Every finding on record at Forest Hill Health & Rehabilitation

Based on Observation, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to maintain an environment that was free from hazards, that each Resident received supervision, and that ongoing monitoring was implemented to prevent accidents and hazards for four (4) Residents (#'s 42, 106, 124, and 130) in a survey sample of 63 Residents, which resulted in Immediate Jeopardy. The findings included: The facility staff admitted Resident #42, #106, #124, and #130 with known substance abuse histories. They continued to use illicit drugs and alcohol, returning to the facility after a leave of absence under the influence of illegal drugs and or/alcohol. There was no evidence that the facility implemented ongoing monitoring or effective interventions to address the ongoing substance abuse. Resident # 42 was sent to the emergency room on more than one occasion for alcohol and drug overdose; Resident #106 was found with alcohol on more than one occasion, sent to the ER for alcohol and drug use, and was also found to have made weapons out of cutlery from his dinner tray; Resident #124 was found under the influence of illicit drugs admitted to being high however when EMS arrived he refused to go to the hospital on the first drug overdose, but was transferred via EMS with the second overdose incident; Resident #130 was found to be under the influence of an illicit substance and admitted to staff that he was high. However, when EMS arrived, he refused hospital transport. 1. Resident # 42 was sent to the emergency room on more than one occasion for alcohol and drug overdose. There was no evidence that the facility implemented ongoing monitoring or effective interventions to address the ongoing substance abuse. Resident #42 was admitted to the facility with diagnoses that included but were not limited to COPD (Chronic Obstructive Pulmonary Disease), bipolar disorder, sleep apnea, hypertension, fusion of cervical spine, heart failure, major depressive disorder, history of venous thrombosis, (blood clot), anxiety disorder and viral hepatitis C. On [DATE] at approximately 1:47 pm, an interview was conducted with Resident #42, who stated that he was given a 30-day notice and had nowhere to go. When asked why he was given the 30-day notice, he stated that someone saw him smoking something at the bus stop (Please note the bus stop is at the end of the driveway to the facility). When asked what he was smoking, Resident #42 stated that he was smoking weed. Resident #42 then added, I did not do it on the property, and I didn't bring it into the facility. When asked if the facility Social Worker was attempting to find his placement elsewhere, he stated that they were. On [DATE] at approximately 10:00 a.m., an interview was conducted with Resident #42, who was asked if he had been taken to the hospital for overdose in the past, and he stated that he had. When asked what substance he uses, he stated, marijuana, cocaine, and sometimes heroin. When asked if he drinks alcohol, he answered that he did. When asked where he gets the substances, he stated, I go out of the facility to get it. When asked if he brought the substances into the facility, he denied using any drugs or alcohol on the property. A review of the clinical record revealed the following excerpts related to non-compliant behaviors with smoking, drugs, and alcohol use: [DATE] 2:43 am-Nurse's Note Text: Resident has smoke vape in room fire alarm was going off panel stated, room [ROOM NUMBER], writer and staff went into room smoke alarm over resident bed was red, resident had a smoke vape in bed and one on the table writer educated about smoking in facility resident stated, He understood. [DATE] 10:49 am - Nurse's Note Text: [Resident #42 name redacted] today to discuss his oxycodone capsules that he gets. We have been opening them up to give them to him. He would like to have another attempt at taking the capsule whole. I am ok with this. He understands that If nursing has any further concerns he will be switched to liquid oxycodone. We also discussed a referral to the pain specialist to ensure he is getting the correct dose. [DATE] 2:13 pm-Nurse's Note Text: I see [Resident #42 name redacted] today due to a report that he may not be swallowing his oxycodone capsule. I am going to switch him to liquid, and he is still awaiting pain management appt. [DATE] 11:31 pm-Nurse's Note Text: Resident is on mouth checks after taking oxycodone. Resident did not complying [sic] with swallowing the pill. Resident held it in his mouth and was told to swallow the pill. Resident then proceed to fake swallow the pill again. NP [Nurse Practitioner] made aware of this behavior order oxycodone HCl Oral Solution 5 MG/5ML. Physician note: [DATE] 9:41 am - I saw [Resident #42 name Redacted] after he was taken to the ER for intoxication. He was found outside of the facility intoxicated and taken to the ER to be evaluated. He eloped from the ED and came back here. He is at baseline, no evidence of alcohol abuse at this time. Unable to obtain drug testing at the ED. All records reviewed; staff notified. Physician Note: [DATE] 1:37 pm -In to see [Resident #42 name redacted] today due to reports of possibly not taking his oxycodone. I am going to change his meds to liquid to avoid any confusion and eliminate the ability for him to cheek or not take the meds. [DATE] 12:45 am- Nurse's Note Text: 6:15 p.m. Writer was notified [sic] that resident was sweating profusely and not really able to hold self-up while sitting on the bed. Writer assessed resident. Resident was sweaty profusely (beads of sweat coming off their head and face). BUE sweaty. Resident could not answer any of the writer's questions. Resident alert, nonverbal. Resident continues to stare off into the distance focusing on the wall in front of them. BP:73/59 P:121 R:16 T:98.8 O2:96% BS:84. 1822 Writer contacted 911. 1821 Supervisor [name redacted] notified. 1823 Supervisor notified NP [Nurse Practitioner name redacted] 1834 EMT arrives at facility. 1844 EMT leaves w/resident. 1939 Resident calls the facility asking how did they get to the hospital? And why is they [sic] at the hospital? Resident also requested that someone looks in there [sic] rm. to see if they left their phone and wallet because they didn't have it on them. Writer put resident on hold. While searching for resident phone and wallet, Writer found a cigarette box (Brand name redacted) that contained a lighter, glass pipe (ends of pipe burned and white residue stained the middle of the [NAME] [sic] pipe), one whole and half of a cigarette that has been lit at some point. Supervisor notified. Physician Note: [DATE] 9:28 a.m. - I see [Resident #42 name redacted] today after him being sent to the ED yesterday for substance abuse and AMS [Altered Mental Status]. He would not admit to what he used to us but in the ED notes he admitted to heroin. I have asked him to provide urine for a drug screen for us if he would like for me to continue to prescribe his oxycodone. This is safety issue. He adamantly refused the drug screen. Physician Note: [DATE] -Patient is a [AGE] year-old male with bipolar disorder, anxiety and polysubstance abuse on Cymbalta Trazodone and most recent Suboxone. He is here for LTC. He is being seen today at the staff request d/t suspected ongoing drug use. Per the DON, patient was on LOA on [DATE] and taken to the hospital because he overdosed on heroin. A review of ED record states that patient admitted to snorting heroin and bystanders called EMS. He was given Narcan and responded immediately. Patient had another ED visit on 11.8.24. EMS found him sitting on the floor at the bus stop and appeared intoxicated and couldn't walk. He was taken to the ED although he resisted, and he refused having any labs done once in the ED and eloped from the ED. He is found in bed asleep and is easily awakened. He says he left the facility and went to see a friend with whom he smoked heroin and was drinking alcohol. He says he doesn't remember when he passed out but remembers being awakened by the EMS. He says he has never used any drugs or used or brought or distributed any alcohol on these premises. He reports h/o personal and family polysubstance use. Polysubstance abuse: very recent use of alcohol and heroin. Couseling [sic] provided against substance use. Patient has continued to refuse any drug testing even here at the facility. Risk of drug use and associated negative impact remains if this patient has access to drugs. Maintain close monitoring. Patient understand that he signed a discharge notice. On [DATE] at 1:00 pm, an interview was conducted with LPN A, who stated that they are aware of the Residents going out on LOA (Leave of Absence) and coming back high, but they could not always be with them and cannot stop them from leaving the facility. When asked what is done if they catch them smoking, drinking, or using drugs in the facility, she stated, We document in the chart, notify the supervisor, and educate them. That is all we can really do. When asked if the care plan should reflect the behaviors and interventions, she stated it should. A review of the care plan revealed the first time the behaviors were addressed were as follows: BEHAVIORS: the resident has admitted behaviors of drug and alcohol abuse when leaving the facility. Date Initiated: [DATE]. INTERVENTION: Notify MD as indicated Date Initiated: [DATE] Referral to inpatient drug abuse recovery center. Date Initiated: [DATE] Revision on: [DATE] 2. Resident #106 was found with alcohol on more than one occasion, sent to the ER for alcohol and drug use, and was also found to have made weapons out of cutlery from his dinner tray. There was no evidence that the facility implemented ongoing monitoring or effective interventions to address the ongoing substance abuse or the formulation of handmade weapons. Resident #106 was admitted to the facility on [DATE] with diagnoses that included but were not limited to a history of multiple medical problems, including a gunshot wound to the head with stroke secondary to injury, hemiplegia, moderate recurrent major depression disorder, seizure disorder, late effect of traumatic brain injury, insomnia, and muscle spasms. On [DATE] at approximately 3:00 pm, an interview was conducted with Resident #106, who stated that he did get caught with beer in the facility. He stated that he goes out of the facility with his girlfriend, and that is when he gets the beer. When asked about being taken to the hospital, he stated that he did go to the hospital a couple of times because of drug and/or alcohol use. Resident #106 stated that the facility offered to try and get him into inpatient treatment, but there were no beds available. A review of the clinical record revealed the following excerpts about illicit drug and or alcohol use by Resident #106: [DATE] 4:30 pm - Nurse's Note Text: Resident found in the shower room on the floor on his left side. Resident stated he fell trying to get on the toilet. This writer with the help of another nurse assist resident from the floor. Resident denied hitting his head. Resident refused neuro checks. Resident alert and oriented x4. Resident had a bottle of beer that this writer took from resident and reported beer to the DON, approximately 3 minutes before fall resident was verbally inappropriate to this writer stating I am hard and I want some pussy, give me some pussy. This writer redirect resident. Resident also stated he is ready to go to the [NAME].NP notified and gave orders for resident to be transferred to ER for evaluation. Change of condition completed, risk management and transfer summer [sic]. NP/RP notified. [DATE] 10:27 pm - Nurse's Note Text: Resident returned from hospital at approximately 4:00 pm via stretcher. Resident was seen for depression, alcohol intoxication, and polysubstance abuse (resident overdosed on [DATE]). No new orders at this time. Resident needs to f/u with MD. Resident s/p fall day 1/3, no c/o pain or discomfort noted. Continues to be safety checks for suicidal or homicidal ideations. [DATE] Physician Progress Note: Per staff, resident fell in the shower room and hit his head; he appears to have altered mental status. Staff assisted him back to his chair and a can of beer rolled out of his chair. Pt insisted on drinking this beer, but staff prevented him from doing so. Pt then left the unit and was found in the middle of the road in his w/c. Staff assisted him back to the facility. He appeared altered, speech was slurred and there a facial droop. Again, another can of beer was found in his chair and patient open the can in an attempt to drink it. Staff intervened. Patient admitted having stolen the beer from the gas station convenience store. He also admitted to have consummed [sic] alcohol, marijuana and cocaine. Per staff he was making inappropriate sexual comments in both incidents. Per staff, drug paraphenalia [sic] (pipe) was found in his possession and taken by staff; he denied feeling suicidal. He was sent to the ED where he tested positive for all substances above. immediately left the unit. [DATE] 4:39 pm -Nurse's Note Text: Writer observed this resident sitting in his wheelchair next to the service elevator sleeping. Writer was able to easily arouse resident but noted slurred speech and a strong odor while speaking with him. Resident was assisted back to his room. Vitals- BP107/68, P: 88, 02: 95% room air. R:10. While writer and another nurse were speaking with this resident, he reported that he consumed Suboxone and alcohol. Notified NP and advised to closely monitor resident for any changes in level of consciousness, respiratory rate and 02 sats and to notify NP/MD immediately. Charge nurse made aware. DON made aware. [DATE] 10:48 am - Nurse's Note Text: He admitted to drinking during the day and then consuming Suboxone. He reports that he got this off the street. Narcan is at bedside, staff aware of frequent checks. Patient then left the building again and did not return until hours later. I educated him on the dangers of this. He is on no other controlled substances that I can discontinue. [DATE] 10:00 am -Nurse's Note Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Abnormal vital signs (low/high BP, heart rate, respiratory rate, weight change) Altered mental status Seems different than usual Talks/Communicates Less Tired, Weak, Confused, or Drowsy Nursing observations, evaluation, and recommendations are: Resident noted in wheelchair, leaning forward onto bed with poor trunk control, blue in the face, excessive drooling, heavy sweating, not easily aroused but responded to sternal rub, resident presented with lethargy stable vitals with the exception of HR and O2sat. when asked what happened, resident was unable to provide a clear answer, NP [NAME] made aware and gave orders to send to ER to eval and treat. [DATE] 8:13 a.m.