 14 out of 15 in section C, cognitive patterns. This is an admission MDS. Resident #10's clinical record was reviewed on [DATE]. It contained a signed POS (physician's orders [REDACTED]. Resident #10's MAR's (medication administration record) for the months of September and [DATE] were reviewed. The MAR for September contained an entry which read in part [MEDICATION NAME] Powder, Give 17gm by mouth daily. This entry had been signed as having been administered as ordered. The MAR for October contained an entry which read in part [MEDICATION NAME] Powder, Give 17gm by mouth daily. Discontinue date [DATE]. This entry had been signed as having been administered as ordered. The MAR for October also contained an entry which read in part [MEDICATION NAME] Powder-Give 17gm by mouth daily as needed. Order date: [DATE]. This entry had not been signed as having been administered. Resident #10's electronic record contained BM (bowel movement) Record Roster for the months of September and [DATE]. For the month of September, the BM roster indicated a period of 6 days (,[DATE]-[DATE]) and a period of 5 days (,[DATE]-[DATE]) with no recorded BM for Resident #10. For the month of October, the BM roster indicated a period of 5 days (,[DATE]- [DATE]) and a period of 4 days (,[DATE]-[DATE]) with no recorded BM. The Resident's clinical record also contained copy of the facility Bowel Protocol which read in part No BM x 2 days-Please administer 30ml Milk of Magnesia q.h.s. x 1 at bedtime. No BM x 3 days- Please administer [MEDICATION NAME] suppository x 1 at bedtime. No BM x 4 days-Please administer Fleets enema x 1 at bedtime. Bowel movement documentation will be reviewed by the ,[DATE] charge nurses for each unit and medication administered per review of the BM record for each Resident. All laxatives will require documentation on MAR fro (sic) that Resident. The surveyor could not locate any supporting documentation to indicate that the bowel protocol had been instituted for Resident #7. The concern of not following the bowel protocol was discussed with the administrative team during a meeting on [DATE] at approximately 1410. No further information was provided prior to exit. 3. For Resident #16, the facility staff failed to administer the medications [MEDICATION NAME] and [MEDICATION NAME] as ordered by the physician. The record review revealed that Resident #16 had been admitted to the facility [DATE]. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of [DATE] included a BIMS (brief interview for mental status) score of 14 out of a possible 15 points. Resident #16's clinical record included the following physician ' s telephone orders. 1. [DATE] for [MEDICATION NAME] 100 mg 1 PO (by mouth) q (every) 8 hours X 72 hours for dysuria. For a total of 9 doses. 2. [DATE] for [MEDICATION NAME] 500 mg 1 TID (three times a day) X 2 days for tooth extraction. For a total of 6 doses. A review of Resident #16's eMAR (electronic medication administration records) indicated that only 6 doses of the [MEDICATION NAME] and 4 doses of the [MEDICATION NAME] had been administered. On [DATE] at approximately 8:25 a.m. the surveyor and the QA (quality assurance nurse) reviewed the Residents [MEDICATION NAME] and [MEDICATION NAME] orders. After reviewing the orders and eMAR the QA nurse verbalized to the surveyor that the Resident did not receive enough doses of either medication. After this issue was identified by the surveyor the Resident was out for [MEDICAL TREATMENT] and was unable to be interviewed. The administrative staff were notified of the above in a meeting with the survey team on [DATE] at approximately 3:10 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference. 4. For Resident #23, the facility staff failed to obtain treatment orders for unstageable pressure ulcers when the Resident was admitted to the facility. This was a closed record review the Resident had expired at the facility. Resident #23 was added to the sample due to a complaint. The facility had completed an internal investigation prior to the survey and substantiated an allegation that the treatment nurse LPN (licensed practical nurse) #10 had failed to obtain treatment orders after the Resident had been admitted to the facility and identified as having unstageable pressure ulcers. The facility re-educated the nurse on professional standards in regards to obtaining appropriate treatments for identified skin issues. The record review revealed that Resident #23 had been admitted to the facility [DATE]. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents admission MDS (minimum data set) assessment with an ARD (assessment reference date) of [DATE] was coded [DATE] to indicate the Resident had problems with long and short term memory and was severely impaired in cognitive skills for daily decision making. Section G (functional status) had been coded for bed mobility indicating the Resident required extensive assistance of two persons to perform this activity. Section M (skin conditions) was coded to indicate the Resident was at risk for developing pressure ulcers and had 6 unstageable deep tissue pressure ulcers. The Residents CCP (comprehensive care plan) included the problem area .at risk for skin breakdown R/T (related to) functional status and incontinence. He requires staff assistance with ADLs (activities of daily living) and is incontinent. He was admitted with multiple pressure ulcers . Approaches included, but were not limited to, Provide treatments as ordered .Observe and report s/s (signs/symptoms) of skin breakdown, pressure reducing mattress to bed and cushion to w/c (wheelchair). The Residents Nursing Admission Assessment had been completed on [DATE] and had been signed by LPN #1. This nursing assessment included the following-pressure ulcer of sacral region, unstageable, pressure ulcer of left buttock, unstageable, pressure ulcer of right ankle, unstageable, pressure ulcer of left heel, unstageable, pressure ulcer of left ankle, unstageable, pressure ulcer of other site, unstageable. The clinical record also included wound assessment reports dated [DATE] that identified the following. · Unstageable due to suspected DTI (deep tissue injury) pressure ulcer right bottom of foot. 4.0 cm length X 1.5 cm width. · Unstageable due to suspected DTI pressure ulcer left bottom of heel. 2.5 cm length X 3.5 cm width. · Unstageable due to suspected DTI pressure ulcer left bottom of heel. 3.5 cm length X 2.5 cm width. · Unstageable due to suspected DTI pressure ulcer right medial malleolus. 3 cm length X 1 cm width. · Unstageable due to suspected DTI pressure ulcer left medial malleolus. 2.25 cm length X 1.5 cm width. · Unstageable due to suspected DTI pressure ulcer coccyx. 1 cm length X 2 cm width · Unstageable due to suspected deep tissue injury pressure ulcer left buttock. 3 cm length X 1.25 cm width. These wound assessments were electronically signed by LPN #10 and the previous DNS (director of nursing services). Definition of unstageable and DTI from the National Pressure Ulcer Advisory Panel http://www.npuap.org Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. There were no treatments ordered when the Resident was admitted to the facility. The following treatments were obtained during the Residents stay at the facility (,[DATE]-[DATE]) [DATE]-Comfort Care [DATE]-[MEDICATION NAME] to both ankle wounds. [MEDICATION NAME] to both heels and buttocks wound everyday. [DATE]-Discontinue [MEDICATION NAME] to buttocks heels and ankles. Cleanse coccyx wound with normal saline pat dry. Pack with ,[DATE] strength dakins solution and cover with secondary dressing twice a day. [DATE]-Skin prep to right and left heel wounds everyday may cover with secondary dressing if needed. Skin prep to right inner and outer ankle wounds everyday may cover with secondary dressing if needed for skin protection. [DATE]-Skin prep to left inner and outer ankle wounds may cover with secondary dressing for skin protection daily. [DATE]-Heel protectors to bilateral feet as resident will allow. [DATE]-Low air loss mattress to aid in prevention of skin breakdown. [DATE]-Skin prep to wounds to bilateral feet. May cover with secondary dressing for skin protection everyday. [DATE]-Skin prep to left hip discoloration. May cover with secondary dressing for skin protection everyday. [DATE]-Skin prep to red area left lower leg. May cover with secondary dressing everyday for skin protection. [DATE]-Change sacral wound twice a day with ,[DATE] dakins solution. Crush 1 500 mg [MEDICATION NAME] (antibiotic) tablet and sprinkle over wound at dressing change. The clinical record included documentation by the physician that indicated the Resident had multiple wounds that were unstageable and not preventable secondary to terminal illness and decreased nutrition. On [DATE] at approximately 12:45 p.m. the surveyor interviewed LPN #1. LPN #1 was shown her electronic signature on the admitting assessment and asked why treatment orders were not obtained when the Resident had been admitted . LPN #1 stated she did not remember signing the assessment and stated this was the first time she had completed an admission and she had only assisted another nurse as this was not her Resident. LPN #1 added that the Resident had no open areas on admission that the areas were just red. LPN #10 was not working during the course of the survey. The facility attempted to contact her via phone but was unsuccessful. The DNS that had signed off on the wound assessments was no longer employed at the facility and per the facility the investigation was completed by the previous administrator. The facility staff provided the surveyor with copies of their facility policies/procedures titled Wound Care Management and Physician Orders. The policy title Wound Care Management read in part Each resident receives the care and services necessary to retain or regain optimal skin integrity to the extent possible .Notify the charge nurse, physician and responsible party of the presence of the wound . The policy titled Physician Orders read Purpose Physician orders [REDACTED]. The facility also provided the surveyor with a copy of their standard of practice in regards to wounds from LIPPINCOTT Nursing Procedures (seventh edition). This standard of practice included the following .Consult with your facility's wound, continence, and ostomy nurse; nutritionist or registered dietician; and physician or occupational therapist as indicated, because pressure ulcer prevention requires a multidisciplinary approach .If left untreated, pressure ulcers may produce ischemia and local infection . On [DATE] at approximately 3:10 p.m. the administrative staff were made aware of the concerns regarding the absence of treatment orders for Resident # 23. No further information regarding this issue was provided to the survey team prior to the exit conference. THIS IS A COMPLAINT DEFICIENCY. 5. The facility staff failed to follow the physician ordered bowel protocol for Resident #3. Resident #3 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. The resident was coded on the quarterly MDS with an ARD (Assessment Reference Date) of [DATE] as having a BIMS (Brief Interview for Mental Status, an assessment tool) score of 5 out of a possible score of 15. Resident #3 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene. The surveyor conducted a chart review of Resident #3 ' s clinical record on [DATE]. It was noted by the surveyor that on the Bowel report or Resident #1 that there was no bowel movements documented in the clinical record for the following dates: [DATE] through [DATE], [DATE] through [DATE] and [DATE] through [DATE]. The surveyor also reviewed the standing orders for the bowel protocol. The bowel protocol stated the following in which to be followed by the nursing staff: · No BM (bowel movement) X (times) 2 days-Please administer 30 ml (milliliters) Milk of Magnesia qhs (every night) X 1 at bedtime. · No BM X 3 days-Please administer Dulcoloax suppository X1 at bedtime. · No BM X 4 days-Please administer Fleets enema X1 at bedtime. · Bowel movement documentation will be reviewed by the ,[DATE] charge nurses for each unit and medication administrated per review of the BM record for each resident. · All laxatives will require documentation on MAR (Medication Administration Record) for that resident. The resident ' s Mar for the above documented dates were reviewed as well as the nurses ' notes for interventions of the bowel protocol given to the resident as needed. The surveyor found no documentation of the bowel protocol being followed for the above documented dates. The administrative staff was notified of the above documented findings on [DATE] at approximately 3 pm by the surveyor. No further information was provided to the surveyor prior to the exit conference on [DATE]. 