-Nurse's Note Text: Late entry [DATE] resident returned to the facility with no report given or paperwork. Writer attempted to call hospital, but nurse was busy with another patient. Resident refused vital signs. [DATE] 3:09 pm-Nurse's Note Text: Please describe the behavior demonstrated: Writer was notified by therapy that this resident was seen in his wheelchair around wing 2 with an alcoholic beverage on his person. Staff was able to confiscate an opened alcoholic beverage from him. How often did this behavior occur/last: first occurrence. Describe any interventions attempted: educated on appropriate behavior in a skilled nursing facility setting. placed on one-on-one monitoring & 5-day d/c to be given to resident per facilities RDO (Regional Director of Operations). [DATE] 1:36 pm-Nurse's Note Text: CNA came to nursing station and reported burning smell in residents room. This writer iddmeditely [sic] got up to assess sitatuon [sic]. As walking in resident room, this writer smelt burning smell. This writer asked resident what is the smell? Resident denined [sic] the smell. This writer asked resident asgain[sic] what was he do, and what's burning. Residnent[sic] deined[sic] smelling anything burning and then stated he wasnt doing anything. This writer oserved [sic] a burnt fork with only one tines. Resident took the rest of the tines off the fork pervisuosly[sic] before this incident. This writer called another nurse to assess the satiation. Once nurse arrived this writer went to find The Supervisor on shift. Supervisor confiscated the fork And stated restident [sic] needs to go back on 1:1. Once supervisor left. Resident then immediately transferred to bed out of sight of This writer and other staff. This writer then re-enters the room from standing outside the residents room to observer resident with another fork and lighter on bed and with a weed pipe in his hands. When asked to hand it over resident tried to hid weed pip within his fanny pack. This writer then asked resident to hand over fanny pack. Resident took weed pipe out then then tried to hid weed pipe around his back. Resident was asked to put weed pipe in the fanny pack after placing it in fanny pack this write Confiscated it. Resident was then asked to exit the room to be physical in sight of staff till a sitter was avail Describe any interventions attempted: Confiscated fanny pack with lighter, weedpipe [sic], and fork with only one tines. Resident palaced [sic] on 1:1. Resident siting with sitter no more attmps [sic] to use lighter, weed pipe, or fork it's in supervisor [sic] possession. A review of the care plan revealed the first time the behaviors were addressed were as follows: BEHAVIORS: the resident has drug and alcohol behaviors when leaving the facility and has been caught with alcohol while in the facility. Date Initiated: [DATE] GOAL: the resident's behaviors will cause them less distress through the review period Date Initiated: [DATE] Target Date: [DATE] The resident's behaviors will not cause them or other resident's distress through the review period Date Initiated: [DATE] Target Date: [DATE]. INTERVENTIONS: Referred to inpatient recovery for drug and alcohol abuse. Date Initiated: [DATE] 1:1 activities as needed Date Initiated: [DATE] Explain all procedures to the resident before starting and allow the resident time to adjust to changes Date Initiated: [DATE] Physician review of medications as needed Date Initiated: [DATE] 3. Resident #124 was found under the influence of illicit drugs and admitted to being high; however, when EMS arrived, he refused to go to the hospital on the first drug overdose but was transferred via EMS with the second overdose incident. There was no evidence that the facility implemented ongoing monitoring or effective interventions to address the ongoing substance abuse. Resident #124 was admitted to the facility on [DATE] with diagnoses of acute osteomyelitis, type diabetes, chronic viral hepatitis, hypertension, complications of skin graft, major depressive disorder, chronic kidney disease, and diabetic foot ulcer. On [DATE] at approximately 3:00 pm, an interview was conducted with Resident #124, who stated that he had been unfairly treated by staff due to another Resident stating that he was using drugs. He noted that the facility had no proof of this, and he was being given a discharge notice. When asked if the facility had explained why he was being given the notice, he said they had. When asked if he had been using drugs or alcohol while in the facility, he stated that he had not. A review of the clinical record revealed the following progress notes: [DATE] 4:02 pm - Nurses Note Text: Resident left facility at 7 AM. Resident did not return to facility until 11 AM. on resident arrival he reported to this writer and stated he was having chest pains, stomach pains, and that he could not breathe and that he wanted to go to the hospital. This writer resident signs. Bp 164/78, temp 98.3, p83, R18, O2 99. NP [Nurse Practitioner] was notified. Came to see resident. Resident insisted on calling 911. Resident and proceeds to call 911. When EMS arrived on the scene. Resident stated he wanted to go to [Hospital name redacted], EMS told resident There is a [appears words were left out] at [hospital name redacted]. Resident refused to go to the hospital. The NP in this writer went to speak with resident. Resident Then admitted to snorting and unknown substance within his nose, and that he believes it was laced with fentanyl. NP asked resident to do a drugs test. Resident then refused. NP ordered Mucinex, relief and acetaminophen. Resident Took meds. This writer informed oncoming nurse. Medical Doctor (MD) Note: [DATE] 12:29 pm -CHIEF COMPLAINT - Patient seen at the request of nursing for congestion, feeling like he is withdrawing from something He reports feeling congested and has not slept in 3 days. He reports snorting something 3 days ago and that is when he started not being able to sleep. He is unsure the substance. He also reports that she snorted a little something again this morning while outside of the building, he reports not having any of this substance on his person at this time. I have notified the staff to use Narcan if at any point they find the patient difficult to arouse. Start Mucinex and Tylenol for the congestion and aches. MD Note: [DATE] 3:15 pm Primary Chief Complaint: GI: Nausea -History Present Illness: Patient with partner history of alcohol dependence drinks six pack four times a week and heroin dependence uses four times a week who has been without both for the past t3 days due to restrictions on leaving the facility. Patient is actively complaining of nausea, diarrhea, body aches, chills, and headaches. Patient appears to be actively withdrawing actively in withdrawal from combination of alcohol and opiates. High risk of adverse outcome in current setting requires active and frequent monitoring with frequent interventions. Therefore, we will transfer patient to the emergency department - Opioid dependence with withdrawal. [DATE] 5:21 pm - Nurse's Note Text: Resident has been going though alcohol and opioids withdrawal. Resident stated the last day he used both was 3 days ago. Resident Has been getting chills, headache, tremors, Nausea, Prickling and tingling in body, and body aches. BP 164/90, Temp 98.2, p 92. Resident has revived PRN Ativan, PRN Tylenol, PRN Zofran. Resident stated pain medication was not helping. This writer decided to call [On call physician name redacted]. Spoke with [Physician name redacted] MD Spoke with Resident. MD decided to send resident to hospital. Resident being transported to [Hospital name redacted]. [DATE] 7:45 pm -Nurse's Note Text: Nurse from the ER called and stated that the resident will be discharged back to the facility. Basic labs were completed and showing increase in his sugar, but no abnormal findings noted. Withdrawal medication offered to the resident however the resident did refuse stating that he will follow up with receiving methadone. ER nurse stated transportation was being set up by the social worker. [DATE] 3:17 pm-Nurse's Note Text: Res prescription for Suboxone still needed. Unit manager notified of whom contacted NP to get order prescription to be faxed to facility pharmacy, order faxed, and writer called for order to be sent STAT. Pharmacy will send order STAT. (Suboxone is a medication used by drug treatment facilities for heroin/opiate withdrawal) A review of the clinical record revealed the following care plan entry with regard to the use of illicit drugs and or alcohol: FOCUS: Hx of drug use. The resident is at risk for complications due to a history of illicit drugs use Date Initiated: [DATE] GOAL: The resident will not have any adverse reactions related to alcoholism thru review period Date Initiated: [DATE] INTERVENTIONS: Observe resident for any signs and symptoms of intoxication or withdrawal from drugs such as tremors, nausea/vomiting(severe), sweating and notify MD as indicated Date Initiated: [DATE] Administer medication as ordered Date Initiated: [DATE] Vitals as needed Date Initiated: [DATE] 4. Resident #130 was found to be under the influence of an illicit substance and admitted to staff that he was high. However, when EMS arrived, he refused hospital transport. Resident #130 was admitted to the facility on [DATE] with diagnoses included but were not limited to sepsis due to methicillin-susceptible staph, major depressive disorder, anxiety disorder, acquired hypertension, acute kidney failure, type 2 diabetes, nicotine dependence, protein-calorie malnutrition, and history of infectious parasitic disease. [DATE] 6:43 am - Nurse's Note Text: Resident room noted with a strong odor of weeds [sic] by CNA, nurse and CNA went in to ask resident, resident confirmed he has been smoking weed, we asked him to turn it over, he declined, resident educated about the implication of that, he was told his action will be reported to management. Describe any interventions attempted: Resident told he will be reported to management. Effectiveness of Interventions: Resident will continue to be monitored. [DATE] 7:24 a.m.- Nurse's Note Text: 4:10 Writer notified of patient lethargic in dining room. Writer into dining room, patient seen with his head behind wheelchair, lethargic and hard to arouse. Obtained vitals at 413 65/40, 56, 16, 100RA, BS 140. Called residents several times, he responded and said, I'm high as a bitch. Writer asked resident several times what he had taken, he refused to say. 911 called made per his nurse. 911 into building. Assessed patient, resident remained with a low BP and heart rate. EMTs encouraged resident to go to hospital. Resident refused. Educated the resident on the importance of going to the hospital to monitor low BP and heart rate, resident continued to refuse. Multiple nurses from units educated the patient on the importance of his health. Encouraged resident to go with EMT to be seen at hospital. Resident then became aggressive saying he wasn't going to the hospital because there was nothing wrong with him. EMTs left building. Writer and nurse attempted to take resident to his room, he refused. Resident remained in dining room area. Medical Doctor (MD) note - [DATE] - [Resident #130 name redacted] was found asleep in in his wheelchair. He reported that he was high. He was difficult to arouse, BPs were in the 60-70s systolic. EMS was called. Upon arrival his BP was still low, but he refused to go the hospital. He is at baseline this morning when I see him. All reports reviewed and spoke with staff about the incident. I am holding his BP meds over the weekend. No reports of fever, chills, chest pain, shortness of breath, nausea, vomiting, or diarrhea. ' [DATE] - 10:22 p.m. Nurse's Note Text: Nurse went to resident door, there was strong smell of weed in room, coming right to the hallway. Nurse supervisor notified. A review of the clinical record revealed the following care plan entry concerning the use of illicit drugs and or alcohol: A review of the care plan revealed the following entry about the use of illicit drugs and/or alcohol: FOCUS: Resident has behavior in using drugs and alcohol while on premise. Drugs have been confiscated from the resident's room. Revision on: [DATE] GOAL: The resident's behaviors will cause them less distress through the review period Date Initiated: [DATE] Target Date: [DATE] INTERVENTIONS: Approach with a calm quiet voice, divert attention, and remove from the situation and take to an alternative assure the resident they are safe and being cared for if they become distressed Date Initiated: [DATE] Explain all procedures to the resident before starting and allow the resident time to adjust to changes Date Initiated: [DATE] Monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved and situations. Date Initiated: [DATE] Notify MD as indicated Date Initiated: [DATE] On [DATE] at 1:00 pm, an interview was conducted with LPN A, who stated that they are aware of the Residents going out on LOA (Leave of Absence) and coming back high, but they cannot always be with them and cannot stop them leaving the facility. When asked what is done if they catch them smoking, drinking, or using drugs in the facility, she stated, We document in the chart, notify the supervisor, and educate them. That is all we can really do. When asked if the care plan should reflect the behaviors and interventions, she stated it should. A review of the admission Contract signed by all Residents revealed the following statement: Pg 3, #2. C. Alcohol and Controlled Substances: The Facility will not permit, without Facility's permission and a physician order, the possession of alcohol or any controlled substance on its premises or in violation of any law. Any resident who, while on Facility premises, engages in the sale, consumption, and/or unauthorized possession of alcohol or any controlled substance will be subject to discharge. Any violations of law subject the violator to immediate discharge and possible prosecution. On [DATE], an interview with the interim Administrator was conducted, and she stated that she had only been in the facility less than a week and was unaware of the issues surrounding the drug and alcohol use by residents. On the morning of [DATE], an interview was conducted with the Director of Nursing (DON), who was asked about Residents #42, 106, 124, and 130 care plans concerning drug and alcohol use. When asked if the care plans had adequately addressed the supervision of Residents after it was discovered they were using illicit drugs and/or alcohol, she said that they did not. When asked what they could have implemented, she stated they could have implemented 1:1 supervision and nursing assessments after LOA (Leave of Absence) from the building. On the morning of [DATE], an interview was conducted with the Corporate Administrator, who stated that they were trying to find placement for the Residents who are continuing to be non-compliant with the use of drugs and or alcohol. She stated that at first, a couple of the residents wanted drug treatment; however, they have since changed their minds. She said that the Ombudsman was working with her to recommend some facilities and group homes for placement of residents that would be appropriate for those settings. She said she would continue to issue 30-day notices until she could find safe discharges for those involved. On [DATE] at 11:30 a.m., the survey team notified the facility that it was in immediate jeopardy (IJ) in the area of accident hazard and supervision. It was determined that the facility knew as early as [DATE] that they were not able to provide ongoing monitoring for residents who were addicted to illicit drugs and failed, resulting in the continued use of illegal drugs and alcohol in the facility. Also, there was no evidence that effective care plan interventions that included monitoring and supervision of the identified residents were implemented. The residents were leaving the facility seeking illegal drugs and alcohol, returned under the influence of those substances, and created weapons in the facility, risking the safety of other residents. The survey team and the State Agency supervisory review accepted the Immediacy Removal Plan on 1/10[TRUNCATED]

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to administer the building in a manner that uses its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for four (4) residents (R#42, #106, #124 and #130) and each Long-Term Care Resident which resulted in Immediate Jeopardy. The findings included: For all facility residents, the Administration failed to act on the residents found to be using illicit drugs and alcohol in the building, failed to ensure all residents were protected from those substances being brought into the building, and failed to act on one (1) Resident creating sharp stabbing-like weapons from dining room cutlery. For Resident #42, the facility failed to act on the following incidents documented in the clinical record: On 7/15/24, 9/9/24, and 10/3/24, Resident #42 was caught smoking in the facility. On 10/11/24 - Resident #42 Cheeking PRN Narcotic Pain Meds (storing meds in cheek to avoid swallowing, this is done to hoard medication for later consumption) On 10/22/24 - Resident #42 was sent to emergency room (ER) for intoxication On 12/27/24 -Resident #42 was sent to the ER for AMS (Altered Mental Status). The ER notes document that Resident #42 was admitted to the hospital for the use of heroin. On 12/30/24 - MD notes refer to Resident #42 being on LOA (Leave of Absence) and being sent to the ER (while on LOA, the Resident overdosed on heroin.) For Resident #106, the facility failed to act on the following incidents documented in the clinical record: On 7/16/24 - Resident #106 was caught smoking in his room On 8/21/24 - Resident #106 admitted to taking money from their roommate to buy alcohol and methamphetamine and not doing so and not returning the money. On 9/9/24 -Resident #106 was found to possess a knife/boxcutter. On 9/16/24 - Resident #106 was found with alcohol, and the Resident presented with AMS and was sent to the ER, found to be positive for alcohol, marijuana, and cocaine use. Resident overdosed. On 12/16/24 - Resident #106 admitted to staff obtaining Suboxone and beer and using them both in the facility. On 12/23/24 - Resident #106 was sent to the ER for AMS and returned without paperwork from the ER. On 12/31/24 - Resident #106 was found in the facility with alcohol. On 1/4/25 - Resident #106 was found making weapons in his room with a lighter and fork (removed all but 1 of the tines on two forks found burning them with a lighter, producing a stabbing-like weapon). For Resident #124, the facility failed to act on the following incidents documented in the clinical record: On 12/12/24 - Resident #124 was found with chest pain and shortness of breath after going LOA 7-11 am. He admitted to snorting an unknown substance that he believed was laced with fentanyl. NP asked the resident to do a drug test. The resident refused to go to the ER and Refused drug testing. On 12/13/24 - Sent to the ER - Resident #124 was found sweating profusely and stated, I feel like I'm withdrawing from something. The staff indicated the resident admitted to snorting something starting 3 days ago and did not know what it was and also stated, I snorted a little something this morning. On 1/4/25 - Sent to the ER for drug withdrawal. For Resident #130, the facility failed to act on the following incidents documented in the clinical record: On 9/9/24 - Resident #130 was caught smoking marijuana in the room and refused to give it to staff. On 12/20/24 - Resident #130 was found by staff at 4:00 a.m. in the dining room with AMS, very lethargic sitting in a wheelchair, stating, I'm high as a bitch. The resident refused to