6. The facility failed to change a PICC (Percutaneous Indwelling Central Catheter) line dressing change as ordered by the physician for Resident #25. Resident #25 was readmitted to the facility on [DATE]. The resident had the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE], Resident #25 was coded as having a BIMS (Brief Interview for Mental Status, an assessment tool) score of 0 out of a possible score of 15. The resident was also coded as being totally dependent on 2 or more staff members for personal hygiene and bathing. This resident was added to the survey sample due to the investigation of a complaint in which the resident was found to be in that the Office of Licensure and Certification obtained on [DATE] by an anonymous staff member. The surveyor reviewed the clinical record of Resident #25 on [DATE]. The surveyor noted that on the monthly physician orders [REDACTED]. The surveyor also reviewed the Treatment Administration Record (TAR) for the month of August, 2016. It was noted that on [DATE] and [DATE], LPN #10 initialed these dates that indicated the PICC line dressing change for that date was performed. During investigation of this complaint, the QA (Quality Assurance) nurse #1 was interviewed on [DATE] at approximately 2:30 pm by the surveyor in the conference room. The QA nurse #1 was asked by the surveyor if she knew anything about an allegation of wound care nurse not providing proper treatment LPN #10. The QA nurse #1 stated I know that I did staff education on proper documentation when providing wound care. I can go to my office and get the in service training that I did on this. QA nurse #1 returned to the conference room with the sign in sheet and in service training that was provided to the staff on [DATE]. The corporate nurse was interviewed by the surveyor on [DATE] at approximately 2:45 pm in the conference room. The surveyor notified the corporate nurse of the above documented allegation that was called into our office. The corporate nurse stated that there was a complaint called into the corporate hot line on this and stated let me go and look into the documentation concerning this matter. The QA nurse #1 returned to the conference room at approximately 3:30 pm and stated this is the documentation of the complaint that was called into the corporate hot line. The surveyor reviewed the documentation that was received from the facility. The following documentation was noted: On [DATE], it was brought to my attention that resident ____ (name of resident) family member stated her PICC line dressing was not changed. _____ (name of nurse) .signed out for the dressing change as being done and completed. On [DATE] _____ (name of nurse) stated she was sick and another nurse was going to change for her but the dressing was not performed. The PICC line was completed on [DATE] by the treatment nurse immediately. The administrative staff was notified of the above documented findings on [DATE] at approximately 2:50 pm. No further information was provided to the surveyor prior to the exit conference on [DATE]. COMPLAINT DEFICIENCY 7. During medication pass observation the facility staff failed to follow physician orders [REDACTED].#14. Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Resident #14's minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE] assessed him to understand and could be understood. He was assessed to have as cognitive status of 12 out of 15. His assessment revealed in section G, he needed assistance with daily activities of living. On [DATE] starting at 7:51a.m., the surveyor observed LPN #1 administer Resident #14 ' s morning medications. During the medication pass the LPN#1 administered Calcium 500 mg one by mouth. The surveyor observed the bottle that the medication came from; it read calcium 500 mg. During physician order [REDACTED]. LPN #1 administered Calcium 500 mg. The surveyor returned to the medication cart and asked LPN #1 to look at the Calcium bottle and the order. She stated I thought it had vitamin D2 in it. On [DATE] at 3:55 pm, the surveyor discussed the above medication pass observance with the administrator, director of nurses and other administrative staff. Prior to exit, no further information was provided by the facility staff related to the medication error. 8. For Resident #5 the facility staff failed to follow physician orders [REDACTED]. Resident #5 was admitted to the facility [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #5's clinical record revealed on the most recent minimum data set (MDS) with an assessment reference date of [DATE], the facility staff assessed the resident to understand and usually to be understood. She was assessed to have a cognitive summary score of 03. Review of Resident #5 ' s physician's order [REDACTED]. The medication was not given for the entire 45 days. On [DATE] at 3:35 pm, the quality assurance nurse (QA) nurse was asked why the vitamin had not been given for a full 45 days as ordered. Looking at the chart she said I don ' t see a discontinue order, I will check why it wasn ' t given. She then told the surveyor someone has stopped the vitamin without an order. On [DATE] at 3:55 pm, the surveyor discussed the above medication error with the administrator, director of nurses and other administrative staff. Prior to exit, no further information was provided by the facility staff related to the medication error.

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, the facility staff failed to honor the advance directive of 1 of 3 residents in the survey sample (Resident #1). Regardless of the interview where CNA #1 described the resident as color ashey gray/teeth outside mouth/no sign of breathing/cold, as the first person on the scene, CNA #1 failed to implement faciltiy policy and procedure which required her to begin CPR and call for help. The findings include: The facility staff failed to honor the advance directives for Resident #1 by failing to perform cardiopulmonary resuscitation (CPR). The certified nursing assistant (CNA#1) and licensed practical nurse (LPN#1) performed duties outside their scope of practice by failing to determine code status and failing to initiate CPR. The resident expired in the facility on [DATE]. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) with a reference date of [DATE] assessed the resident with a cognitive score of 14 of 15. The resident was assessed requiring extensive assistance of 2 persons for bed mobility, transfers, dressing, eating, toileting, bathing, and hygiene. The clinical record was reviewed. The admission physician orders [REDACTED]. The clinical record contained a form for Advance Directive Acknowledgement. The form identified the resident not having executed an advance directive. The admission care plan dated [DATE] contained a problem listed the resident was a Full Code with goal the resident's wishes would be honored. The clinical record contained a full page notation the resident was a FULL CODE. Nursing note by RN#1 reflected called to room @153 by C.n.a. noted (res name) in bed non responsive with head of bed at approx 30 degrees elevation ,upon auscultation no breath sounds heard, no heartbeat felt or heard for over 2 minutes. MD notified, DON notified and Family notified. Written on ,[DATE] 2:26am. Next note was written on addendum [DATE] at 12:10 p.m. Same nurse RN#1 wrote, resident full-code status, however resident showed no signs of revivable life, res mottled, cool to touch, CPR not initiated to resident at this time . The surveyor interviewed nursing staff on both units upon arrival to the facility on [DATE] at 12:00 p.m. The nurses identified as LPN#2, #3, and #4 answered the code status for each resident was located in the front of the resident chart and also could be found on the Medication Administration Record [REDACTED]. The administrator provided written statements from the staff present on the night Resident #1 expired. The CNA#1 statement dated [DATE](sic) stated she had checked the resident between 12 and 1230 and offered a drink of water and found him dry at the time. CNA#1 stated between 130 and 2 :00am she went to check another resident and looked in Resident #1's room and went to get nurse and called the supervisor. The interview conducted by the administrator contained quotes, Knew he had been dead for awhile when saw him. When you've been doing this as long as I have you just know. CNA#1 described the resident as color ashey gray/teeth outside mouth/no sign of breathing/cold when I went in. The written statements did not contain a statement from the nurse on the unit (LPN#1). LPN#1 was interviewed via telephone on [DATE] at 7:50 p.m. LPN#1 stated she did not know the resident's code status and did not check it. LPN#1 stated she was called to the room by CNA#1 and stated the resident was dead with no pulse or respiration and she did not initiate CPR. LPN#1 stated the CNA went to get the supervisor and she stayed with the resident until the supervisor (RN#1) arrived. LPN#1 stated she then left and went back to the desk. RN#1 was interviewed via telephone on [DATE] at 12:15 p.m. RN#1 stated she was called on the phone by CNA#1 on the other unit and told the resident had died . RN#1 stated she went to the resident's room and LPN#1 was walking down the hall. RN#1 stated LPN#1 stated to Just go pronounce. RN#1 stated she assessed the resident and determined CPR was not warranted and did not initiate CPR because it was too late. RN#1 stated the CNA told her she had told LPN#1 about the resident ,[DATE] minutes earlier. RN#1 stated she notified the physician, director of nursing, and family. The administrator provided the facility policy on Code Arrest- Procedure and Protocol. The policy stated to ,assess need to call a code. This was explained as whether the resident was a DNR or Full code. The interventions included the first person on the scene will begin CPR and call for help. Continue until otherwise directed by physician or relieved. The administrator provided evidence all the staff were currently certified to perform CPR. She provided certificates of CPR certification for RN#1, LPN#1 and CNA#1. The administrator, director of nursing, and regional director of clinical services nurse were informed of the findings on [DATE] at 10:30 a.m. This is a complaint deficiency.