go to the ER. On 1/3/25 - the staff reported a strong odor of marijuana in Resident #130's room. A review of the admission Contract signed by all Residents revealed the following statement: Pg 3, #2. C. Alcohol and Controlled Substances: The Facility will not permit, without Facility's permission and a physician order, the possession of alcohol or any controlled substance on its premises or in violation of any law. Any resident who, while on Facility premises, engages in the sale, consumption, and / or unauthorized possession of alcohol or any controlled substance will be subject to discharge. Any violations of law subject the violator to immediate discharge and possible prosecution. On the morning of 1/10/25, an interview with the interim Administrator was conducted, and she stated that she had only been in the facility less than a week and was unaware of the issues surrounding the drug and alcohol use by Residents. A review of the clinical records revealed a lack of, or ineffective interventions implemented to prevent re-occurrences. A review of the care plans for each Resident revealed that the facility failed to address the recent history of substance abuse and subsequent noncompliant behaviors with regard to the alcohol and substance abuse policy. On 1/10/25 at 11:30 a.m., the survey team notified the facility that it was in immediate jeopardy (IJ) in the area of administration. It was determined that the facility knew as early as 9/16/24 that they were not able to provide a substance abuse program for residents who were addicted to illicit drugs and failed, resulting in the continued use of illicit drugs and alcohol in the facility. Residents were leaving the facility seeking illegal drugs and alcohol, returned under the influence of those substances, and created weapons in the facility, risking the safety of other residents. The survey team and the State Agency supervisory review accepted the Immediacy Removal Plan on 1/10/25 at 4:35 p.m. The removal plan read as follows: Deficiency Statement: The facility failed to implement effective interventions to address ongoing substance abuse among residents with known substance abuse histories. This failure resulted in overdoses, weapon creation, and possession of illicit substances, which posed a serious risk of harm, injury, or death to all residents. Immediate corrective action is necessary to mitigate these hazards Resident Safety Measures: Conducted immediate comprehensive assessments of all residents potentially impacted to evaluate psychosocial and physical harm. Implemented one-on-one supervision for residents #'s 42, 106, 124, and 130 until further care plans can be established. Residents #'s 61, 101, 109, 127, do not require enhanced supervision as prior investigation regarding allegation of drug abuse was found to be unsubstantiated. Secured all entrances and exits to the facility to prevent unauthorized entry or re-entry of residents suspected of leaving the facility to obtain illicit substances. Prohibited Substance Management: Conducted a full facility sweep to identify and remove illicit drugs, alcohol, and weapons. Implemented a no-tolerance policy for possession or use of illicit substances and weapons within the facility, communicated to all residents and staff immediately. Partnered with local law enforcement for ongoing assistance with identifying and preventing the presence of illicit substances and weapons in the facility. Systemic Changes to Prevent Recurrence: Measures to Address Psychosocial Harm: Resident Support: Provided immediate counseling and mental health services for Resident #109, Resident #33, and any other residents expressing fearfulness or experiencing psychosocial harm. Facilitated group therapy sessions to address concerns related to the recent incidents and restore a sense of safety and community among residents. Family and Resident Communication: Held meetings with residents and their families to address concerns, outline corrective actions and rebuild trust. Established a dedicated hotline for residents and families to report ongoing concerns or incidents confidentially. Discharge Plans for Noncompliant Residents: Evaluation for discharge: Residents violating the no-tolerance policy for illicit substance use, possession of weapons, or engaging in violent or unsafe behaviors will be evaluated for discharge. The interdisciplinary team (IDT) will review each case to ensure compliance with federal and state discharge regulations. On 1/10/25, the survey team verified through observation that Resident #'s 42, 106, 124, and 130 had 1:1 observation while in the facility as outlined in their plan. Security was present in the building, and front desk staff was at the entrance monitoring the visitors and Residents entering and exiting the facility. On 1/14/25, the facility notified the survey team that they had educated those who had worked and were moving forward with educating staff before the start of the shift. The facility submitted copies of the curriculum used to educate staff, in-service sign-in sheets, and documents signed by each staff member who was educated. The survey team verified via staff interview that staff education and training on the abovementioned topics was completed. The staff members interviewed were able to correctly answer questions about the substance use/abuse, policy, procedures, leave of absence policy and procedures, and signs and symptoms of substance use and or abuse. All staff interviewed (Nurses, CNAs, and receptionists) verified receiving education and handouts and signed the attestation for the training received document. The Immediate Jeopardy was removed on 1/14/25 at 12:45 p.m., and the scope and severity were lowered to level 2, patterned. On 1/14/25, during the end-of-day meeting, the Administrator was made aware of the findings, and no further information was provided.

Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to maintain an effective pest control program in the rooms of Resident # 3 and #130 and throughout the entire facility. The findings include: 1. On 1-28-25 during resident room observations, the room of Resident #3 was noted to have a sticky, tape style insect trap, hanging from the ceiling in the bathroom. The 2 inch wide by 24 inch long tape was so covered in insects that it had the appearance of fur covering it. A nurse was coming down the hall at that time and was asked to view the area. When asked if he thought it was safe and sanitary for the Resident, he stated no. Resident #3 stated yes, they have pest control bug people come and spray, however, she stated they only spray the halls, not the rooms, because they don't want to move things around in the room. During the entire survey there were fruit flies as well as large flies, and cock roaches noted on all 4 living units, and in the common areas as well. A review of the pest control logs revealed that the facility is having pest control services come to the building monthly, however, the pests continue to be in the facility. On 2-5-25 at the time of survey exit the facility Administrator, and Director of Nursing stated that pest control services had been in and treated rooms on unit #2, and that they had nothing further to provide. 2. On 1-28-25 during resident room observations, the room of Resident #130 was noted to have small red bugs on the floor under the bed of the Resident's room mate. The room mate was wearing stained dirty clothing with wet spots noted in his lap while he sat in a wheel chair. A nurse was coming down the hall at that time and was asked to view the area. When asked if he thought it was safe and sanitary for the Resident, he stated no. He further stated he would get the Maintenance Director to have pest control come and treat the room. Resident #130 also stated yes, they have pest control bug people come and spray, however, they only spray the halls, not the rooms, because they don't want to move things around in the room. During the entire survey there were fruit flies as well as large flies, and cock roaches noted on all 4 living units, and in the common areas as well. A review of the pest control logs revealed that the facility is having pest control services come to the building monthly, however, the pests continue to be in the facility. On 2-5-25 at the time of survey exit the facility Administrator, and Director of Nursing stated that pest control services had been in and treated rooms on Unit #2, and had eradicated the bed bugs in Resident #130's room, and that they had nothing further to provide. 3. Throughout the facility during the course of the survey, there was evidence of live pests including cock roaches and bed bugs. During the initial tour of the facility on 1/28/2025 at 1:30 p.m., the surveyor was touring the rooms of residents on Unit 2. As the surveyor walked in the hallway in front of the nurses station, one Certified Nursing Assistant-G stopped the surveyor and said Excuse me, there is a bug on your back. He knocked the bug off of the surveyor's back and killed it once it fell on the floor. The bug was medium brown in color (cock roach) and approximately an inch long. The surveyor thanked the Certified Nursing Assistant for observing and removing the bug. The surveyor asked if that was a frequent problem in the facility. Certified Nursing Assistant-G stated, yes. There were residents standing in the hallway and in the doorways of their rooms. One Resident, who was standing in the doorway of the room that the surveyor was about to enter, laughed and stated there were lots of bugs in the facility. The Resident stated, bugs are everywhere. During the Resident Council meeting conducted on 1/29/2025, residents complained about roaches in the facility. There were more than four staff members at the nurses station and in the hallway. When the surveyor asked if they saw bugs in the facility, the staff members stated there were bugs seen in the facility. Throughout the days of survey, flying and crawling bugs were observed in several areas of the facility including residents' rooms, in hallways, in shower rooms, on the elevator and in the stairwell. The Maintenance Director stated (the following day after the observation of the bed bugs) that We had the pest control company come in and erradicate the bed bugs. During the end of day debriefings on 2/3/2025 and 2/4/2025, the Administrator, Director of Nursing and Corporate Consultants were informed of the findings. No further information was provided.

3. Unit two: For Resident #3, the facility staff failed to maintain a clean, comfortable, homelike living environment. On 1-28-25 during resident room observations, the room of Resident #3 was noted to have a sticky, tape style insect trap, hanging from the ceiling in the bathroom. The 2 inch wide by 24 inch long tape was so covered in insects that it had the appearance of fur covering it. A nurse was coming down the hall at that time and was asked to view the area. When asked if he thought it was safe and sanitary for the Resident, he stated no. Resident #3 stated yes, they have pest control bug people come and spray, however, she stated they only spray the halls, not the rooms, because they don't want to move things around in the room. Pest Control Review: During the entire survey there were fruit flies as well as large flies, and cock roaches noted on all three living units, and in the common areas as well. A review of the pest control logs revealed that the facility is having pest control services come to the building monthly, however, the pests continue to be in the facility. The Resident's room was shared with a second Resident. The room tour included but was not limited to the following being observed; broken vinyl window blinds, a urine soaked bathroom with a bedpan full of urine stained panties on the floor, a pervasive smell of urine and feces in the room and on the entire unit. The floor of the room was sticky and made a sucking sound as one walked across it, and the base board was peeling and drooping over in places. The floor was crusted with crumbs, brown debris, and black particles. The walls were scraped and stained, and covered in crayon coloring book pages completed by the Resident, which encircled the walls of the entire room and were also on the room door The bed divider curtain had brown stains and smeared tan substances on it. The Residents both had a 16 ounce Styrofoam cup with a plastic lid and straw in it for water which were stained. The Maintenance Director was a member of the corporate staff and not regular staff in the facility. The facility Maintenance director had resigned leaving the position open for a substantial period of time, and the Corporate Maintenance Director was on site during survey training the new Maintenance Director who had just started while survey was being conducted. On 1-29-25 during a meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns and that unit #2 was not safe, clean and comfortable, and homelike. On 2-5-25 at the time of survey exit the facility Administrator, and Director of Nursing stated that pest control services had been in and treated rooms on unit #2, and that they had nothing further to provide. 4. Unit Two: For Resident #130, the facility staff failed to maintain a clean, comfortable, homelike living environment. On 1-28-25 during resident room observations, the room of Resident #130 was noted to have small red bugs on the floor under the bed of the Resident's room mate. The room mate was wearing stained dirty clothing with wet spots noted in his lap while he sat in a wheel chair. A nurse was coming down the hall at that time and was asked to view the area. When asked if he thought it was safe and sanitary for the Resident, he stated no. He further stated he would get the Maintenance Director to have pest control come and treat the room. Resident #130 also stated yes, they have pest control bug people come and spray, however, they only spray the halls, not the rooms, because they don't want to move things around in the room. Pest Control Review; During the entire survey there were fruit flies as well as large flies, and cock roaches noted on all 3 living units, and in the common areas as well. A review of the pest control logs revealed that the facility is having pest control services come to the building monthly, however, the pests continue to be in the facility. The Resident's room tour included but was not limited to the following being observed; broken vinyl window blinds, a urine soaked bathroom a pervasive smell of urine and feces in the room and on the entire unit. The overbed tables, and bedside tables were littered with crumbs, smears, dried food particles, used paper napkins and waste from food containers, and were unclean. The floor of the room was sticky and made a sucking sound as one walked across it, and the base board was peeling and drooping over in places. The floor was crusted with crumbs, brown debris, and black particles. The walls were scraped and stained, and had holes in various areas. The bed divider curtain had brown stains and smeared tan substances on it. The Residents both had a 16 ounce Styrofoam cup with a plastic lid and straw in it for water which were stained. The Maintenance Director was a member of the corporate staff and not regular staff in the facility. The facility Maintenance director had resigned leaving the position open for a substantial period of time, and the Corporate Maintenance Director was on site during survey training the new Maintenance Director who had just started while survey was being conducted. On 1-29-25 during a meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns and that Unit #2 was not safe, clean and comfortable, and homelike. On 2-5-25 at the time of survey exit the facility Administrator, and Director of Nursing stated that pest control services had been in and treated rooms on unit #2, and had eradicated the bed bugs in Resident #130's room, and that they had nothing further to provide. Based on observations, resident interviews, staff interviews, facility document reviews, and review of the facility's policy, the facility staff failed to provide a sanitary, comfortable, and homelike environment on three of three units (Unit 2, 3 and 4 only operational units, Unit 1 under renovation) and in the main entryway, which resulted in Substandard Quality of Care. The findings included: 1. Unit Four: Upon entering the facility on 1/31/25 at approximately 11:30 AM, water was observed leaking overhead between the two entryway doors. A large amount of water continued to pool in the entryway making the area unsanitary as people walked and pulled bags through the water into the facility. Each day through 2/5/25 the overhead of the entryway dripped water and it accumulated into puddles which was brought into the facility. At approximately 12:55 PM, after exiting the elevator on the second floor to reach Unit Four, a pervasive stench engulfed the area outside the elevator. Upon reaching the corridor of Unit Four the stench grew in intensity and the search for causative factors revealed, Resident #26 was observed in a wheelchair, urine saturated, wandering the corridor and in and out of other resident rooms. No staff were observed to intervene. At approximately 1:13 PM, a 3/4 full urinal of dark yellow urine was observed hanging on the side of a trash can in room [ROOM NUMBER]. Piles of clothing were observed on the floor between the TV stands, on the TV stand, and in the corner bedside the wardrobe. The wardrobe's right door was falling off. Resident #27 was observed sitting in a wheel chair in room [ROOM NUMBER], he had a disheveled appearance. The resident's skin was extremely dry and scaly, there was an unpleasant body odor and the resident's clothing was remarkably soiled. a. Resident #27 was originally admitted to the facility 01/30/2015 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included COPD and a major depressive disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/2/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were intact. An interview was conducted with Resident #27 at approximately 1:15 PM. He stated he wanted to keep the long beard but, he very much desired a haircut and maybe a hot bath. Resident #27 was overheard asking a Certified Nursing Assistant (CNA) in the corridor for a haircut and the staff member stated she did not have her clipper with her therefore she could not cut his hair that day. b. During observation rounds on 1/28/25 at 2:15 PM it was observed in room [ROOM NUMBER] that the light fixture above the sink was missing a light fixture cover, and the inside of the sink was very stained with a yellow discoloration. Also, the wall under and around the sink was very dirty with black marks, damage to the wall, and the floor was very dirty around the perimeter of the room where the floor meets the baseboard. On 2/2/25 approximately 3:09 PM addtional observations were made in room [ROOM NUMBER]. Beside Resident #81's bed, was a large amount of clothing were on the floor and the four bed room had much debris on the floor, a left over breakfast tray on a table and unpleasant odors. Resident #81 was originally admitted to the facility 12/9/2024 after an acute care hospital stay. He had never been discharged from the facility. The current diagnoses included a right buttock wound secondary to a peri-rectal abscess, fecal diversion surgery status post colostomy to prevent reinfecting the wound and heart attack. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/16/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #81's cognitive abilities for daily decision making were intact. An interview was conducted with Resident #81. The resident stated he was not going to pick the clothing up because roaches were beneath the clothing and they would stay there if he did not disturb them. Two small roaches were observed crawling along the floor beside the clothing. The privacy curtain between Resident #81's bed and the bed beside his, had a large amount of a dark brown substance on it and the curtain was missing many top hooks which allowed draping at the top. c. During general observations, in room [ROOM NUMBER] the privacy curtain also required hooks for proper hanging and was it appeared soiled. There was debris on the floor and pieces of paper. In room [ROOM NUMBER] the faucet at the sink allowed the water to drip rapidly. d. Resident #21 returned to room [ROOM NUMBER] at approximately 4:10 PM, his pants were extremely saturated with urine. The urine made a puddle on the floor beneath the resident's chair, next to his bed and when the resident rolled into the hallway, trails of urine was observed up and down the corridor. Resident #21 was originally admitted to the facility 05/27/2022 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included high blood pressure and bilateral lower extremity swelling. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/31/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were intact. An interview was conducted with Resident #21, he stated he was not the cause of the odors in room [ROOM NUMBER], it was his roommate who does not bathe. Resident #21 stated he does not like living with the bad odors. On 2/1/25 at approximately 10:00 AM upon exiting the elevator on the Unit Four the same pervasive stench engulfed the area outside the elevator. Upon entering the corridor to Unit Four the intense stench remained. Environmental Services staff were observed mopping floors but as you progressed to the higher room numbers the pervasive stench continued to permeate the unit. On 2/4/25 at 4:20 PM an interview was conducted with the Administrator, Director of Nursing and four Corporate staff members. They all acknowledged the pervasive odors as you exit the elevator on the second floor. The Administrator stated they conducted Angel rounds every morning Monday through Friday and if concerns are identified the appropriate department is notified and follow up on the concern is revisited prior to the end of the day. 5. Unit Two: For Resident # 128, the facility staff failed to ensure the walls near the bed were painted. Resident # 128 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Diabetes, Amputation of Left Leg-Above the Knee, Osteomyelitis of Vertebra, Sacral and Sacrococcygeal region, and Benign Prostatic Hyperplasia of lower urinary tract. The most recent Minimum Data Set (MDS) was an admission Assessment with an Assessment Reference Date (ARD) of 9/10/2024. Resident # 128's BIMS (Brief Interview for Mental Status) Score was a 14 out of 15, indicating no cognitive impairment. Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025. During rounds on 1/28/2025 at 1:15 p.m., Resident # 128 was observed lying in the bed. Resident # 128 stated the rooms look pretty bad. He stated the walls were left with white patches when the walls were repaired. Resident # 128 stated he did not like the way the room looked with all of the white patches where the walls were repaired. Resident # 128. On 2/3/2025 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the residents' rooms to be comfortable and homelike. She stated the rooms did not look homelike. During the end of day debriefing on 2/3/2025, the Facility Administrator, two Regional Nurse Consultants and Director of Nursing were informed of the findings. No further information was provided. 6. Unit two: For Resident #113, the facility staff failed to ensure a clean, comfortable homelike environment due to the unpainted walls and the presence of roaches. During rounds on 1/28/2025 at 3:15 p.m., Resident # 113 was observed sitting on the side of the bed and watching television. The walls on the side of the bed were noted to have large white colored areas that looked like holes had been patched. Resident # 113 stated the room looked like that for a while. When asked if there were any other problems, he stated there were a lot of roaches were in the facility. On 2/03/2025 at 01:28 p.m.- An interview was conducted with Resident # 113 who stated there were lots of areas on the walls that were repaired. He stated the walls had not been painted and they looked bad. He stated roaches were in the residents' rooms and in the hallways. He also stated he had seen roaches in the facility several times. On 2/3/2025 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the residents' rooms to be comfortable and homelike. She stated the rooms did not look homelike. During the end of day debriefing on 2/3/2025, the Facility Administrator, two Regional Nurse Consultants and Director of Nursing were informed of the findings. No further information was provided. 7. Unit two: For Resident # 2, the facility staff failed to ensure a clean, comfortable homelike environment. Resident # 2 was admitted on [DATE] with diagnoses including but not limited to: Epilepsy, Seizures, Confirmed Physical Abuse, Confirmed Psychological Abuse, Major Depressive Disorder, Anxiety Disorder, and Neoplasm of the Brain. Resident #2's most recent MDS (Minimum Data Set) was a Quarterly Assessment with an ARD (Assessment Reference Date) of 12/27/2024 coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 13 out of 15 indicating no cognitive impairment. Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025. Resident # 2 complained that the room looked terrible. She stated she had recently moved to that room and there was stuff everywhere. Clutter was observed in the empty areas where residents formerly resided. The room was equipped for four residents but only two resided there during the survey. On 2/3/2025 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the residents' rooms to be comfortable and homelike. She stated the rooms did not look homelike. During the end of day debriefing on 2/3/2025, the Facility Administrator, two Regional Nurse Consultants and Director of Nursing were informed of the findings. No further information was provided. 8. Unit Three: On 1/15/25 approximately 1:45 p.m. getting off of the elevator on the Unit three a strong odor of urine and body odor was detected. The shower room on the 300's hall had 2 dirty towels on the floor a washcloth hanging over the arm of the shower chair. The walls were patched up where holes had been repaired but never painted over, the shower chairs were soiled with brown substance, and there was a soiled brief in the corner near the trash can. The shower curtains do not completely cover the shower stalls, and they are stained with brownish yellow substance. On 1/16/25 at approximately 10:30 a.m., getting off of the Unit three elevator once again there was a strong odor of urine and body odor, while interviewing Resident #24 noted his blanket had what appeared to be food stains and the sheet had black marks on it. Throughout the rest of the survey all subsequent trips to the second-floor surveyors encountered this same odor of urine and body odor on the second floor. Throughout the 300's hall floors were noted to be dirty in the hallway and in Resident rooms. Strong stale cigarette smell in the dining room on the first floor as residents smoke in the patio area outside of the dining room door. On 2/3/25 at 11:00 an interview was conducted with Employee H & Employee J from the housekeeping dept. Employee H was asked how often floors are washed she stated they are washed daily. Employee J was asked about the shower curtains, and she stated that the shower curtains were on back order since December. She stated that they have to wash and re-hang whatever is here now until a new shipment comes in. When asked about the odor on the second floor she stated that there are Residents who refuse to bathe and that it is a nursing issue not a housekeeping issue. On 2/5/25 during the end of day meeting the Administrator was made aware of the issues and no further information was provided. Unit Four: 2. On 1/28/25 at approximately 1:45 PM., immediately after stepping off the elevator on Unit 4 were strong urine odors which lasted throughout the survey. A brief tour was conducted on unit four (400 Unit) of various rooms. On 1/29/25 at approximately 12:26 PM., room [ROOM NUMBER]B had a partial privacy curtain, not fully providing the resident privacy from all 3 beds present in his room. On 1/29/25 at approximately 3:45 PM., a brief tour of shower room was conducted. Upon entering the shower room, rusty pipes were observed near the sink and wall area. The walls had several areas of peeling paint, a Hoyer lift was stored in a shower stall. There were missing privacy curtains from 2 shower stalls, towels and hospital gowns were observed on the floor. A roach was observed crawling on the floor. On 01/30/25 at approximately 10:45 AM., an interview was conducted with Resident #33 concerning the shower room. Resident #33 said I want to use the shower down stairs because the shower on this floor has rusty pipes. On 02/05/25 at approximately 1:56 PM., an interview was conducted with CNA F. CNA F said that months ago she had informed a nurse that some of the rooms didn't have privacy curtains. CNA F also said that if the rooms don't have privacy curtains, she will just make sure the door is closed. A tour was conducted in room [ROOM NUMBER] on 1/28/25 3:48 PM., piles of clothing were observed in several corners of the room, as well as large open trash bags with clothing exposed on the floor. The Resident located in C bed (room [ROOM NUMBER] C) said that she's afraid roaches may be in the clothing and could crawl into her area. On 2/03/25 at approximately 4:41 PM., an interview was conducted with the Director of Nursing (DON), concerning the 400 hall (located on Unit 4) shower room. The DON said maintenance is going to see what can be down about the rust. The DON also said that Resident #33 can use the other shower room on the 300 hall. On 02/03/25 at approximately 2:57 PM., the shower room on the 400 hall was toured with Certified Nurses Aide (CNA) H. CNA H said that only 1 resident at a time can enter the shower room due to having one privacy curtain. 10. Unit Three (memory care, locked unit): On 01/28/2025, during the initial tour of facility, all units were toured. The halls had a strong smell of urine upon exiting the elevator on the second floor. Residents were observed in wheelchairs, and some ambulating, in the halls. The Memory care unit had a nurse assigned to the door as the door lock was broken. The Blinds, in rooms [ROOM NUMBER], of the Memory Care Unit, all had damage, broken slats, and openings on the sides preventing privacy. On 02/03/2025, at approximately 2:00 p.m., an interview was conducted with the Regional Maintenance Director. When asked if he was aware that there are multiple rooms on the memory unit with broken and ill-fitting blinds? He stated that he is aware that there are a number or window blinds and privacy curtains that need to be replaced. He went to say, He just hired a maintenance director for the building and that he is training him. He also stated that the blinds and curtain hooks have been ordered but are on back order. On 02/04/2025, at approximately 1:30 p.m., the above findings were shared with the Administrator and Regional Administrator. Regional Administrator states that on 01/01/2025, she re-educated the staff regarding Angel Rounds and introduced a new form to be used during morning rounds. The Rounds include a wall-to-wall tour with documentation and follow up regarding anything that is out of order in the common areas, on the units and in the residents' rooms. An opportunity was offered to the facility's staff to present additional information. A copy of the Angel Round Forms was provided by the Regional Administrator. The forms documents some of the broken items seen on observation and that some of the items needed to repair or replace the item had been requested through Tells, the service request system, but there was no documentation of the broken blinds in the rooms listed. On 2/04/2025 during the end of day meeting the Administrator was made aware of the findings and no further information was provided. 9. Conference room: During observation rounds on 1/28/25 at 3:00 PM and on 2/5/25 at 2:10 PM it was observed in the Conference Room that (2) two light fixtures had a large number of dead pests in the light fixtures covers.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility failed to ensure residents on three of three living units were free from misappropriation of resident property, to include specifics for one Resident #441 in a sample of 63 residents. The findings included; On three of three units the facility staff failed to prevent misappropriation of resident property. 1. On 1/31/2025 at 1:10 p.m., an interview was conducted with the Social Services Assistant who stated the facility staff conducted clothing drives for residents. He stated that whenever clothing was located in the Laundry department that did not have labels with names of residents identified, those items were placed in an area for residents to search through at a later time. The Social Services Assistant stated family members were not asked to search through the unlabeled clothing when there were complaints about missing clothing. On 1/31/2025 at 2:20 p.m., an interview was conducted with the Housekeeping Director who stated all clothing without labels that came to the laundry would be placed in a designated area. The Housekeeping Director stated that sometimes the laundry staff would find personal items rolled in the soiled linens. There was no way to determine who the personal items belonged to if there were no names on the items. The unlabelled items could come from any of the three units. The Housekeeping Director stated residents and families could search in the Designated area if accompanied by a facility staff member. On 2/4/2025 at 1:10 p.m., an interview was conducted with the Director of Social Services and the Social Services Assistant who both stated they did not have any information about unlabeled clothing. Both were new in their positions at the facility. They stated the facility should try to ensure resident's belongings get returned to them. They stated families and residents were encouraged to put their names in their clothing so they could be identified. Review of the Grievances Log revealed documentation of complaints from residents and families about missing clothing. One surveyor reported that a family member of one of the Residents complained of seeing another resident wearing his jacket. The family member told that surveyor that he knew for a fact that the jacket did not belong to the resident who was seen wearing it. During the end of day debriefing on 2/4/2025, the facility Administrator, Director of Nursing and Corporate Consultants were informed of the findings that the facility did not ensure there was no misappropriation of resident property. They stated the facility should ensure residents' have their personal belongings returned to them. No further information was provided. 