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property were immediately reported to the administrator of the facility and to the other officials in accordance with Federal and State requirements for 8 of 37 residents (Residents #6, 1, 35, 34, 29, 33, 30, and 31). This resulted in immediate jeopardy and substandard quality of care. Findings: 1. Facility staff failed to ensure that allegations of abuse for Resident # 6 were reported & investigated. The MDS (minimum data set) assessment date 12/3/12, coded the resident with slight cognitive impairment, but noted she usually understands staff and is usually understood by staff. The resident needed assistance with all the ADLs (activities of daily living) with the exception of eating. She could feed herself independently with set-up assistance and oversite from staff. The CCP (comprehensive care plan) updated 12/12/12, directed staff to assist with ADL care and incontinence care. On 2/27/13 at approximately 10:00 AM, members of the survey team interviewed Resident #6 about her life at the facility. Resident #6 told the surveyors that she needed to use the bedpan sometime and sometimes they (nursing staff) get here on time and sometime they don't. The resident said she didn't drink a lot because it took so long to get a bedpan. Resident # 6 said sometimes it took them up to two hours to get there and said one staff member had come in to check on her and told her, "You'll have to hold it!" The resident raised her voice at this juncture and said the CNA #10 (who she identified by name) said she had too many patients to help her. Resident #6 stated, "That made me feel like a dog." She went on to say she didn't know why anyone would treat her so ugly when she always tried to be nice to people. On 2/27/13 at approximately 7:15 PM, the DON, administrator and corporate staff members were called in to inform them of Resident #6's allegation. The DON said she would immediately investigate the matter and report back to the survey team in the morning. On 2/28/13 at 11:05 AM, the DON brought the results of #6's abuse allegation investigation in to share her findings. The DON said she had implemented the facility's abuse protocols and began her investigation the night before. After interviewing several staff members and the resident, the DON said they had decided that the resident was repeating statements that were inaccurate and CNA #10 that was accused of the verbal abuse had not worked night before last (2/25/13) as Resident #6 claimed, but she had worked on Sunday 2/24/13. The DON did say CNA #10 was suspended until the investigation was completed. The DON also added the resident was known to be "combative with staff" and had statements from CNA #10 that the resident had been combative with her about two weeks ago and the resident had refused to let her help her and even tried to pull her hair. CNA #10 statement reported these incidents happened about two weeks ago. The DON had not reported the allegations to the State OLC, Adult Protective Services or the Ombudsman. When asked about her reporting process the DON stated, "I have ZERO tolerance for verbal abuse in this facility. I terminated a CNA 2 weeks ago for verbal abuse." The DON was asked for her report on this incident which she went to her office and retrieved and brought back to the surveyor. The date of the occurrence was 2/8/13 and it was written up on a personnel consultation form. The CNA (CNA #14) had been written up and terminated due to a report called into the DON by the instructor of a class of CNA students. The CNA students had overheard CNA #14 yelling "son of a [***] " and cursing Resident #29, telling her to "get the f@#k in the bed!" The instructor told the DON that the students checked the resident and she was soaked, upset, tearful, and agitated when CNA #14 left the room. The DON was asked if she reported the 2/8/13 incident to the state survey agency and she said, "No, I didn't think it rose to the level of what I'm supposed to report." The DON was informed all allegations of abuse were to be reported immediately to the state agency. The DON said that was not in their policy, that only substantiated allegations were supposed to be reported. The surveyor pulled the facility's "ABUSE PREVENTION POLICY & PROCEDURE" that was provided the prior day by staff members. The DON went to the section on "reporting" and discovered that the facility had not provided this part of the policy to the surveyor. Only 7 pages of a 10 page policy had been provided. The last three pages which comprised the facility reporting policies were received by the survey team on the evening of 2/27/13. Upon review the next morning it was determined the facility policy made no provisions for the immediate reporting of allegations of abuse to any agencies or that any allegation that was not substantiated had to be reported at all. On 3/1/13 at approximately 9:00 AM the survey team met and discussed immediate jeopardy and substandard quality of care in the area of abuse prevention with two tags (F225 and 226) cited in the one area of Resident Behavior & Facility Practice. The survey team reviewed and discussed the survey findings regarding abuse prevention. After consulting supervisors at the state agency, the survey team determined that residents at the facility were in immediate jeopardy and substandard quality of care due to the facility's failure to ensure that allegations of abuse were consistently reported to the administrator and required agencies; allegations investigated; and develop and implement abuse policies and procedures in congruence with Federal and State regulations. The facility administrator, director of nursing, and corporate director of clinical services were notified of the immediate jeopardy status (scope/severity of widespread, level 4*) on 03/01/2013 at 11:28 a.m. The survey team at this time advised the administrator to develop/present a plan of removal for the immediate jeopardy status. On 03/05/2013 at 4:24 p.m. the administrator presented a plan of removal for review by the survey team. The facility's plan of removal for the immediate jeopardy included the following interventions: a) The provider implemented abuse policies involving five residents identified at risk for abuse. This included assessing residents, notifying the responsible parties, physicians, Ombudsman and the state agency. Investigations were completed by the administrator, DoN and Regional Director of Clinical Services. b) Prior to the acceptance of the provider's plan for removal, they notified the state agency, adult protective services, ombudsman, and the local police department of the allegations of potential abuse for the five residents. c) The facility policy was revised on 3/1/13 to include the immediate reporting (means as soon as possible, but not exceed 24 hours after discovery of the incident, in absence of a shorter state timeframe requirement) of any allegation to the department of health. The policy included conducting audits regarding other residents, incident reports, and grievance logs. In-services were conducted with staff with a plan to in-service other staff. A monitoring protocol was implemented by the administrator with steps to protect residents when there is an allegation of abuse. Attached to the plan of removal was the facility's Abuse Prevention Policy and Procedure. The following was included under the procedure: 2. Definitions Abuse, Institutional Abuse, Mental Abuse, Physical Abuse, Sexual Abuse, Verbal Abuse, Involuntary Seclusion, Misappropriation, Neglect 3. Abuse Awareness 4. Employment Practices Policy 5. Resident to Resident Abuse Policy 6. Reporting/Investigating/Response Policy 7. Prevention Through QA Policy The survey team reviewed the plan of removal and accepted the plan with removal of the immediate jeopardy status on 03/05/2013 at 4:24 p.m., reducing the scope and severity level of the remaining deficient practice to widespread, level 2. 2. The facility staff failed ensure that allegations of abuse For Resident #1 were reported & investigated. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the clinical record indicates she was not receiving any antipsychotic medications when she was initially admitted to the facility. The MDS (minimum data set) dated, 12/3/12 coded the resident with some cognitive impairment and difficulty focusing her attention. She needed staff assistance with all the activities of daily living and oversite to eat. The resident was coded as continent of bowel. She was not coded for the use of an antipsychotic or the [DIAGNOSES REDACTED]. The resident's CCP (comprehensive care plan) documented the resident with [MEDICAL CONDITION] and the daily use of hypnotics ([MEDICATION NAME] 7.5 mg at bedtime). She was not careplanned for the use of an antipsychotic medications, nor were there any indications in her care plan that she had any behaviors that would warrant the use of [MEDICATION NAME]. On 3/1/13 at 4:45 PM LPN # 9 reported to the survey team that she had reported allegations of verbal and physical abuse against three residents several weeks prior--but could not remember the exact dates. LPN #9 said that one evening (approximately the first week of February) Residents #1, #6, and #31 had all reported that CNAs #9 and #10 were too rough with them and tossing them around while getting them ready for bed on second shift. LPN #9 stated, "Resident #1 told me to keep that beady-eyed devil away from me (referring to CNA #10." The LPN described the resident as angry and agitated and said she had been combative with the CNA in question. (Coincidently, this is about the same time this resident's [MEDICATION NAME] (antipsychotic) was doubled by the physician because she was combative with staff.) LPN #9 said she thought that was unusual that all three residents reported rough handing in the same evening that she reported it to the RN supervisor. LPN #9 stated, "(Name of RN #3) said write the statement and give it to me. Don't say anything to the CNAs. She said she would give the report to the DON." LPN #9 said the two CNAs continued to work that night. LPN #9 stated, "Personally, I think they should have been taken off the hall." LPN #9 said the next time she came in, she saw the DON and the administrator out in the hallway and asked them what they had done about the report she had made on CNAs #9 & #10. LPN #9 said the DON said she hadn't heard anything about it. The administrator said, "We'll get to the bottom of it." LPN #9 said nothing was ever done about it that she knew of. The two CNAs continued to work their schedules uninterrupted. LPN #9 said on another occasion she heard CNA #10 yelling at a resident "clear down the hall." I was at room [ROOM NUMBER] and heard CNA #10 yelling all the way down in room [ROOM NUMBER], "I do not have time to keep taking you to the bathroom!" LPN #9 said she told CNA #10 to take a break and later counseled her that can't yell at the residents. This incident was never reported and the abuser continued to work the same shift. On 3/6/13 at 9:00 AM two CNAs #12 and #15 were interviewed about Resident #1's behaviors. CNA #15 stated, "She's a little sleepy today. Normally she's more talkative. Sometimes she does get confused and angry at times. I just talk to her or back off and give her some space. It just makes residents angrier if they want to be left alone and you continue to try to do something with them." CNA #12 stated, "Awh, she's just a sweetie pie. She does get confused from time to time. If you take your time working with her and explain what's going on she doesn't get upset though." At 3/1/13 at approximately 5:30 PM the administrator, DON and corporate staff were informed of the aforementioned findings of verbal and physical abuse against resident #1, #6 and #30. The administrator and DON said this is the first they had heard of these allegations. The administrative staff said that they would immediately suspend the staff members against whom the allegations had been made and launch investigations into same. On 3/5/13 the following statement regarding the abuse allegations made by Resident #1 was made available to the surveyors as part of the facility's plan of compliance: "Name of Resident #1....was assessed on 3/1/13 and no signs or suspicious area indicating abuse was noted. This allegation was reported to the Virginia Dept. of Health via fax on 3/2/13. The resident is alert with confusion and unable to hold a conversation thus unable to give any witness statement. The family was contacted by Social Services on 3/1/13......physician was notified of possible abuse on 3/1/13. The local police were notified on 3/2/13 by the administrator. The Ombusdsman was notified....3/3/13.....Adult Protective Services was notified on 3/4/13 at 4:20 PM. An investigation was completed by the administrator, director of nursing, regional director of clinical services and the director of clinical services for this allegation." 3. For Resident #35, the facility staff failed to investigate and report to the appropriate agencies, a physical altercation (possible abuse) between Resident #35 and Resident #34. On March 4, 2013, during an extended survey of substandard quality of care in the area of abuse, the survey team reviewed the facility's 24 hour report sheets. The 24 hour report sheets identified that on 2/21/13 Resident #35 grabbed Resident #34's arm. The 24 hour report sheet identified that Resident #34 required an X-ray of her right arm. Resident #35 was an [AGE] year old male who was originally admitted on [DATE] and readmitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) located in the clinical record was a Quarterly MDS assessment with an Assessment Reference Date (ARD) of 1/1/13. The facility staff coded that Resident #35 had short and long term memory loss (1/1) and was severely impaired (3) with daily decision making regarding Activities of Daily Living (ADL's). The facility staff also coded that Resident #35 required extensive (3/3) to total nursing care (4/3) with ADL's. On March 5, 2013 at 10:45 a.m. the surveyor reviewed Resident #35's clinical record. Review of the clinical record failed to produce documentation that a physical altercation (possible abuse) between Resident #35 and Resident #34 occurred on 2/21/13. On March 5, 2013 at 4:55 p.m. the survey team met with the Administrator (Adm), Director of Nursing (DON), two Corporate Compliance Nurses and the Regional Director of Clinical Services. The surveyor asked the Administrative Team (AT) if the physical altercation (possible abuse) between Resident #35 and Resident #34 had been investigated or reported to the appropriate agencies. The DON stated, "No." No additional information was provided to the survey team prior to exiting the facility as to why the facility staff failed to investigate and report a physical altercation (possible abuse) between Resident #35 and Resident #34. 4. For Resident #34, facility staff failed to report and investigate a resident to resident altercation and to report an injury of unknown origin and the results of the investigation of its source. Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident scored 0 on the BIMS on the quarterly MDS assessment with ARD 1/28/13. The resident was added to the survey sample for abuse prohibition review. The 24 hour reports indicated that Resident #34 was grabbed by another resident on 2/21/13. A nurse's note dated 2/21/13 stated the resident was grabbed by another resident and no visible injuries. A note dated 2/22/13 indicated the resident had a dressing over the right arm skin tear. The director of nursing (DON) reported that neither the attack nor the skin tear had been reported or investigated. During an interview on 3/5/13, CNA #1 reported that she had not witnessed the attack on 2/21, but was called to the lobby after the incident to remove the resident who grabbed Resident #34. She stated that the resident was crying and saying her arm hurt. CNA #1 said she had never seen either resident involved in an altercation. LPN#14 stated that she heard the other resident yelling in the lobby and she went to the lobby and found LPN#13 with Resident #34. She did not see evidence of injury. The nurse who wrote the note about the skin tear reported to the DON that she had written that note on the wrong record. LPN#14 stated that the skin of the resident's arm was intact, with no sign of a recent skin tear. While reviewing the clinical record, the surveyor noted a chest Xray report dated 10/3/12. The report stated that there were no signs of infection, but there was evidence of an old, incompletely healed humerus fracture. LPN #14 did not know about a fracture, so the surveyor asked ADMIN #5 if the report appeared to represent an incidence of injury of unknown origin. She acknowledged that it did appear to be an injury of unknown origin. The surveyor asked the DON on 3/5/13 if she had reported or investigated the injury. She replied that she had not. On 3/5/13 at 3:45 PM, the DON produced a hospital emergency department record dated 6/5/12 (prior to admission to the facility) for treatment of [REDACTED]. She did not know when the facility had received the report. Neither she or the physician had documented the origin of the fracture. 5. For Resident #29, the facility staff failed to thoroughly investigate and report an allegation of verbal abuse to the appropriate state agencies within 5 days. Verbal abuse was substantiated by the facility on 2/11/13. C.N.A. #14 was terminated 2/11/13. The Virginia Department of Health was notified of the verbal abuse on 3/1/13. Adult Protective Services was informed of the verbal abuse on 3/4/13. Resident #29 was admitted to the facility 4/9/12 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #29's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/13/13 assessed the resident with a summary score of 00 out of 15. Section C0700 Short Term Memory revealed resident was coded for short term memory problems as a 1. Section C0800 Long Term Memory revealed resident was assessed with [REDACTED]. Section C1000 Cognitive skills for daily decision making assessed Resident #29 as 3-severely impaired-never, rarely made decisions. Section E0200 Behavioral Symptoms-Presence & Frequency did not reveal evidence of symptoms or frequency during the 7 day look back period of 2/7/13 through 2/13/13. All entries were coded "0"-behavior not exhibited. Section E0800 Rejection of care-Presence & Frequency was also coded "0"-behavior not exhibited. During the off-site preparation for the facility on 2/25/13, the surveyor noted there were no FRIs (facility reported incidents) from the last survey with an exit date of 3/14/12 to 2/25/13. The surveyor reviewed a copy of the facility "CONCERN/COMMENT" log on 2/26/13. The log revealed eight (8) areas that included: 1. Date Received 2. Resident Name 3. Room # 4. Name & Relationship of Person Filing C/C (concern/comment) 5. Date of Event 6. Person Investigating 7. Date Resident/Family Informed 8. Disposition The concern/comment log revealed an entry dated 2/8/13; the resident identified was Resident #29; the room # will be omitted for reasons of privacy; the name of the person filing the C/C (concern/comment) was DON (director of nursing); date of event was 2/8/13; the person investigating was listed as the director of nursing; and the date resident/family informed was 3/1/13. The surveyor discussed the incident of 2/8/13 with the director of nursing and the director of clinical services on 3/6/13 at 10:15 a.m. The director of nursing stated she received a call from the student nursing assistant's instructor on 2/8/13 that an employee had been overheard cursing Resident #29 in her room and outside of Resident #29's room. The DON stated the student nursing assistants heard an alarm going off and heard the cursing and told their instructor. The DON stated the nursing assistant instructor called her at the facility after the students returned to school that day. The DON stated she pulled the certified nursing assistant #14 into her office and suspended her. The DON stated "I removed the harm; I suspended her. She didn't come back after that. She was terminated." The DON provided the surveyor the facility investigation of the verbal abuse allegation involving Resident #29. The investigation of the verbal abuse was found on a form titled "PERSONNEL CONSULTATION FORM." The form included the date of the occurrence 2/8/13 and the date of counseling 2/8/13 at 11am. The form also revealed the employee's name C.N.A. #14. Listed on the form was the Department/Supervisor. The DON was listed here. Suspension was checked and the number "3" was listed for # of days of the suspension. The form contained the supervisor's description of the occurrence and read: "C.N.A. students /instructor reported alarm sounding in resident's room ____ (number omitted for privacy reasons) employee (C.N.A. #14) stated "Son of a b_____"; entered room et (and) told resident "get the f_____ in the bed." Instructor stated students changed brief stating resident was soaked, upset/tearful, ? (increased) agitation p (p with a line over it meant after) above employee (C.N.A. #14) left room." Name of witness was left blank. The "Response of Employee" read "Stated she had said "son of a b____" in front of C.N.A. students et (and) entered room stating "get back in bed." Also stated she had changed resident prior to leaving resident's room." Corrective Action Taken: "Suspension x 3 days, employment pending investigation. Instructed employee of RANMP, patient's rights, preventing abuse et (and) neglect as per orientation et (and) Grace policy using standards." The form was signed by C.N.A. #14 on 2/8/13. The form was signed by the DON on 2/8/13. The form was signed by the administrator 2/11/13. "Resident Interview" attached to the "PERSONNEL CONSULTATION FORM" dated 2/8/13 read "Can you tell me what happened?" The entry below read "Resident not interviewable d/t (due to) dementia." This form was signed by the DON 2/8/13 11 am. A note attached to the "PERSONNEL CONSULTATION FORM" was dated 2/8/13 and read "Spoke with other #13 at _____ (name of school and number provided but omitted due to privacy issues). She stated she was not in the room but students relayed that this employee (C.N.A. #14) had cursed outside of the resident's room." Signed by the DON. A second "PERSONNEL CONSULTATION FORM" dated 2/11/13 was completed by the DON. Termination was marked and the comments under supervisor's description of occurrence read "See previous consultation form et (and) spoke with nursing instructor." Corrective action taken read "Termination of employee." Signed by the DON and dated 2/11/13. The surveyor was provided a form titled "SUMMARY OF INVESTIGATION" dated 3/4/13 and read "Re: Resident #29 On 02/08/13, the facility was alerted of an allegation of verbal abuse involving resident #29 and a staff member. As a result, the facility immediately initiated its Abuse Protocol and began an abuse investigation of a resident. The staff member involved was immediately suspended (2/8/13). Conclusion: As a result of the facility's investigation, this allegation of verbal abuse is substantiated. The staff member was terminated on 2/11/13. Sincerely, administrator's name." Attached was a "Notification Checklist (Maintain with Investigative File)." The individual notified and the date/time were listed and were as follows: The Administrative or Nursing Supervisor on Duty and the DON were informed 2/8/13 at 11:00a.m. The Administrator was informed of the incident on 2/8/13 at 11:15 a.m. The Human Resource Department was notified on 2/8/13. The RDCS (regional registered nurse) (administrative #5), the medical director, the social worker and the care plan coordinator were notified on 2/27/13 at 7 p.m. The State Health Department was faxed 3/1/13 at 2:56 p.m.-seventeen (17) days after the allegation of verbal abuse was substantiated (2/11/13). The police were notified on 3/2/13 at 4:00 p.m. The ombudsman was notified 3/3/13 at 3 p.m. APS (adult protective services) was informed of the verbal abuse on 3/4/13 at 4:20 p.m.