2. The facility failed to prevent misappropriation of Residents #441's property. Resident #441 was admitted to the facility on [DATE], with the diagnoses of, but not limited to, sequalae cerebral infarct, diabetes mellitus, major depressive disorder, and dysphagia. The resident was discharged to another facility on 07/02/2024 and did not return. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 06/19/2024 coded Resident #441 with a Brief Interview for Mental Status (BIMS) with a score of 14 out of a possible score of 15 demonstrating minimal cognitive impairment. On 01/28/2025, during the initial tour of facility, residents were observed in wheelchairs in the first-floor activity room going to the smoking area attached to the activity room, dressed in jackets and coats. The activity director stated that some of the residents obtained coats, jackets and clothing items from the clothing drive on 01/24/2025. On 01/31/2025, at 11:15 a.m., an interview was conducted with Facility Housekeeping manager and the Regional Housekeeping manager who stated that the clothing issue has improved since they purchased a new label maker. They also educated the unit managers to re-educate staff and families that all clothing items should be labeled. The Housekeeping Manager states that they had a clothing drive coordinated with Social Services and the Activity Director. Residents were allowed to look through unidentified and unclaimed clothing items (lost and found) that remained in the laundry department along with donated clothing. The residents could pick items that they wanted. The clothing items were then labeled with the resident's name and the resident was allowed to keep the items. On 01/31/2025, a review of the facility grievance logs revealed, although there were no grievances related to Resident #441 missing clothing or a jacket, there were multiple grievances regarding other residents in the facility missing clothing and personal property. On 01/31/2025, and interview was conducted with the Director of Nursing (DON). She was asked if she was aware that there were multiple reports residents missing clothing. The DON stated that she is new to the facility, but that she was informed that resident clothing was going to laundry unidentified therefor not being returned to the residents. She went on to say that they a new label maker and iron and have re-educated the staff on units regarding the importance of having all resident clothing items labeled. A closed record review was conducted during 3 days of the survey 01/28/2025-02/03/2025 revealed that there was no documentation that it was reported that resident #441 was missing clothing or personal items. On 2/03/2025 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on interview, clinical record review and facility documentation review the facility staff failed to review and revise the care plans for 5 Residents (#42, 106, 124, 130, and #132) in a survey sample of 63 Residents. The findings included: For Resident #42 the facility staff failed to review and revise the care plan after non-compliance with alcohol and substance abuse incidents. Resident #42 was admitted to the facility on [DATE] with diagnoses that included but were not limited to COPD (Chronic Obstructive Pulmonary Disease), bipolar disorder, sleep apnea, hypertension, fusion of cervical spine, heart failure, major depressive disorder, history of venous thrombosis, (blood clot), anxiety disorder and viral hepatitis C. A review of the clinical record revealed the following incidents involving Resident #42: 7/15/24, 9/9/24 and 10/3/24 Resident #1 was caught smoking in the facility. 10/11/24 - Cheeking PRN Narcotic Pain Meds (storing meds in cheek to avoid swallowing, this is done to hoard medication for later consumption) 10/22/24 - Sent to ER for intoxication 12/27/24 - Sent to ER for AMS (Altered Mental Status) ER notes document Resident #1 admitted to use of heroin. 12/30/24 - MD notes refer to Resident #1 being on LOA (Leave of Absence) and being sent to the ER while on LOA for overdose of heroin. A review of the clinical record revealed the following care plan entry with regard to substance use: FOCUS: BEHAVIORS- the resident has admitted behaviors of drug and alcohol abuse when leaving the facility. Date Initiated: 01/03/2025. GOAL: [left blank; no data entered] INTERVENTION: Notify MD as indicated Date Initiated: 01/03/2025 Referral to inpatient drug abuse recovery center. Date Initiated: 01/03/2025 Revision on: 01/03/2025 FOCUS: Potential for safety hazard, injury r/t smoking. Date Initiated: 06/13/2024 GOAL - [Resident #1 name redacted] will not smoke without supervision through the review date. Date Initiated: 06/13/2024 Revision on: 06/13/2024 Notify charge nurse immediately if it is suspected that [NAME] has violated facility smoking policy. Date Initiated: 06/13/2024 Observe oral hygiene. Date Initiated: 06/13/2024 Smoking allowed only in designated smoking areas. Smoking only allowed by long term residents that have been grandfathered in by policy. Date Initiated: 06/13/2024 While smoking, will have direct supervision by staff or family member. Date Initiated: 06/13/2024. 2. For Resident #106 the facility staff failed to review and revise the care plan after non-compliance with alcohol and substance abuse incidents and non-compliance with weapons in the facility. Resident #106 was admitted to the facility on [DATE] with diagnoses that included but were not limited to history of multiple medical problems including gunshot wound to the head with stroke secondary to injury, hemiplegia, moderate recurrent major depression disorder, seizure disorder, late effect of traumatic brain injury, insomnia, and muscle spasms. A review of the clinical record revealed the following incidents involving Resident #106: 8/21/24 - Resident #106 admitted to taking money from roommate to buy alcohol and methamphetamine 9/9/24 - Resident #106 was found knife / boxcutter. 9/16/24 - Alcohol found on Resident #106 who was showing signs of AMS (Altered Mental Status) and was sent to ED found to be positive for alcohol, marijuana and cocaine use. 12/16/24 - Resident #106 found with AMS and admitted to staff obtaining Suboxone and beer and using them both in facility. 12/23/24 - Resident #106 was sent to the ER for AMS returned without paperwork from ER 12/31/24 - Resident #106 was found in the facility with alcohol 1/4/25 - Resident #106 was found making weapons in his room with lighter and fork (removed all but 1 of the tines on 2 forks found burning them with a lighter) A review of the care plan revealed the following with regard to smoking, and substance abuse. The care plan did not address the weapon making in the facility. FOCUS: Potential for safety hazard, injury r/t smoking. Date Initiated: 05/23/2024 GOAL: Will not cause injury to self or others, or damage to property r/t smoking. Date Initiated: 05/23/2024 Revision on: 05/30/2024 INTERVENTION: Keep all smoking materials at nurses station. Smoking materials to be returned to nurse's station after smoke break. Date Initiated: 05/23/2024 While smoking, will have direct supervision by staff or family member. Date Initiated: 05/23/2024. FOCUS: BEHAVIORS: the resident has drug and alcohol behaviors when leaving the facility and has been caught with alcohol while in the facility Date Initiated: 01/03/2025 GOAL -The resident's behaviors will cause them less distress thru the review period Date Initiated: 01/16/2025 he resident's behaviors will not cause them or other resident's distress thru the review period Date Initiated: 01/16/2025 INTERVENTIONS: 1:1 activities as needed Date Initiated: 01/16/2025 Explain all procedures to the resident before starting and allow the resident time to adjust to changes Date Initiated: 01/20/2025 Physician review of medications as needed Date Initiated: 01/16/2025 referred to inpatient recovery for drug and alcohol abuse. Date Initiated: 01/03/2025 Revision on: 01/03/2025 3. For Resident #124 the facility staff failed to review and revise the care plan after non-compliance with alcohol and substance use. Resident #124 was admitted to the facility on [DATE] with diagnoses acute osteomyelitis, type diabetes, chronic viral hepatitis, hypertension, complications of skin graft, major depressive disorder, chronic kidney disease, and diabetic foot ulcer. A review of the clinical record revealed the following incidents involving Resident #124: 12/12/24 - Resident #124 found with chest pain and shortness of breath after going LOA 7-11 am admitted to snorting and unknown substance that he believes it was laced with fentanyl. NP asked resident to do a drugs test. Resident refused to go to ER and Refused drug testing. 12/13/24 - Sent to the ER - Resident #124 found sweating profusely and stated, I feel like I'm withdrawing from something, admitted to snorting something starting 3 days ago and not knowing what it was, also stated I snorted a little something this morning. 1/4/25 - Sent to the ER for withdrawals. A review of the care plan revealed the following with regard to smoking, and substance abuse. Focus - HX OF DRUG USE: The resident is at risk for complications due to a history of illicit drugs use Date Initiated: 12/16/2024 Revision on: 12/16/2024 GOAL: The resident will not have any adverse reactions related to alcoholism thru review period Date Initiated: 12/16/2024 Target Date: 03/16/2025 INTERVENTION: Observe resident for any signs and symptoms of intoxication or withdrawal from drugs such as tremors, nausea/vomiting(severe), sweating and notify MD as indicated Date Initiated: 12/16/2024 Administer medication as ordered Date Initiated: 12/16/2024 vitals as needed Date Initiated: 12/16/2024. 4. For Resident #130 the facility staff failed to review and revise the care plan after non-compliance with alcohol and substance use. Resident #130 was admitted to the facility on [DATE] with diagnoses included but were not limited to sepsis due to methicillin susceptible staph, major depressive disorder, anxiety disorder, acquired hypertension, acute kidney failure, type 2 diabetes, nicotine dependence, protein calorie malnutrition, and history of infectious parasitic disease. A review of the clinical record revealed the following incidents involving Resident #130: 9/9/24 - Resident #130 was caught smoking marijuana in room refused to give it to staff. 12/20/24 - Resident #130 was found by staff at 4:00 a.m. in dining room with AMS (Altered Mental Status), very lethargic sitting in wheelchair stated, I'm high as a bitch. Refused to go to the ER 1/3/25 - Staff reported strong odor of marijuana in Resident #130's room. A review of the clinical record revealed the following care plan entry with regard to the use of illicit drugs and or alcohol: FOCUS: BEHAVIORS: the resident has behaviors of (SPECIFY) Resident has behavior in using drugs and alcohol while on premise. Drugs have been confiscated from resident's room. Date Initiated: 11/06/2024 Revision on: 01/03/2025 GOAL: the resident's behaviors will cause them less distress thru the review period Date Initiated: 11/06/2024 Target Date: 01/06/2025 INTERVENTIONS: Approach with a calm quiet voice, divert attention, and remove from the situation and take to an alternative location as needed Date Initiated: 11/06/2024 Assure the resident they are safe and being cared for if they become distressed Date Initiated: 11/06/2024 Explain all procedures to the resident before starting and allow the resident time to adjust to changes Date Initiated: 11/06/2024 Monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved and situations. Date Initiated: 11/06/2024 Notify MD as indicated Date Initiated: 11/06/2024 Physician review of medications as needed Date Initiated: 11/06/2024 A review of the facility policy entitled Care Planning Comprehensive Person-Centered, revealed the following excerpts: 15. Behavior intervention plan (BIP) may be developed when a resident exhibit behaviors that may place the resident, other resident or staff at risk or impedes on their rights. a. The BIP will be developed in collaboration with the resident, interdisciplinary team and mental health professionals as appropriate. b. The BIP will be incorporated into the resident's comprehensive care plan i. The BIP will be reviewed and updated as needed to address changes in the resident's behaviors. c. The BIP will clearly identify the behaviors being addressed, interventions/approaches to reduce behaviors and expected outcomes. The BIP will also include consequences and actions that may be taken should the resident not comply with the agreed expectations. i. The plan will honor the residents rights and dignity. 16. The care planning / interdisciplinary Team is responsible for the review and updating of care plans a. When requested by the resident / resident representative b. When there has been a significant change in the resident's condition. c. When the desired outcome is not met. d. When goals needs and preferences change e. At least quarterly and after each OBRA MDS assessment. On the morning of 1/12/25 an interview was conducted with the DON who was asked about care plans of Resident #'s 42, 106, 124 and 130 with regard to drug and alcohol use. When asked if the care plans had adequately addressed supervision of Residents after it was discovered they were using illicit drugs and / or alcohol, she stated that they had not. When asked what they could have implemented she stated that they could have implemented 1:1 supervision, and nursing assessments after LOA (Leave of Absence) from the building. On 1/12/25 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 5. Resident #132. The facility staff failed to revise the care plan timely in the area of receiving 1:1 staff supervision (Resident #132). Resident #132 was originally admitted to the facility 9/23/24. The resident's diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, schizoaffective disorder, and essential hypertension. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/30/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #132's cognitive abilities for daily decision making were moderately impaired. Observations were made of Resident #132 on 1/29/25 at 11:30 AM having 1:1 staff supervision. A review of the Care Plan interventions on 1/29/25 at 11:50 AM did not reveal Resident #132 having 1:1 staff supervision. An interview was conducted on 1/29/25 at 2:25 PM with the MDS (Minimum Data Set) Coordinator. The MDS Coordinator stated that Resident #132 has been receiving 1:1 staff supervision since 1/1/25. The MDS Coordinator also stated that the care plan was not updated in a timely manner. The MDS Coordinator further stated that she updated the care plan today however the care plan should have been updated at an earlier date due to Resident #132 being on 1:1 staff supervision for a few weeks now. On 2/5/25 at 6:55 PM a final interview was conducted with the Administrator, Director of Nursing, Regional MDS, Regional Nursing Consultant, Regional Maintenance Director, [NAME] President of Clinical Services, Regional Risk Management, and Regional Director of Operations. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on observations, staff interviews, resident record review, and a review of facility documents, the facility staff failed to apply a Occupational Therapy (OT) recommended splitting/orthotic device for one (1) of 63 residents (Resident #50), in the survey sample. The findings included: Resident #50 was originally admitted to the facility 10/27/2016 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included a stroke with right hemiparesis and expressive aphasia. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/22/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #50's cognitive abilities for daily decision making were moderately impaired. Resident #50's Physician's Order Summary included an order dated 12/31/24 to start 1/1/25 for the following: Apply resting hand splint to Right Upper Arm (RUE) for up to four (4) hours as tolerated- daily with skin checks and hand hygiene per shift for contracture management every day shift. Resident #50 received OT services from 11/18/24 through 12/26/24. The discharge plan dated 12/31/24 stated OT recommended that Resident #50 wear an orthotic to his right upper extremity for 2-4 hours per day as tolerated for contracture management. Observations were made of Resident #50 daily from 1/31/25 through 2/5/25, but a right upper extremity was not witnessed. The resident was noted to have the right arm bent upwards at all time. An interview was conducted with the OT on 2/5/25 at approximately 3:37 PM. The OT stated the right upper extremity splinting/orthotic was to be applied by staff and worn daily during the day shift up to 4 hours as tolerated, beginning 1/1/25. No documentation of application or tolerance was identified in the resident's record. On 2/5/25 at approximately 4:20 PM, a final interview was conducted with the Administrator, Director of Nursing and four Corporate Consultants. The administrative team was informed of the above. No additional information was provided and no concerns were voiced.