-twenty days after the incident of verbal abuse was substantiated and the employee terminated on 2/11/13. The responsible party was notified 3/4/13 at 4:45 p.m. The C.N.A. abuse registry was informed on 3/4/13 at 5:10 p.m. The Facility Reported Incident (FRI) revealed a report date of 3/1/2013 and the incident date of 2/8/2013 and read "Alleged inappropriate language used by Certified Nursing Assistant outside of resident room and possibly in the resident room on February 8th, 2013. Certified Nursing Assistant was suspended pending investigation on February 8th, 2013." The surveyor interviewed the social worker on 3/5/13 at 1:45 p.m. The social worker described the events of 2/8/13. She stated if the issue was on her concern/comment log, she would do something about it. The social worker stated the C.N.A. instructor spoke with either the DON or the ADON. "I found out about the allegation of verbal abuse after you all (the surveyors) arrived. I have very little contact with APS (Adult Protective Services)." The surveyor asked if the allegation of verbal abuse had been reported to APS. "No. I didn't report it." The surveyor asked the social worker if she was a mandated reporter. The social worker responded "Yes I am. I am the voice of these people." During the interview with the DON on 3/6/13, she was asked if the allegation of verbal abuse was reported to any state agencies. "No. I thought I fixed the problem when the C.N.A. was terminated." No further information was provided prior to the exit conference on 3/7/13. 6. The facility staff failed to thoroughly investigate an injury of unknown origin for Resident #33. Resident #33 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with a reference date of 2/1/13 assessed the resident with a cognitive score of "7" of "15" . The resident was assessed requiring extensive assistance of 2 persons for bed mobility and transfers. The resident was identified through review of the facility 24 hour reports to being sent to the hospital for a complaint of pain and swelling in the right arm which had been previously fractured prior to admission to the facility. The director of nursing (DON) was asked on 3/5/13 at 9:100 a.m. for any investigation into the injury to the right arm. The DON stated no investigation was done because the arm was not broken and this was not a new fracture. The clinical record for Resident #33 was reviewed. A nursing note dated 2/26/13 at 3:27 p.m. noted , "3pm during shift change, cna (name identified) came to nurse to report that resident c/o right arm pain, assessment of resident arm it swollen, painful, and warm to touch, MD ( name)in building and requested to evaluate res. right arm. resident to go out to (hospital name) for evaluation and tx". The hospital emergency room information found in the clinical record was reviewed. The emergency discharge instructions included a [DIAGNOSES REDACTED]. The x-ray reports from the original injury 10/23/12 noted there is "a displaced comminuted [MEDICAL CONDITION] neck and tuberosity of the proximal humerus. There is no dislocation. The scapula is intact. No acute rib fracture". The x-ray report dated 2/26/13 noted there is "an impacted comminuted [MEDICATION NAME] fracture involving the right humeral surgical neck complicated by an oblique spiral fracture involving the proximal right humeral diaphysis. The right humeral head maintains a normal anatomic position with respect to the adjacent glenoid. The right acromioclavicular joint appears to be intact". The clinical record contained a physician progress notes [REDACTED]. notices a clicking noise in arm (R) did not tell anyone till now". The note also stated the right arm was now swollen and tender. The physician assessment was a "? fx (R) humerus" with plan to send to ER as arm is likely pathological & needs repair or procedure". The physician was ill and not available for further interview. The nurse (LPN#16) taking care of the resident on 2/26/13 was interviewed on 3/5/13 at 8:10 a.m. LPN#16 stated Resident #33 offered no complaints of pain prior to assessment at 2:30 p.m. that day. LPN#16 stated the arm was swollen and painful and the resident had no idea how this happened. LPN#16 stated the resident did not exhibit behaviors and did not resist care. A certified nursing assistant (CNA#3) was interviewed on 3//5/13 at 9:00 a.m. CNA#3 stated the resident could use her arm before and move it and place it on her chest to assist with transfers. CNA#3 stated the resident was in bed on 2/26/13 at approximately 2:30 to 3:00 p.m. The resident would not allow the CNA to touch the arm or move it and this was"unusual" for the resident. The CNA stated the resident told her she fell and "bounced twice" and she reported this to the nurse. CNA#3 stated she was "told the arm was broken" by the nurse. The comprehensive care plan was reviewed. The care plan contained written in information dated 2/26/13 the resident had a fractured right humerus on the falls care plan, activities of daily living, and the alteration in comfort care plan indicating this was a new fracture. The director of clinical services was informed of the concern of the change in condition for Resident #33 and the lack of any investigation into that change on 3/5/13 at approximately 2:00 p.m. The administrative staff was informed of the concern during a meeting with the survey team on 3/6/13 at 4:30 p.m. No further information was obtained from the facility prior to survey exit. 7. For Resident #30, the facility staff failed to investigate an allegation of abuse made by the resident until it was reported to the administrative team (administrator, DON, director of clinical services, and regional director) by the survey team. This allegation of abuse had previously been reported to licensed clinical staff employed by the facility. Resident #30 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The residents admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/27/12 was reviewed. Section B (hearing/speech/vision) was coded with all 0's indicating the resident had adequate hearing, did not use a hearing aid, had clear speech, was able to make self understood and had no problems with understanding others. Section C (cognitive patterns) scored the resident 8 out of a possible 15 points. Section E (behavior) was coded to indicate the resident did not have any hallucinations or [MEDICAL CONDITION] and had no physical or verbal behavioral symptoms toward others. Section G (functio

Based on resident interview, staff interview, facility document review and clinical record review it was determined the facility staff failed to develop and implement abuse policies and procedures in congruence with Federal and State regulations regarding the investigations and reporting of allegations of abuse to the appropriate agencies for 1 of 37 residents and failed to implement screening per their policy of new employees for 2 of 5 records reviewed. This resulted in immediate jeopardy and substandard quality of care. Based on the interviews, failure to consistently report abuse to the proper State agency applied to all residents. Findings: On the morning of 2/27/13, prior to meeting with Resident #6, the DON and the SW were both asked about investigations and their process for following up on resident complaints of mistreatment. Both staff members said they had never had to investigate anything in this facility because they had never had any allegations of abuse. On 2/27/13 at approximately 10:00 AM, members of the survey team interviewed Resident #6 about her life at the facility. Resident #6 told the surveyors that she needed to use the bedpan sometime and sometimes they (nursing staff) get here on time and sometime they don't. The resident said she didn't drink a lot because it took so long to get a bedpan. Resident # 6 said sometimes it took them up to two hours to get there and said one staff member had come in to check on her and told her, "You'll have to hold it!" The resident raised her voice at this juncture and said the CNA #10 (who she identified) said she had too many patients to help her. Resident #6 stated, "That made me feel like a dog." She went on to say she didn't know why anyone would treat her so ugly when she always tried to be nice to people. The MDS (minimum data set) assessment date 12/3/12, coded the resident with slight cognitive impairment, but noted she usually understands staff and is usually understood by staff. The resident needed assistance with all the ADLs (activities of daily living) with the exception of eating. She could feed herself independently with set-up assistance and oversite from staff. The CCP (comprehensive care plan) updated 12/12/12, directed staff to assist with ADL care and incontinence care. On 2/27/13 at approximately 7:15 PM the DON, administrator and corporate staff members were called in to inform them of Resident #6's allegation. The DON said she would immediately investigate the matter and report back to the survey team in the morning. On 2/28/13 at 11:05 AM the DON brought the results of #6's abuse allegation investigation in to share her findings. The DON said she had implemented the facility's abuse protocols and began her investigation the night before. After interviewing several staff members and the resident the DON said they had decided that the resident was repeating statements that were inaccurate and CNA #10 that was accused of the verbal abuse had not worked night before last (2/25/13) as Resident #6 claimed, but she had worked on Sunday 2/24/13. The DON did say CNA #10 was suspended until the investigation was completed. The DON also added the resident was known to be "combative with staff" and had statements from CNA #10 that the resident had been combative with her about two weeks ago and the resident had refused to let her help her and even tried to pull her hair. CNA #10 statement reported these incidents happened about two weeks ago. The DON had not reported the allegations to the state agency, Adult Protective Services or the Ombudsman. When asked about her reporting process the DON stated, "I have ZERO tolerance for verbal abuse in this facility. I terminated a CNA 2 weeks ago for verbal abuse." The DON was asked for her report on this incident which she went to her office and retrieved and brought back to the surveyor. The date of the occurence was 2/8/13 and it was written up on a personnel consultation form. The CNA (CNA #14) had been written up and terminated due to a report called into the DON by the instructor of a class of CNA students. The CNA students had overheard CNA #14 yelling "son of a [***] " and cursing Resident #29, telling her to "get the f@&k in the bed!" The instructor told the DON that the students checked the resident and she was soaked, upset, tearful, and agitated when CNA #14 left the room. The DON was asked if she reported this incident to the state survey agency and she said, "No, I didn't think it rose to the level of what I'm supposed to report." The DON was informed all allegations of abuse were to be reported immediately to the state agency. The DON said that was not in their policy, that only substantiated allegations were supposed to be reported. The surveyor pulled the facility's "ABUSE PREVENTION POLICY & PROCEDURE that was provided the prior day by staff members. The DON went to section 6 on "reporting" and discovered that the facility had not provided this part of the policy to the surveyor. Only 7 pages of a 10 page policy had been provided. The surveyor requested the rest of the policy be delivered to her that day. The last three pages which comprised the facility reporting policies were received by the survey team on the evening of 2/28/13. Upon review the next morning it was determined the facility policy made no provisions for the immediate reporting of allegations of abuse to any agencies or that any allegation that was not substantiated had to be reported at all. The facility policy was not in congruence with the Federal and State Laws that applied to the development and implentation of abuse prevention policies. On 3/1/13 at approximately 9:00 AM the survey team met and discussed immediate jeopardy and substandard quality of care in the area of abuse prevention with two tags (F225 and 226) cited in the one area of Resident Behavior & Facility Practice. The survey team reviewed and discussed the survey findings regarding abuse prevention. After consulting supervisors at the state agency, the survey team determined that residents at the facility were in immediate jeopardy and substandard quality of care due to the facility's failure to ensure that allegations of abuse were consistently reported to the administrator and required agencies; allegations investigated; and develop and implement abuse policies and procedures in congruence with Federal and State regulations. The facility administrator, director of nursing, and corporate director of clinical services were notified of the immediate jeopardy status (scope/severity of widespread, level 4*) on 03/01/2013 at 11:28 a.m. The survey team at this time advised the administrator to develop/present a plan of removal for the immediate jeopardy status. On 03/05/2013 at 4:24 p.m. the administrator presented a plan of removal for review by the survey team. The facility's plan of removal for the immediate jeopardy included the following interventions: a) The provider implemented abuse policies involving five residents identified at risk for abuse. This included assessing residents, notifying the responsible parties, physicians, Ombudsman and the state agency. Investigations were completed by the administrator, DoN and Regional Director of Clinical Services. b) Prior to the acceptance of the provider's plan for removal, they notified the state agency, adult protective services, ombudsman, and the local police department of the allegations of potential abuse for the five residents. c) The facility policy was revised on 3/1/13 to include the immediate reporting (means as soon as possible, but not exceed 24 hours after discovery of the incident, in absence of a shorter state timeframe requirement) of any allegation to the department of health. The policy included conducting audits regarding other residents, incident reports, and grievance logs. In-services were conducted with staff with a plan to in-service other staff. A monitoring protocol was implemented by the administrator with steps to protect residents when there is an allegation of abuse. Attached to the plan of removal was the facility's Abuse Prevention Policy and Procedure. The following was included under the procedure: 2. Definitions Abuse, Institutional Abuse, Mental Abuse, Physical Abuse, Sexual Abuse, Verbal Abuse, Involuntary Seclusion, Misappropriation, Neglect 3. Abuse Awareness 4. Employment Practices Policy 5. Resident to Resident Abuse Policy 6. Reporting/Investigating/Response Policy 7. Prevention Through QA Policy The survey team reviewed the plan of removal and accepted the plan with removal of the immediate jeopardy status on 03/05/2013 at 4:24 p.m., reducing the scope and severity level of the remaining deficient practice to widespread, level 2. For additional information relating to this issue, please see F-223 and 225. 2. The facility staff failed to implement the facility policy for screening of new employees by failing to verify current licensure for 1 of 5 employee records reviewed and failing to obtain a sworn statement from 1 of 5 employees. The employee records were reviewed on 3/1/13. Twenty five employee records were reviewed. One licensed practical nurse (LPN) was noted to not have their license checked with the state agency. The facility policy was reviewed for "Pre- employment Screening". Verification of license or certification and identification of previous disciplinary actions or restrictions on license/certification will be obtained for all applicable positions". The LPN was hired on 7/16/12. A copy of their licenses were located in their employee files. The files did not contain information the licenses were checked with the state agency. The human resource officer was interviewed on 3/1/13 and stated she was new to the position and was unable to locate license verification through the state agency. A certified nursing assistant (CNA) hired on 4/3/12 did not have a sworn statement in the employee file. The pre screening policy stated "applicants to indicate whether they have been convicted of a crime and to detail the conviction". The administrative team were informed of the findings during a meeting with the survey team on 3/4/13 at approximately 4:25 p.m.

Based on observation, resident interview, facility document review and clinical record review it was determined the facility staff failed to provide for the highest practicable well-being for 14 of 37 residents (Resident #6, #1, #5, #3, #8, #9, #12, #15, #16, #2, #11, #13, #23, and #14). 1. Resident #6 - (A) staff failed to provide four doses of a physician prescribed anxiolytic medication ([MEDICATION NAME] 1.0 MG) resulting in the development of withdrawal symptoms in the resident. (B) Facility staff failed to assess for pain and provide pain medication for the Resident #6 following a fall which resulted in a fractured spine. (C) Staff also failed to coordinate the resident's care with hospice and (D) failed to follow physician's orders [REDACTED].. 2. Facility staff failed to follow the physician ordered bowel movement protocol for #1 which resulted in constipation and straining to empty the rectal vault. 3. Facility staff failed to follow physician ordered bowel movement protocol for Resident #5 which resulted in signs and symptoms of constipation. 4. Staff failed to follow the physician ordered bowel protocol for Resident #3. 5. Staff failed to follow the physician ordered bowel protocol for Resident #8. 6. Staff failed to follow physician's orders [REDACTED]. 7. Staff failed to follow the physician's bowel protocol for Resident #12 8. Staff failed to coordinate care with hospice for Resident #15 9. Staff failed to provide physician ordered [MEDICATION NAME] for Resident #16. 10. Staff failed to follow the physician's orders [REDACTED]. 11. Staff failed to provide physician ordered TED hose, follow bowel protocol and respiratory policy for Resident #11 12. Staff failed to follow physician orders [REDACTED]. 13. Staff failed to follow physician's orders [REDACTED]. 14. Staff failed to follow MD orders to obtain wkly weights and use pillows under the arms, administer medications ([MEDICATION NAME]) and treatments (for rash) and follow BM protocol for Resident #4. Findings: 1. Resident #6 - (A) staff failed to provide four doses of a physician prescribed anxiolytic medication ([MEDICATION NAME] 1.0 MG) resulting in the development of withdrawal symptoms in the resident. (B) Facility staff failed to assess for pain and provide pain medication for the Resident #6 following a fall which resulted in a fractured spine. (C) Staff also failed to coordinate the resident's care with hospice. (A) Resident #6 was admitted to the facility on [DATE] and had the following current Diagnoses: [REDACTED]. The resident was under Hospice care for chronic pain management of her back and shoulder. The MDS (minimum data set) assessment date 12/3/12, coded the resident with slight cognitive impairment, but noted she usually understands staff and is usually understood by staff. The resident needed assistance with all the ADLs (activities of daily living) with the exception of eating. She could feed herself independently with set-up assistance and oversite from staff. The initial MDS assessment on 9/21/12 after the resident's admission coded the resident as walking with staff and not taking any pain medications at all. The subsequent MDS dated [DATE] coded the resident as "non-ambulatory" and taking pain medications every day. The CCP (comprehensive care plan) updated 12/12/12, directed staff to assist with ADL care and incontinence care. The CCP documented the resident was at risk for side effects r/t use of [MEDICAL CONDITION] medications for anxiety ([MEDICATION NAME]) and stated to observe for changes in status and report. Resident #6 had a current physician's orders [REDACTED]. This was reflected on the MAR (medication administration record). The behavior monitoring report documented anxiety as the reason for [MEDICATION NAME] administration--but did not give the medical symptoms manifested by the resident that were being treated. On 2/26/13 the MAR indicates the [MEDICATION NAME] was not provided to the resident. The medication nurse on duty obtained a telephone order (dated 2/26/13) from the physician stating to hold until available from pharmacy. During the initial tour on 2/26/13 beginning around 5:15 p.m., the surveyor (S 3)and licensed practical nurse #9 observed Resident #6. She was observed in bed with her dinner tray placed on the over the bed table. She had not eaten anything from the tray. She kept saying " I can ' t do hospice. I can ' t do hospice. " She kept repeating this over and over during the few minutes the surveyor observed her during the tour. She was noted to be fidgety, changing position from side to side in bed as if she couldn ' t ' ' get comfortable, her hands were observed to be shaky, agitated, and the tone of her voice was fearful She was observed to be continuously rubbing her oxygen tubing. Her speech was noted to be loud and pressured but understandable. L.P.N. #9 who toured with the surveyor stated Resident #6 had problems with her back and vertebrae, stomach, was incontinent of urine but could use the bed pan and also had a pressure ulcer on the sacrum/coccyx area. L.P.N. #9 also informed the surveyor Resident #6 had had no recent falls and could be interviewed. The following morning at 8:15 AM Resident #6 was interviewed. She was calm and conversational. No signs or symptoms of anxiety or agitation (shaking, fidgeting or fearfulness.) The resident told S-1 that she was feeling much better today than yesterday. She stated, "I felt terrible all day long. I was so jumpy I was CRAWLING OUT OF MY SKIN!" Resident #6 also told the surveyor she was so shaky and nauseated she could not eat the day before. There was no mention in the documentation by nursing staff of her increased symptoms of anxiety or change in status, either on the behavior sheets or in the nursing notes. The physician was not notified of her change in condition. On 3/1/13 at 12:00 noon the MD (medical director) was interviewed in the conference room with the DON in attendance. The MD was asked if the the dosage of [MEDICATION NAME] 1 mg four times daily was not a large dose for someone in this (geriatric) population. The MD said it was a "pretty good dose" but that he would prescribe the right amount to manage a resident's symptoms. When asked if the medication was addictive the MD said that wasn't an issue. The MD said addiction would only be a problem if someone ran out of their medication that shouldn't be an issue because the facility would provide what the resident's needed at this stage of their life. When asked what kind of symptoms would ensue if a resident taking 4 mg of [MEDICATION NAME] a day were to actually "run out." the MD replied that could make a difference. If they missed a couple of doses then they could have some increased anxiety. If they missed four doses they could suffer withdrawal effects from not having the medication. "That could make a difference. You would see some agitation and shakiness." On 3/1/13 at 12:00 noon the DON & MD were informed of the [MEDICATION NAME] being with held from Resident #6 and asked why the medication was not obtained for Resident #6 in a timely fashion. The DON was asked why the nursing staff would get in touch with the doctor to obtain a "hold order" rather than call the pharmacy. There was no additional feedback provided prior to the survey team exit. On 