Based on observation, resident interview, staff interview, resident record review, the facility staff failed to obtain dental services for two (2) of 63 residents (Resident #27 and 96), in the survey sample. The findings included: 1. Resident #27 was originally admitted to the facility 01/30/2015 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included COPD and a major depressive disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/2/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were intact. On 1/28/25 at approximately 3:25 PM an interview was conducted with Resident #27. Resident #27 stated his primary concern was obtaining dentures. He further stated he had made his dental concerns known to staff but no one had followed-up with him. A review of the resident's record revealed he had seen the dentist and completed a dental assessment on 11/22/24. The recommendation was for upper full denture for mastication, and to resubmit for approval of the upper full denture. An interview was conducted with Social Services members on 2/4/25 at 1:53 PM, neither was aware that the resident's desired dental services or the information in the previous dental assessment. On 2/5/25 at approximately 12:40 PM the Social Services Director stated the dentist would be returning to the facility in March 2025 and the resident would be seen. The resident's person centered care plan had a problem dated 3/3/23 which stated (name of resident) will have consults as ordered, Dental, audiology, podiatry, optometry/ophthalmologist, psychiatry/psychology, wound, and dietary. The goal stated Resident will have consults maintained and followed as ordered through the review date, 5/3/25. The intervention stated follow consults as ordered. On 2/5/25 at approximately 4:20 PM, a final interview was conducted with the Administrator, Director of Nursing and four Corporate Consultants. The administrative team was informed of the the above information. No additional information was provided and no concerns were voiced. 2. Resident #96 was originally admitted to the facility 07/21/2023 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included traumatic subdural hemorrhage and high blood pressure. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/6/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #96's cognitive abilities for daily decision making were intact. On 1/28/25 at approximately 2:50 PM an interview was conducted with Resident #96. Resident #96 stated he had dental concerns and is very self-conscious of his dental status. No documentation regarding the resident's oral status was documented in the resident's record. The person centered care plan had a problem dated 08/09/2023 which stated the resident had oral/dental health problems related to poor oral hygiene. The goal stated The resident will comply with mouth care at least daily through review date, 2/20/25. The interventions included monitor/document/report as needed any signs/symptoms of of oral/dental problems needing attention: pain (gums, toothache, palate), abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed, tongue (black, coated, inflamed, white, smooth), ulcers in mouth, or lesions. An interview was conducted with Social Services members on 2/4/25 at 1:53 PM, neither was aware that the resident's desired dental services. On 2/5/25 at approximately 12:40 PM the Social Services Director stated the dentist would be returning to the facility in March 2025 and the resident was scheduled to be evaluated. On 2/5/25 at approximately 4:20 PM, a final interview was conducted with the Administrator, Director of Nursing and four Corporate Consultants. The administrative team was informed of the the above information. No additional information was provided and no concerns were voiced.

Based on record review and staff interview, the facility failed to ensure the required in-service training for nurses' aides be sufficient and no less than 12 hours per year for 4 of 6 Certified Nursing Assistant's (CNA's) reviewed during the survey. The findings included: An interview was conducted on 2/5/25 at 11:35 AM with the Human Resources Manager. The Human Resources Manager stated that the required 12 hours of nurses' aide training was not completed for CNA(C), CNA(D), and CNA(E). The Human Resources Manager also stated that the facility has not had a full-time Human Resources Manager, and she works at various facilities and has been filling in at the position until the facility hires a new Human Resources Manager. A review of the facility's records revealed that CNA(C), CNA(D), and CNA(E) did not complete the required 12 hours per year of in-service training for nurses' aides. On 2/5/25 at 6:55 PM a final interview was conducted with the Administrator, Director of Nursing, Regional MDS, Regional Nursing Consultant, Regional Maintenance Director, [NAME] President of Clinical Services, Regional Risk Management, and Regional Director of Operations. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on observation, Resident interview, staff interview and clinical record review, the facility staff failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for 4 Residents (# 123, #2, # 76 and # 113) in a survey sample of 63 Residents. The findings included: 1. For Resident # 123, the facility staff failed to ensure the clock on the bedroom wall had the proper time. Resident # 123 was admitted to the facility on [DATE] with the diagnoses of, but not limited to: Dementia with Agitation, Diabetes, Hypertension, and Legal blindness. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 1/8/2025. Resident # 123's BIMS (Brief Interview for Mental Status) Score was a 13 out of 15, indicating no cognitive impairment. Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025. During rounds on 1/28/2025 at 1:15 p.m., Resident # 123 was observed lying in the bed. Resident # 123 was alert, oriented and able to converse with the surveyor. Resident # 123 stated the facility staff acted like she didn't know what she was talking about and stated that clock is wrong. The time on the clock in Resident # 123's room closest to her bed was observed to have the time of 2:15. The second hand was working. Resident # 123 stated she technically was blind but could see some things. She pointed to a watch on her right arm and stated it was hard to see the time on it. She stated the watch was very special to her. The room was a quad room designed and equipped to house four residents. However, there were only 2 residents residing in the room. One resident ( Resident # 2) was in the bed on the far left corner with the bed in a vertical position and Resident # 123 was in the far right corner with the bed in a horizontal position. There was another clock approximately 6 feet away from Resident # 123's bed that was positioned over a space where another resident must have resided formerly. There was nobody residing in that space during the time of the survey. The time on that clock had the time of 6:42 over the area with an empty bed space. It was observed that the second hand was not working. On 1/29/2025 at 11:02 a.m., the clock had the time of 12:02. The time on that clock over the empty space adjacent to Resident # 123's bed had the time of 6:42. On 1/30/2025 at 9:40 a.m., the clock had the time of 10:40. The time on that clock over the empty space adjacent to Resident # 123's bed had the time of 6:42. On 1/31/2025 at 2:03 p.m., the clock had the time of 3:03. The time on that clock over the empty space adjacent to Resident # 123's bed had the time of 6:42. On 2/3/2025 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the time on the clocks to be correct. She stated the correct time helped the residents with orientation of time. Staff persons were observed in the room picking up food trays, and delivering ice and water. No staff person addressed the issue of the clock having the wrong time. The Director of Nursing stated the clock in the rooms should have had the correct time because it was important for the orientation of the residents. She stated staff members should have observed the clock was wrong and should have corrected the issue. During the end of day debriefing on 1/31/2025, the Facility Administrator, two Regional Nurse Consultants and Director of Nursing were informed of the findings that the clock closest to Resident # 123's bed was working properly but was always one hour ahead of time and the clock over the empty space was not working and had the time of 6:42. They all stated the clocks in residents' rooms should be accurate. No further information was provided. 2. For Resident # 2, the facility staff failed to ensure the clock on the bedroom wall had the correct time. Resident # 2 was admitted on [DATE] with diagnoses including but not limited to: Epilepsy, Seizures, Confirmed Physical Abuse, Confirmed Psychological Abuse, Major Depressive Disorder, Anxiety Disorder, and Neoplasm of the Brain. Resident #2's most recent MDS (Minimum Data Set) was a Quarterly Assessment with an ARD (Assessment Reference Date) of 12/27/2024 coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 13 out of 15 indicating no cognitive impairment. Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025. During rounds on 1/28/2025 at 1:15 p.m., Resident # 2 was observed lying in the bed watching TV. Resident # 2 was alert, oriented and able to converse with the surveyor. On 1/29/2025 at 11:02 a.m. during rounds, Resident # 2 was heard yelling loudly in the room. When the surveyor entered the room and asked what was wrong, Resident # 2 stated that she wanted to know why the staff had not brought her lunch. Resident # 2 seemed upset and agitated. The surveyor stated it was only 11:02 and asked what time lunch normally was served. Resident # 2 yelled that they always bring her food late. She looked diagonally across the room to the clock over her roommate's bed and stated it's after 12 and no lunch yet. The time on the clock over the roommate's bed ( Resident # 123) was observed to have the time of 12:02. The second hand was working properly. Resident # 2 stated she did not have a clock near her bed so she always looked at the clock over her roommate's bed. When the surveyor told her the time was after 11, Resident # 2 stated the time on the clock said 12 so that's what time she thought it was. The room was a quad room designed and equipped to house four residents. However, there were only 2 residents residing in the room. Resident # 2 was in the bed on the far left corner with the bed in a vertical position and the roommate (Resident # 123) was in the far right corner with the bed in a horizontal position. There was another clock approximately 6 feet away from Resident # 123's bed that was positioned over a space where another resident must have resided formerly. There was nobody residing in that space during the time of the survey. The time on that clock had the time of 6:42 over the area with an empty bed space. It was observed that the second hand was not working. Resident # 2 could look to her left and see the clock over her roommate's bed and the the clock over the empty space beside the roommate. On 1/29/2025 at 11:02 a.m., the clock had the time of 12:02. The time on that clock over the empty space adjacent to Resident # 123's bed had the time of 6:42. On 1/30/2025 at 9:40 a.m., the clock had the time of 10:40. The time on that clock over the empty space adjacent to Resident # 123's bed had the time of 6:42. On 1/31/2025 at 2:03 p.m., the clock had the time of 3:03. The time on that clock over the empty space adjacent to Resident # 123's bed had the time of 6:42. Staff members were observed providing care, delivering and picking up trays during the survey. No staff member addressed the time on the clock. The time on the clock over the roommate's bed was always one hour ahead and the time on the clock over the empty space was 6:42. On 2/3/2025 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the time on the clocks to be correct. She stated the correct time helped the residents with orientation of time. The Director of Nursing stated the clock in the rooms should have had the correct time because it was important for the orientation of the residents. She stated staff members should have observed the clock was wrong and should have corrected the issue. During the end of day debriefing on 1/31/2025, the Facility Administrator, two Regional Nurse Consultants and Director of Nursing were informed of the findings that both clocks in the room had the wrong time. One clock closest to the roommate's bed ( Resident # 123) bed was working properly but was always one hour ahead of time and the clock over the empty space was not working and had the time of 6:42. They all stated the clocks in residents' rooms should be accurate. No further information was provided. 3. For Resident # 76, the facility staff failed to ensure the clock on the bedroom wall had the proper time. Resident # 76 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Hemiplegia and Hemiparesis following Cerebral Infarction, Bipolar Disorder, Osteoarthritis, Type 2 Diabetes, Contracture of Left hand, and Blindness in right eye. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 12/7/2024. Resident # 76's BIMS (Brief Interview for Mental Status) Score was a 13 out of 15, indicating no cognitive impairment. Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025. During rounds on 1/28/2025 at 1:15 p.m., Resident # 76 was observed lying in the bed. Resident # 76 was alert, oriented and able to converse with the surveyor. The time on the clock in Resident # 76's room was above the bed of the roommate (Resident # 113.) The time on the clock was 12:15. The second hand was working properly. On 1/29/2025 at 12:04 p.m., the clock had the time of 11:04. On 1/30/2025 at 10:45 a.m., the clock had the time of 9:45. On 1/31/2025 at 2:10 p.m., the clock had the time of 1:10. Staff persons were observed in the room picking up food trays, and delivering ice and water during the survey. No staff person addressed the issue of the clock having the wrong time. On 2/03/2025 at 01:28 p.m.- Observed the time on the clock was wrong during 5 days of survey- Interview conducted with Resident # 76 who stated he uses his phone but sometimes he can't find the phone. Stated he likes to look at the clock. On 2/3/2025 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the time on the clocks to be correct. She stated the correct time helped the residents with orientation of time. The Director of Nursing stated the clock in the rooms should have had the correct time because it was important for the orientation of the residents. She stated staff members should have observed the clock was wrong and should have corrected the issue. During the end of day debriefing on 2/5/2025, the Facility Administrator, two Regional Nurse Consultants and Director of Nursing were informed of the findings that the clock closest to Resident # 113's bed was working properly but was always one hour behind time. They all stated the clocks in residents' rooms should be accurate. No further information was provided. 4. For Resident #113, the facility staff failed to ensure the clock on the bedroom wall had the proper time. Resident # 113 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Diabetes, Chronic Kidney Disease, Acute and Chronic Respiratory Failure, Hypertension, Non-[NAME] Lymphoma, Congestive Heart Failure, Major Depressive Disorder, Venous Thrombosis and Embolism and Ischemic Heart Disease. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 1/1/2025. Resident # 123's BIMS (Brief Interview for Mental Status) Score was a 14 out of 15, indicating no cognitive impairment. Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025. During rounds on 1/28/2025 at 3:15 p.m., Resident # 113 was observed sitting on the side of the bed and watching television. Resident # 113 was alert, oriented and able to converse with the surveyor. The time on the clock at the head of the bed stated 2:15. On 1/29/2025 at 12:04 p.m., the clock had the time of 11:04. On 1/30/2025 at 10:45 a.m., the clock had the time of 9:45. On 1/31/2025 at 2:10 p.m., the clock had the time of 1:10. On 2/03/2025 at 01:28 p.m.- Observed the time on the clock was wrong during 5 days of survey. An interview was conducted with Resident # 113. When asked about any concerns, Resident # 113 stated he had was wondering why the staff never fixed the time on the clock. He stated they don't even look at the clock. Resident # 113 pointed to a clock on the wall and laughed. The time on the clock in Resident # 113's room was observed to have the time of 12:15. Resident # 113 stated they leave it alone so that they only have to change it once a year. It's only wrong when the time changes. He stated he was going to check to see how long they were going to let it be wrong. He stated he used his phone but sometimes the phone could be off. On 2/3/2025 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the time on the clocks to be correct. She stated the correct time helped the residents with orientation of time. The Director of Nursing stated the clock in the rooms should have had the correct time because it was important for the orientation of the residents. She stated staff members should have observed the clock was wrong and should have corrected the issue. During the end of day debriefing on 1/31/2025, the Facility Administrator, two Regional Nurse Consultants and Director of Nursing were informed of the findings that the clock closest to Resident # 123's bed was working properly but was always one hour behind time. They all stated the clocks in residents' rooms should be accurate. No further information was provided.

Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to implement their abuse policies to protect Residents, report abuse timely, investigate fully, and allow a police report of the abuse for 4 Residents (Residents #130, #131, #7, and #39) in a survey sample size of 63 residents. The findings included: 1. The facility failures described above resulted in the sexual abuse/harassment of Resident #131 by Resident #130. Resident #131 (victim) was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Traumatic Brain Injury (TBI) after a motor vehicle accident, diplopia, muscle weakness, unsteadiness on feet, abnormal gait and mobility, wheelchair use, and cognitive communication deficit, although there was no communication deficit noted at the time of survey. Resident #131's most recent Minimum Data Set with an Assessment Reference Date of 1-23-25 was coded as a discharge assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and his own responsible party. The Resident required touch assistance from one staff member for transferring and was wheelchair bound at times and was able to stand or walk independently for short distances. He required set up or touch assistance only with hygiene and bathing. The Resident denied complaints against any other staff or Residents since his admission on [DATE]. The Resident was discharged to a group home on 1-23-25 to be closer to family and to the least restrictive environment. Resident #130 (aggressor of victim #131) was admitted to the facility on [DATE]. Hospital discharge records indicated that the Resident was alert and oriented to person, place and time, and was ambulatory. Diagnoses included but were not limited to: Major depressive disorder, recurrent anxiety, Chronic hepatitis C, type two diabetes, nicotine dependence, fractured left heel with infected wound sepsis due to Methicillin Susceptible Staphylococcus Aureus, enhanced barrier precautions, and history of infectious parasitic disease. Resident #130's most recent Minimum Data Set with an Assessment Reference Date of 12-17-24 was coded as a significant change assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicated no cognitive impairment. The Resident was his own responsible party. The Resident required partial to moderate assistance from one staff member for hygiene and bathing. Resident #130 was observed during survey as ambulating without assistance or device. Resident #130 went out of the facility daily using the public city bus transportation and repeatedly returned under the influence of drugs and alcohol. Instances of this were recorded in the nursing progress notes to include the following most recent to survey. 9-19-24 6:43 am Resident room noted with a strong odor of weeds [sic] by (Certified Nursing Assistant) CNA, nurse and CNA went in to ask resident, resident confirmed he has been smoking weed, we asked him to turn it over, he declined, resident educated about the implication of that, he was told his action will be reported to management. Describe any interventions attempted: Resident told he will be reported to management Effectiveness of Interventions: Resident will continue to be monitored. 12-20-24 7:24 a.m. (documentation time). Note Text: 4:10 am (time of actual observation) Writer notified of patient lethargic in dining room. Writer into dining room, patient seen with his head (laid backward supine fashion) behind wheelchair, lethargic and hard to arouse. Obtained vitals at 4:13 am 65/40, 56, 16, 100% RA (oxygen saturation on room air alone), BS 140 (blood sugar). Called resident several times, he responded and said, I'm high as a bitch. Writer asked resident several times what he had taken, he refused to say. 911 called made per his nurse. 911 into building. Assessed patient, resident remained with a low BP and heart rate. EMTs encouraged resident to go to hospital. Resident refused. Educated the resident on the importance of going to the hospital to monitor low BP and heart rate, resident continued to refuse. Multiple nurses from units educated the patient on the importance of his health. Encouraged resident to go with EMT to be seen at hospital. Resident then became aggressive saying he wasn't going to the hospital because there was nothing wrong with him. EMTs left building. Writer and nurse attempted to take resident to his room, he refused. Resident remained in dining room area. MD (physician) note - 12-20-24 - [Resident #130 name redacted] was found asleep in in his wheelchair. He reported that he was high. He was difficult to arouse, BPs were in the 60-70s systolic. EMS was called. Upon arrival his BP was still low, but he refused to go the hospital. He is at baseline this morning when I see him. All reports reviewed and spoke with staff about the incident. I am holding his BP meds over the weekend. No reports of fever, chills, chest pain, shortness of breath, nausea, vomiting, or diarrhea. ' 1-3-25 - 10:22 pm. Note Text: Nurse went to resident door, there was strong smell of weed in room, coming right to the hallway. Nurse supervisor notified. A review of Resident #130's care plan revealed the following entry regarding the use of illicit drugs and or alcohol: FOCUS: The Resident is at risk of complications due to a history of illicit drug use. Revision on: 12-16-24. GOAL: The Resident will not have any adverse reaction to alcoholism thru review period. Date Initiated: 12-16-2024. Target Date: 3-16-25. INTERVENTIONS: (3) 1. Observe Resident for signs and symptoms of intoxication or withdrawal from drugs such as tremors nausea/vomiting (severe) sweating and notify MD (doctor) as indicated. Date Initiated: 12-16-2024. 2. Administer medication as ordered. Date Initiated: 12-16-2024. 3. Vitals as needed. Date Initiated: 12-16-2024. On 1-7-25 at 11:14 am nursing progress notes documented Verbal spat with roommate .both parties speaking in elevated tones, no physical contact noted both parties separated. On 1-7-25 at 12:23 pm Resident #15 agreed to a room change, and his spouse was notified. Adult Protective Services (APS) was called by an anonymous caller at the facility and the incident of sexual abuse was reported to them. The caller stated in the APS report of 1-7-25 that the facility Administration did not notify police, and they (the Administration) stated the reason as that can't happen (because) is that Resident (Resident #131 victim) would be charged with assault for pushing Resident (#130 aggressor) out of the doorway so that Resident (#131) could escape. This note indicated that there was physical contact known by staff at the time which was denied in the 1-7-25 nursing note. It was also alleged by the caller to APS that Resident #130 had been making sexual advances toward Resident #131 and wanted to get in his pants. It was also alleged that Resident #131 was asked by facility staff Why can't you just go home? The caller went on to state that Resident #131 had been moved 4 times for different assaults, verbal and such, but this was the only sexual assault. This assertion of frequent moves was found to be true as Resident #131's census in the facility documented those moves. The APS caller stated that on this day (1-7-25) the situation escalated and Resident #130 blocked the door of the room and told Resident #131 you are going to let me F K you. The caller stated that Resident #130 proceeded to touch, molest, and sexually assault Resident #131 who began yelling and screaming, and pushed Resident #130 out of the doorway into the hallway to escape when staff came to see what the commotion was about. Resident #131 told them immediately what had happened. On 1-9-25 at 1:00 pm an interview was conducted with LPN A who stated that they are aware of the Residents going out on LOA (Leave of Absence) and coming back high, also stating but we cannot be with them at all times and cannot stop them leaving the facility. When asked what is done if they catch them smoking or drinking or using drugs in the facility, she stated, We document in the chart, notify the supervisor and educate them, that is all we can really do. When asked if the care plan should reflect the behaviors and interventions, she stated that it should. On 1-9-25 (the second day of survey) at 3:00 pm, Resident #130 was interviewed during an investigation involving Resident drug, alcohol, and weapons abuses that were found to be actively occurring in the facility. This Resident was found to be involved in drug abuse while a Resident. The Resident was asked about an altercation with his roommate which was documented in the nursing progress notes as having occurred on 1-7-25. Resident #130 stated he bought Resident #131 cigarettes and Resident #131 refused to pay him for them. He stated he had indeed used drugs but not in the facility, only outside. This statement was found to be false as staff stated they had removed drugs and drug paraphernalia from his room, and documented that at 4:00 AM on 12-20-24 the Resident was found in the dining room after using drugs in the facility, and was also using in the facility on 9-19-24, and 1-3-25. On 1-9-25 at 3:30 pm, Resident #131 in person, and his spouse by phone were interviewed. They both stated that Resident #130 had made advances toward Resident #131, however, Resident #131 stated he made it Clear that I am straight, married, and got no interest in no [NAME]. Resident #131 stated he would ask me to dress in front of him to see my chest, and I didn't care about that, because he said he would get me some cigarettes, but when he cornered me in the room and wouldn't let me leave the room and grabbed my D k and said I'm gonna F k you in the A , that was it! I screamed for help and pushed him through the door and the nurses almost got knocked down coming in, they heard it all just ask them. Resident #131 stated the temp agency nurse (name) and the other nurse who works here all the time (name) came. Resident #131 stated He (#130 name) and (Resident #106 name) smoke stuff in the room and have overdosed sometimes. I just want out of here. Resident #131 was asked if he had reported the sexual abuse, and he stated I told the nurses, they saw it happen! I told the Administrator who said I would be arrested for pushing him if I called the police, and I've told everybody, but they just moved me to another room. On 1-9-25 A copy of all Facility Reported Incidents (FRI's) for the prior 6 months were requested. 9 were provided by the Administrator, and all 9 followed the standardized format and documentation included notification of the state agency the Virginia Department of Health Office of Licensure and Certification (VDH/OLC), the state Long Term Care Ombudsman, and Adult Protective Services (APS). The 9 completed FRI's were all prior to 9-20-24. On 1-9-25 at 4:00 pm the facility Administrator was asked for any investigation from 1-7-25 involving Residents #130, and #131. On 1-10-25 at 5:00 pm Resident #130 was interviewed by surveyors and stated I feel as though I'm being targeted by a staff member. The Director of Nursing (DON) she don't like me and wants me out of here. She believes anything anyone tells her. He continued to say, Yes I smoke weed but not on the property and I use heroin sometimes, not a lot. The surveyor asked how do you use it, and he replied, I smoke it. The surveyor asked if he received it from someone in the facility. He replied, No I get it outside. He was asked where do you use it? His response was I use it at the bus stop, I go out almost every day. He was asked if he was caught by staff in the facility with drugs or alcohol, and he replied, No they said I was smoking weed in my room, but I won't. He was questioned about the accusations from his roommate, and he stated, I bought him cigarettes, I didn't touch that [NAME] I didn't ask him for no sex. He didn't give me money for the cigarettes he is a liar. They gave me a notice to leave but I got nowhere to go. On 1-10-25 The Administrator delivered a 2-page document dated 1-10-25 entitled Facility Reported Incident (FRI), Date reported 1-10-25, and was signed by the current Administrator. The synopsis was a simple typed document on a clean white unlined sheet of copy paper, and did not state that it was an initial FRI, nor a 5 day follow up. The document described a portion of the incident of 1-7-25, and the fact that Resident #131 alleged that his roommate (Resident #130) had made sexual advances to him and had attempted to block the doorway to keep him (Resident #131) from leaving the room. This was the third time that the allegation of abuse was made to someone in the facility, and to others. The first being the day of the occurrence to staff witnesses, the second to APS who reported it to the facility, to police, and the state agency, and the third on this day 1-10-25. The document reported that Resident #131 had moved Resident #130 out of the way and exited the room. The document included that Resident #131 stated again he was tired of his roommate (Resident #130) making sexual advances at him and he wanted to be out of that room. Resident #131 also stated he wanted to be discharged . The Administrator documented on 1-10-25 that Resident #130 denied the allegation of sexual abuse, and that the facility had concluded that the allegation was unsubstantiated, and was first reported to them on this day. These assertions are incorrect as staff were aware and present on 1-7-25 when the abuse was alleged to have occurred and was first documented. Further the Resident stated to the Administrator (as written in the above portion of the Administrators document) that he was blocked from leaving by his roommate, he was tired of his roommate (Resident #130) making sexual advances at him and he wanted to be out of that room. Sexual abuse and sexual harassment are both crimes. By the facility staff's documentation, and own admission this was reported repeatedly to them, observed by floor baseline staff when it occurred, reported to APS by a complainant, and they continued to report it as unsubstantiated. The facility Resident Protections from abuse policy failures included all of the following 4 areas; 1. The facility was expected to complete background checks on all employees to protect the Resident population from abuse, also training was to be conducted annually for staff. (Training) 2. The Abuse policy document also stated that Residents would be protected if an allegation of abuse was made, and the police involved if that allegation alleged that a crime had happened. (Protection) 3. The Abuse policy document also stated that a comprehensive investigation would be conducted. (Investigation) 4. The document further stated that the state agency and other stake holders would be notified within 24 hours of an allegation of abuse, and that the report would occur within 2 hours if injury occurred. Then the initial report would be followed by a five day follow up report which would be sent to the state agency after the facility investigated to reveal their findings. (Reporting) The facility staff failed to conduct required education for staff, failed to complete background checks in compliance with regulations. The facility staff failed to report the allegation of abuse to the state agency until the state agency reported it to them again 3 days after the allegation was made to, and witnessed by, staff. Police were not called after an allegation that a crime had occurred which was requested by the Resident and his spouse, and a comprehensive investigation was not conducted until the state agency asked for one 3 days after the allegation of abuse was known by staff The facility Abuse policies were not implemented specifically involving and including the following evidence; TRAINING failure: Protections from Abuse and other annual training records in the facility were reviewed and revealed that Certified Nursing Assistants (CNA's) 12 hours of required annual training was not completed for 4 of the 6 employees reviewed, and background checks for staff were also found to be deficient. PROTECTION failure: Resident #131 was not afforded police intervention, he was protected by a room move, however, there were no other Resident interviews to ascertain if any other Residents in the building had ever experienced this abuse, and if from this abuser. INVESTIGATION failure: None of the staff witnesses of the 1-7-25 incident were interviewed, nor were statements received, and Resident #4's previous and current roommates were not interviewed. The spouse of Resident #131 was not interviewed, and other Residents on the unit were not interviewed. The