3/5/13 at 9:40 AM LPN #6 was asked about the procedure for obtaining medications when residents ran out of something. LPN #6 said the "regular pharmacy was out of Nashville and had two runs daily. One at around 2 AM and a second around 6 AM. LPN #6 said if the medication were needed any sooner than that, the nurse could tell the regular pharmacy to call the local back-up pharmacy. LPN #6 said the local pharmacy could deliver meds within 1-2 hours of notification and were open 7 days a week. On 3/5/13 at 10:00 AM RN II was interviewed about STAT meds. RN II stated, "The regular pharmacy takes 7-8 hours to obtain medications and I disagree with that, but I have nothing to do with it." RN II said they could get medications from the local pharmacies for "must have" situations, but they had to get permission from the DON to call the back-up pharmacy. RN II said residents had missed doses of medications because she couldn't obtain them in time from the regular pharmacy. RN II checked the STAT box and determined there was no [MEDICATION NAME] 1 mg tablets available for residents. (6.B) Facility staff failed to assess for pain and provide pain medication for the Resident #6 following a fall which resulted in a fractured spine. On 2/27/13 at 8:15 AM Resident #6 was interviewed. She was calm and conversational. No S/S of anxiety or agitation (shaking, fidgeting or fearfulness.) During this interview the resident said she had been up walking and getting therapy when she had first come into the facility. The resident said she had fallen and broken her back a few months ago. She told the surveyor she had not walked since that time. When asked if she had any pain from this injury the resident stated, "I have pain every day. My shoulder and back hurt all the time." The incident and accident reports indicate Resident #6 fell on [DATE] at 11:30 PM. The report states, "No apparent injury." The nursing note follow-up was a "late entry" written the day after the resident fell . On 12/14/12 at 4:34 AM LPN # 9 wrote, "Found on floor next to bed. Stated she fell out of bed. Small bruise on right shoulder. No apparent injuries. Complaining of back pain and right shoulder pain. Started neuro-checks and notified POA.....continue to monitor until next shift....." The resident had a physician's orders [REDACTED]. Even though she complained of pain she was only provided with pain medication on 12/15/12 and 12/18/12. The MAR assessment for pain is documented as "ZERO" pain 12/1/12--12/18/12 12/23 & 12/24 and 12/26-- 28 even though the resident complained of pain and was provided with [MEDICATION NAME] on 12/15 and 12/18/12, 12/24, and 12/26-28. On 12/17/12 the physician signed and dated an order for [REDACTED]. (Hold if sedated.) The [MEDICATION NAME] was then (same day) reduced back, per the family request, to an "as needed" medication. The results of the x ray revealed the resident had moderate compression fracture of L1, age indeterminate. On 12/18/12 the physician wrote an order for [REDACTED]. The orthopedic consult was kept--but the family decided against having the MRI to evaluate the age of the injury, so that remains unknown. The family subsequently canceled the next scheduled ortho consult as well. On 3/1/13, at noon MD and DON were asked what happened to the resident to cause her to be bedfast. The surveyor noted the resident came into the facility and she was walking and was not taking any pain medications, according to their documentation. By December of 2012 she was bedfast and taking pain medication 7 out of 7 days. The MD and DON could not remember any falls or other trauma related to Resident #6 to cause the significant change in condition, but said they would check into it. No additional information was provided prior to survey by the MD. On 3/6/13 at 4:00 PM the DON presented a statement from LPN #9. The statement said the LPN had called the RP and told her of the accident and fall and that she was going to give the resident a [MEDICATION NAME] for her pain. The DON said the nurse did not give the pain medication because the RP wanted her to hold off as long as possible because "the pain medication made her act weird." (6.C) Staff also failed to coordinate the Resident #6's care with hospice. Resident #6's clinical record contained a current physician's orders [REDACTED]. There was no order for hospice noted in this recertification order. On 11/19/12 the physician gave a telephone order for "Hospice consult per family request." On 11/20/12 the physician gave the following telephone order: "May admit to Hospice if it is appropriate." Documentation of the Hospice contact information indicates the resident elected to start her Hospice benefit starting 11/20/12. There was no hospice care plan observed in the clinical record. On 3/5/13 at 9:30 AM LPN #4 was asked about Resident #6's hospice care plan and coordination of services between hospice and the facility staff. LPN #4 looked for the hospice care plan on the clinical record and determined there was not one. LPN #4 stated, "They (hospice) come in and give her a bath. The medication nurse (facility staff) gives her the medications. I would have to call the hospice provider to determine the division of duties." On 3/5/13 at 9:40 AM LPN #6 was asked about Resident #6's hospice care plan and coordination of services between hospice and the facility staff. LPN #6 told the surveyor the hospice staff would come in to check the resident's pain level. "We'll call hospice to make adjustments to pain medications or we can make adjustments to pain medications via our doctor here (name of medical director) Hospice uses their own doc and they change the med orders. When hospice orders meds the nurse on duty (facility) faxes the order to our pharmacy and gets the medication." On 3/5/13 at 10:00 AM RN II was asked about Resident #6's hospice care plan and coordination of services between hospice and the facility staff. RN II checked the clinical record, but did not find the care plan. She stated, "They (hospice) come in 1-2 times a week a check head to toe assessments and CNAs come 2 times a week to give baths and nail care....We have to notify hospice for all changes in treatment. (Name of medical director) has to get approval for medication changes from hospice." At the conclusion of the interviews the surveyor determined that LPN #4 did not know what hospice care entailed. LPN #6 believed medication and treatment changes could be made by both facility staff and hospice. RN II was of the understanding that all medication and treatment orders for Resident #6 must be routed through hospice for approval. On 3/5/13 at 10:15 AM LPN #6 delivered a ream of hospice papers 1 and 1/4 inches deep (approximately 300 pages) and handed it to the surveyor. She stated, "These papers were in medical records and the care plan is in there somewhere.) The surveyor located the hospice care plan on 3/5/13 at 4:30 PM. Since it was not in the active clinical record and not accessible to nursing staff members, it was considered to be, for all intents and purposes non-existent. Therefore, the coordination of care between the two entities was also non-existent. On 3/5/13 at 6:00 PM during an evening exit session, the facility administrator, DON and corporate team were informed of these observations. No additional info was provided prior to exit. (6.D) failed to follow physician's orders [REDACTED]. On 3/5/13 the resident's paper and electronic record was reviewed for the monthly pharmacy reviews. One communication from the pharmacy was observed. This communication was dated 10/23/12 and recommended that the physician discontinue the [MEDICATION NAME]. The physician responded with an order to "D/C [MEDICATION NAME]." This order to discontinue the [MEDICATION NAME] was signed and dated by the physician on 11/27/12. A review of the resident's medication records from 11/27/12 until present indicated the resident was still receiving the [MEDICATION NAME]. It had not been discontinued by the facility nursing staff as ordered by the physician. On 3/6/13 at 4:00 PM the DON was shown the documentation that the [MEDICATION NAME] had been discontinued by the physician and was still being administered by staff. She conceded the medication should have been discontinued on 11/27/12. Two physician's orders [REDACTED]. 1. 10/2/12 the physician ordered [MEDICATION NAME] 750 Mg for 5 days for an upper respiratory infection. This order was documented on the MAR as having been provided on for only four days between 1/3/12 and 10/7/12. No Leaguing was charted as provided on 10/5 12. 2. On 12/29/12 the physician signed and dated a telephone order for Leaguing 500 mg for 10 days for an upper respiratory infection. The MAR records the administration of only 9 doses of Leaguing. None was administered on 12/30 or 12/31/12. On 3/6/13 at 4:00 PM the DON said she had determined the resident had not received the medication in December as it had been ordered. She presented a medication error report dated 3/5/13 to the survey team and said staff would be inserviced on medication administration and the 6 rights of med admin. No additional info was provided prior to the survey team exit. 2. Facility staff failed to follow physician ordered bowel movement protocol for Resident #1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS (minimum data set) dated, 12/3/12 coded the resident with some cognitive impairment. She needed staff assistance with all the activities of daily living and oversite to eat. The resident was coded as continent of bowel. The resident's CCP (comprehensive care plan) gave instructions to staff to assist with ADLs as needed. She required help with incontinence care and personal hygiene. The clinical record was observed to contain a copy of the physician's standing orders with the bowel movement protocol for constipation. The order was signed, but not dated by the physician and the resident. The orders read as follows: "No BM for 2 days admin 4 oz. prune juice times one. No BM for 3 days admin 30 cc MOM po times one. No BM for 4 days admin [MEDICATION NAME] supp P R time dose. No BM for 5 days admin SSE times one. If no results in 6 days notify MD." Resident #1's bowel movement records were reviewed for February. On 2/12/13 the resident was not documented with a bowel movement. Between 2/13/13 and 2/15/13 the resident did not have BM. There was no documentation to support the standing BM protocol was used for days 2 and 3 to provide prune juice or MOM. On 3/6/13 at 9:00 Am CNA #12 said that the resident had a tendency to get constipated. CNA 12 was asked if the resident had any pain while evacuating her bowels. CNA 12 state, "She has to strain pretty hard after several days without a BM. She had pain that one time (no dates given) cos she was constipated. We usually try to set her on the toilet, gravity helps." The administrative team was informed of the findings during a meeting with the survey team on 3/6/13 at 4:00 p.m. The facility offered no further information prior to survey exit. 3. Facility staff failed to follow physician ordered bowel movement protocol for Resident #5. Resident #5 was admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. The latest MDS (minimum data assessment) dated 1/2/13 coded the resident as usually understood and usually understands others--but the mental status interview to determine cognitive patterns was not completed with the resident. The MDS coded the resident as dependent on staff for the accomplishment of all ADL (activities of daily living) tasks. The resident's CCP (comprehensive care plan) updated 1/9/13 documented the resident required extensive assistance with all ADLs to include personal hygiene, eating, and incontinence care. On 3/5/13 the care plan was updated to include "MOM po prn per standing order- see MAR - C/O(complains of) S/S(signs and symptoms) constipation." The clinical record was observed to contain a copy of the physician's standing orders with the bowel movement protocol for constipation. The order was signed and dated by the physician but the date was illegible. The orders read as follows: "No BM for 2 days admin 4 oz. prune juice times one. No BM for 3 days admin 30 cc MOM po times one. No BM for 4 days admin [MEDICATION NAME] supp P R time dose. No BM for 5 days admin SSE times one. If no results in 6 days notify MD." The bowel movement records were reviewed for January, February and March 2013. Resident #5 did not have a bowel movement between 2/26/13 and 3/3/13--a total of 8 days. The only documented intervention provided was one dose of Milk of Magnesia on 3/4/13 at 9 PM. The physician had not been notified. Between 2/12/13 and 2/14/13 the resident did not have a bowel movement. The staff did not provide prune juice. Between 1/23/13 and 1/27/13 the resident did not have a bowel movement. The staff did not administer prune juice, MOM or [MEDICATION NAME] suppository as ordered. The administrative team was informed of the findings during a meeting with the survey team on 3/6/13 at 4:00 p.m. The facility offered no further information prior to survey exit. 4. For Resident #3, the facility staff failed to follow physician orders [REDACTED]. Resident #3, an [AGE] year old female, was originally admitted on [DATE] and readmitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was a Quarterly MDS assessment with an Assessment Reference Date (ARD) of 11/28/12. The facility staff coded that Resident #3 had a Cognitive Summary Score of 6. The facility staff also coded that Resident #3 required extensive (3/3) to total nursing care (4/3) for Activities of Daily Living (ADL's). On February 27, 2013 at 3:30 p.m. the surveyor reviewed Residents #3's clinical record. Review of the clinical record produced "Physician's Standing Orders." The standing orders included, but were not limited to the following order: "Constipation No BM (bowel movement) in 2 days admin. (administer) 4 oz (ounce) prune juice times one No BM for 3 days admin. M.O.M. (Milk of Magnesia) p.o. (by mouth) times one No BM for 4 days admin. [MEDICATION NAME] supp (suppository) P.R. (per rectum) time one No BM for 5 days admin. SSE (soap suds enema) times one If no BM in 6 days notify MD)." (sic) The standing orders were signed by the physician but were not dated; however, the document was revised in May 2012. Continued review of the clinical record produced the "BM with detail." The document revealed that Resident #3 went from February 11, 2013 through February 15, 2013 (4 days), from February 15 2013 through February 18, 2013 (3 days), and from February 20, 2013 through February 23, 2013 (3 days) without a bowel movement. Further review of the clinical record produced the February 2013 Medication Administration Record (MAR's). Review of the February 2013 MAR's failed to document the administration of [MEDICATION NAME] Supp, MOM or SSE during the month of February 2013. On February 27, 2013 at 5:30 p.m. the surveyor notified the Unit Manager, who was a Licensed Practical Nurse (LPN #2), that Resident #3 had physician standing orders for a bowel protocol if Resident #3 did not have a bowel movement. The surveyor notified the UM (LPN #2) that review of the clinical record failed to produce evidence that the facility staff followed the physician ordered bowel protocol. The surveyor reviewed the clinical record with the UM (LPN #2). The UM (LPN #2) was unable to locate and documentation of bowel movements and/or administration for medications for constipation as ordered by the physician. On February 28, 2013 at 4:45 p.m. the survey team met with the Administrator (Adm), Director of Nursing (DON) and two Corporate Compliance Nurses (CCN's #1 and #2). The surveyor notified the Administrative Team (AT) that Resident #3 had physician standing orders for constipation/bowel protocol. The surveyor notified the AT that the facility staff had not followed the orders on multiple occasions in February 2013. No additional information was provided to the survey team prior to exiting the facility as to why the facility staff failed to follow the physician ordered bowel protocol orders for Residents #3. 5. For Resident #8, the facility staff failed to follow physician orders [REDACTED]. Resident #8, a [AGE] year old female was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was a Quarterly MDS assessment with an Assessment Reference Date (ARD) of 1/28/13. The facility staff coded that Resident #8 had short and long term memory loss (1/1) and was severely impaired (3) with daily decision making regarding Activities of Daily Living (ADL's). The facility staff also coded that Resident #8 required extensive (3/3) to total nursing care (4/3) with ADL's. On February 28, 2013 at 9 a.m. the surveyor reviewed Resident #8's clinical record. Review of the clinical record produced "Physician's Standing Orders." The standing orders included, but were not limited to the following order: "Constipation No BM (bowel movement) in 2 days admin. (administer) 4 oz (ounce) prune juice times one No BM for 3 days admin. M.O.M. (Milk of Magnesia) p.o. (by mouth) times one No BM for 4 days admin. [MEDICATION NAME] supp (suppository) P.R. (per rectum) time one No BM for 5 days admin. SSE (soap suds enema) times one If no BM in 6 days notify MD)." (sic) The standing orders were signed by the physician but were not dated; however, the document was revised in May 2012. Further review of the clinical record produced the BM (bowel movement) sheet. Review of the document revealed that Resident #8 went from January 2, 2013 through January 7, 2013 (4 days), January 7, 2013 through January 15, 2013 (7 days), January 19, 2013 through January 26, 2013 (6 days), January 28, 2013 through February 2, 2013 (4 days), February 3, 2013 through February 10, 2013 (6 days) and from February 22, 2013 through February 26, 2013 (3 days) without having a bowel movement. Continued review of the clinical record produced the January and February 2013 Medication Administration Records (MAR's). Review of the January and February 2013 MAR ' s failed to document that Resident #8 received prune juice, MOM, [MEDICATION NAME] supp or a SSE. On February 27, 2013 at 5:25 p.m. the surveyor notified the Unit Manager (UM), who was a Licensed Practical Nurse (LPN #2), that Resident #8 had physician standing orders for a bowel protocol if Resident #8 did not have a bowel movement. The surveyor notified the UM (LPN #2) that review of the clinical record failed to produce evidence that the facility staff followed the physician ordered bowel protocol. The surveyor reviewed the clinical record with the UM (LPN #2). The UM (LPN #2) was unable to locate and documentation of bowel movements and/or administration for medications for constipation as ordered by the physician. On February 28, 2013 at 4:45 p.m. the survey team met with the Administrator (Adm), Director of Nursing (DON) and two Corporate Compliance Nurses (CCN's #1 and #2). The surveyor notified the Administrative Team (AT) that Resident #8 had physician standing orders for constipation/bowel protocol. The surveyor notified the AT that the facility staff had not followed the orders on multiple occasions in January and February 2013. No additional information was provided to the survey team prior to exiting the facility as to why the facility staff failed to follow physician orders [REDACTED].#8. 6. For Resident #9 the facility staff failed to follow physician orders [REDACTED]. Resident #9, a [AGE] year old female was originally admitted on [DATE] and readmitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Date Set (MDS) assessment located in the clinical record was an Annual MDS assessment with an Assessment Reference Date (ARD) of 2/21/13. The facility staff coded that Resident #9 had a Cognitive Summary Score of 9. The facility staff also coded that Resident #9 required limited assistance (2/2) with Activities of Daily Living (ADL's). On February 27, 2013 at 8:35 a.m. the surveyor reviewed Resident #9's clinical record. Review of the clinical record produced a "Telephone Order" dated 1/29/13. The order read ... "[MEDICATION NAME] 4 mg/6 day dose pak F/U c me/1wk RA ([MEDICATION NAME] 4mg/6day dose package follow up with me in 1 week. [MEDICAL CONDITION] arthritis)." (sic) Further review of the clinical record produced the January and February 2013 Medication Administration Records (MAR's). Review of the January and February 2013 MAR ' s documented that the facility staff failed to follow the physician orders [REDACTED]. Review of the January and February MAR's revealed that the facility staff administered one tablet at 9 a.m. on 1/30/13. On January 31, 2013 the facility staff administered 2 tablets at breakfast, 1 tablet at 11:30 a.m. and 1 tablet at 9 p.m. On February 1st and 2nd the facility staff administered 1 tablet at 7:30 a.m., 1 tablet at 11:30 a.m. and 1 tablet at 9 p.m. On February 3, 2013 the facility staff administered 1 tablet at 7:30 a.m. and 1 tablet at 9:30 p.m. On February 4, 2013 the facility staff administered 1 tablet at 7:30 a.m. On February 27, 2013 at 9 a.m. the surveyor notified the Unit Manager (UM), who was a Licensed Practical Nurse (LPN #2), that review of Resident #9's clinical record failed to document that Resident #9 received the physician ordered [MEDICATION NAME] pack as ordered by the physician. The surveyor and the UM (LPN #2) reviewed the clinical record. The surveyor specifically reviewed the January and February MAR's with the UM (LPN #2). The surveyor asked the LPN (#2) how the [MEDICATION NAME] pack was supposed to be administered? The UM (LPN #2) went into her office and looked into a cardboard box and retrieved a document that read ... "Day #1 [MEDICATION NAME][MEDICATION NAME] 4 mg PO 2 tablets before breakfast. Day #1: [MEDICATION NAME][MEDICATION NAME] 4 mg PO 1 tablet after lunch. Day #1 [MEDICATION NAME][MEDICATION NAME] 4mg PO after supper. Day #1: [MEDICATION NAME][MEDICATION NAME] 4 mg PO 2 tablets at bedtime. Day #2: [MEDICATION NAME][MEDICATION NAME] 4 mg PO 1 tablet before breakfast. Day #2 [MEDICATION NAME][MEDICATION NAME] 4mg PO 1 tablet after lunch. Day #2 [MEDICATION NAME][MEDICATION NAME] 4 mg PO 1 tablet after supper. Day #2: [MEDICATION NAME][MEDICATION NAME] 4 mg PO 2 tablets at bedtime. Day #3: [MEDICATION NAME][MEDICATION NAME] 4 mg 1 tablet before breakfast. Day #3: [MEDICATION NAME][MEDICATION NAME] 4 mg PO 1 tablet after lunch. Day #3: [MEDICATION NAME][MEDICATION NAME] 4 mg PO 1 tablet after supper. Day #3 : [MEDICATION NAME][MEDICATION NAME] 4 mg PO 1 tablet at bedtime. Day #4: [MEDICATION NAME][MEDICATION NAME] 4 mg PO 1 tablet before breakfast. Day #4 [MEDICATION NAME][MEDICATION NAME] 4 mg PO 1 tablet after lunch. Day #4: [MEDICATION NAME][MEDICATION NAME] 4 mg PO 1 tablet at bedtime. Day #5: [MEDICATION NAME][MEDICATION NAME] 4 mg PO 1 tablet before breakfast. Day #5 [MEDICATION NAME][MEDICATION NAME] 4 mg PO 1 tablet at bedtime. Day #6: [MEDICATION NAME][MEDICATION NAME] 4 mg PO 1 tablet before breakfast." The surveyor reviewed the document with the UM (LPN #2). The UM (LPN #2) stated that she did not know why the staff had not administered the [MEDICATION NAME] pack as ordered. On February 28, 2013 at 4:45 p.m. the survey team met with the Administrator (Adm), Director of Nursing (DON) and two Corporate Compliance Nurses (CCN's #1 and #2). The surveyor notified the Administrative Team (AT) that Resident #9 had a physicians order for a [MEDICATION NAME] dose pack. The surveyor notified the AT that the facility staff had not administered the [MEDICATION NAME] dose pack as ordered. On March 5, 2013 at 4:25 p.m. the surveyor requested for the Pharmacy Nurse Consultant (PNC) to provide the dosing/administration guidelines for M