FRI document stated that on 1-10-25 the first notification by the Resident was obtained. This was incorrect, as staff witnessed the incident partially, if not fully, and documented it. A witness to the incident called APS on 1-7-25. The Resident was blockaded from leaving his room which was witnessed by staff, as he was told police would arrest him for pushing his aggressor, proving involuntary seclusion/kidnapping, and he screamed for help which resulted in staff intervention. Further the Resident wanted a room change because of the allegation which was made by Resident #131 to staff. The allegation of abuse was alleged by a witness to APS, alleged by the Resident's spouse, alleged by the Resident, and by Administration in their synopsis/FRI (facility reported incident) to the state agency on 1-10-25. The 1-10-25 initial facility document does not include many of the avenues that were available to the facility for a complete investigation, and thus they were unable to reach a more comprehensive conclusion of events. Initial REPORTING failure: The 1-10-25 FRI document was the first report by the facility after the allegation of a sexual abuse that facility staff were made aware of on 1-7-25. This document was derived on 1-10-25 only after surveyors requested documentation of it, and 3 days after the abuse occurred. Any allegation of abuse is mandated to be reported within 24 hours if no serious injury occurred to the state agency (VDH/OLC) Virginia Department of Health/Office of Licensure and Certification. The Department of Social Services office of Adult protective Services (APS) were not notified by the facility, and the police were not called by the facility as was requested by Resident #131 and his spouse on the day of the occurrence. INVESTIGATION follow up RESULTS failure: The 5-day mandated follow up reporting after a full investigation; The Administrator's synopsis on 1-10-25 alleges that the abuse was unsubstantiated. A review of all the above evidence by the state agency reveals it to be substantiated, in part, or in all. A police investigation would have been appropriate in this case, as both Residents were alert, and oriented to person, place, time, and situation, however, this was not afforded to Resident #131. On 1-10-25 Two nursing staff members spoke to surveyors on agreement of anonymity as they feared retaliation if it were known that they had spoken to surveyors. The two Nursing staff members worked on the units where Residents #131, and #130 were housed and both agreed that Resident #130 bought cigarettes for Resident #131, however, they stated that they had never known of a problem with that as no one complained about it, and they agreed that Resident #131 always went outside to smoke and had not created an issue. One was an agency nurse who worked in the facility, and one was a facility employee. Both stated they were aware of the incident involving Residents #130, and #131, and stated they wondered when the situation would blow up because Resident #130 was obviously grooming and pursuing Resident #131 (name), with the cigarettes, and Resident #131 (name) was married. The nurses were asked if the Administration was aware and they both stated yeah they knew, we all knew. During interview on 1-29-25 and review of the clinical record, it was found that the Social Worker had only been there a short time, however, was aware of the incident with Resident's #131, and #130. She stated that Resident #131 (name) had been discharged on 1-23-25 to a group home in (name) closer to family a near by county. She also stated that Resident #130 would be discharging on 1-29-25 to a different group home closer to the facility. At that time the Administrator was informed that the investigation was incomplete, and no FRI was ever received at the state agency VDH/OLC for the first allegation of abuse. She was further notified they had not implemented their policies on abuse. The allegations were never reported to the state agency until the day after surveyors asked for an investigation. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any added staff supervision for Resident #130 to prevent the abuse from continuing with another Resident. No staff ever reported the suspicion of a crime, and no police report was ever filed. The first alleged report by the Administrator was incomplete and had errors in information giving the appearance of a verbal altercation and that the victim was not touched. APS, was not notified of the alleged abuse by facility Administration, and was instead notified by a complainant resulting in an investigation being opened by the state agency. On 1-30-25 at approximately 4:00 p.m., the facility Administrator, Corporate Registered Nurse, and DON were notified of the findings. They stated they had no further information or documentation to offer. 2. Resident #7 while in psychosis and having suicidal ideation was admitted to the hospital was found to have a switch blade in her bedside table on 1/26/25, on the same day was re-admitted to the facility on [DATE]. The facility staff failed to report the above allegation within the required time frame of 2 hours to the State Survey Agency. Resident #7 was originally admitted to the facility 12/04/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Schizoaffective Disorder and Bipolar Disorder Unspecified. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/16/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #7 cognitive abilities for daily decision making were intact. In sectionG(Functional Status) the resident was coded as requiring supervision of one person with transfers, bed mobility, eating and toileting. The Care Plan dated 12/05/23 read that Resident #7 has a mood problem related to: schizoaffective disorder, depression, anxiety and bipolar disorder. The resident has a history of hospitalization through suicidal ideation. The goal for the resident was that the resident will have improved mood state through the next review date. Interventions for the resident are to monitor medications as ordered and Behavioral consults as needed. During the initial tour an interview was conducted to Resident #7 concerning hospitalizations. Resident #7 said that she went to the hospital recently for having a cough but was recently admitted back to the facility. A change of condition note dated on 01/26/2025 at 5:34 PM., Resident alerted writer that she was actively SI (Suicidal Ideation) with plan to cut herself. Resident admitted to having switchblade in her bedside drawer. Writer entered residents' room to find carpenter knife in her top drawer on the right-hand side. Resident states the staff put it in her drawer. Writer notified provider on call, resident refused to take any medications at this time, stating I need to go to the hospital if you don't call 911 I will. Writer informed provider of this who advised writer to send her to the ER for further evaluation. 911 called, charge nurse notified, residents POA contacted with no answer, will try to call again. VSS 137/69, 18RR, 97.6T, 70HR, 96%RA. Resident is A&OX3. An interview was conducted on 02/05/25 at approximately 2:57 PM., with Licensed Practical Nurse (LPN) H. LPN H said that while working the 3-11 shift, Resident #7 said that she was feeling suicidal, wanted to go to the hospital and was going to use the switch blade in top drawer on the right side of her bed. LPN H also said that she grabbed the weapon the knife and the resident told her to hurry up and call the police. LPN H said that the police confiscated the weapon from her. On 02/05/25 at approximately 2:28 PM., an interview was conducted with LPN J concerning Resident #7. LPN J said that she was called up stairs by the facility staff informing her that Resident #7 had a Swiss knife. LPN J said that once she saw the Swiss knife it looked like something a [NAME] would use to clean fish, it had a wine cork remover, a screwdriver and a nail file attached to it. Once I came upstairs and entered the resident's room, she informed me that it (Swiss knife) was in her drawer, but the nurse had informed me that she took it. resident said that she wanted to kill herself. the resident was sent out for psych eval. she told EMTS that it was in her drawer. On 2/04/25 at approximately 4:20 PM., an end of day meeting was conducted with Administrator, the Director of Nursing (DON)., the Regional/Corporate staff, Regional Risk Management, the Regional Nurse Consultant and with the [NAME] President of Clinical Services concerning Resident #7. They were asked if an incident report or facility synopsis had been documented concerning the above incident involving a knife. The Administrator said that no facility synopsis had been filed but a soft file should have been completed instead. The administrator also mentioned that witnessed statements were received today as well as staff interviews. The above staff were also asked if death or harm could have been caused if the resident had used the Swiss Knife to cut herself. No comments were made. Swiss Army knife The Swiss Army knife is a pocketknife, generally multi-tooled. The term Swiss Army knife was coined by American soldiers after World War II because they had trouble pronouncing the German word Offiziersmesser, meaning officer's knife. The Swiss Army knife generally has a drop-point main blade plus other types of blades and tools, such as a screwdriver, a can opener, a saw blade, a pair of scissors, and many others. These are folded into the handle of the knife through a pivot point mechanism. https://en.wikipedia.org/wiki/Swiss_Army_knife. 3. The facility staff failed to report allegations of abuse in a timely manner to the State Survey Agency after Resident #39 alleged being physically abused by a staff member. Resident #39 was originally admitted to the facility 11/09/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Depression, Unspecified. The 5-day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/17/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #39 cognitive abilities for daily decision making were moderately impaired. In sectionGG(Functional Abilities Goals) the resident was coded as requiring partial/moderate assistance with eating, oral hygiene. Resident coded as dependent in lower body dressing, personal hygiene and rolling left and right. The care plan dated 11/22/23 read that Resident #39 had an Activities of Daily Living (ADL) self-care performance deficit related to multiple sclerosis, rheumatoid arthritis, spinal stenosis, right foot drop, morbid obesity, osteoarthritis, bilateral hand contractures and personality disorder. The Goal was to have the resident participate in as much of her ADL care as possible. The intervention for the resident requires total dependance by 2 staff members for toileting and requires max assist to total dependance by 2 staff members for bed mobility, transfers and one person assist for mobility in wheelchair. A review of a nursing note dated 2/04/25 at 12:33 PM., read: State surveyors question this writer about concerns that resident stating that there was an incident with a cna handling her roughly during incontinent care, when this writer spoke with resident concerning this incident, resident denied speaking to surveyor about incident, stating it never happened. Progress note on 2/05/25 at 12 Midnight: Patient with h/o depression, on no psychotropics. She was seen on 9.18.24 and no change was made to her treatment regimen. She is being seen today at the staff request because she reported to the department of health that a CNA was rough with her during care in early 2024. She is found in bed today; she is alert, calm and pleasant. She says she is doing well. She says this incident took place in April 2024. She says a CNA who was caring for her pushed her too far towards the wall. She felt this person was too rough with me. She says she reported this to the unit manager immediately and this individual never cared for her again. She says she also reported this to the VDH because she felt she needed they needed to know. She says she is surprised it took until today for someone from the VDH to come see her. She says she was told this CNA is no longer here but the reason for her living is not related to her incident with her. She says nothing like that happened to her ever again and she feels safe here. A review of Facility Reported Synopsis dated 2/05/25 read that Resident #39 alleged she was handled roughly by staff during incontinent care. The incident occurred April or May of 2024. The alleged staff member is no longer employed with the facility. On 01/28/25 at approximately 3:48 PM., during the initial tour Resident #39 alleged that a Certified Nurses Aide was rough with her while turning her onto her side to provide incontinent care. The Abuse/Neglect/Misappropriation/Crime Policy reads dated 10/17/23 reads: There is zero tolerance for abuse, neglect, misappropriation of property, or any crime against a patient of the Health and Rehabilitation Center. Procedure: Any suspected or witnessed incidents of patient abuse, neglect, theft against a patient should be reported to the administration, an internal investigation conducted, appropriate and timely reporting to the State Survey Agency and other legally designated agencies, as well as staff corrective action, suspension, and/or termination as necessary. Failure for an employee to report any suspected or witnessed incident of mistreatment, abuse, neglect against a patient will result in corrective action. Immediately upon notification of any alleged violations involving, abuse, neglect or exploitation the administrator will immediately report to the state agency, but no later than 2 hours after the allegation is made. On 2/05/25 at approximately 7:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant.

Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to report an allegation of abuse to the state agency, police, and other stake holders timely for 4 Residents (Residents #131, #130, #7, and #39) in a survey sample size of 63 residents. The findings included: 1. The facility failures described above resulted in the sexual abuse/harassment of Resident #131 by Resident #130. Resident #131 (victim) was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Traumatic Brain Injury (TBI) after a motor vehicle accident, diplopia, muscle weakness, unsteadiness on feet, abnormal gait and mobility, wheelchair use, and cognitive communication deficit, although there was no communication deficit noted at the time of survey. Resident #131's most recent Minimum Data Set with an Assessment Reference Date of 1-23-25 was coded as a discharge assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and his own responsible party. The Resident required touch assistance from one staff member for transferring and was wheelchair bound at times and was able to stand or walk independently for short distances. He required set up or touch assistance only with hygiene and bathing. The Resident denied complaints against any other staff or Residents since his admission on [DATE]. The Resident was discharged to a group home on 1-23-25 to be closer to family and to the least restrictive environment. Resident #130 (aggressor of victim #131) was admitted to the facility on [DATE]. Hospital discharge records indicated that the Resident was alert and oriented to person, place and time, and was ambulatory. Diagnoses included but were not limited to: Major depressive disorder, recurrent anxiety, Chronic hepatitis C, type two diabetes, nicotine dependence, fractured left heel with infected wound sepsis due to Methicillin Susceptible Staphylococcus Aureus, enhanced barrier precautions, and history of infectious parasitic disease. Resident #130's most recent Minimum Data Set with an Assessment Reference Date of 12-17-24 was coded as a significant change assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicated no cognitive impairment. The Resident was his own responsible party. The Resident required partial to moderate assistance from one staff member for hygiene and bathing. Resident #130 was observed during survey as ambulating without assistance or device. Resident #130 went out of the facility daily using the public city bus transportation and repeatedly returned under the influence of drugs and alcohol. Instances of this were recorded in the nursing progress notes to include the following most recent to survey. 9-19-24 6:43 am Resident room noted with a strong odor of weeds [sic] by (Certified Nursing Assistant) CNA, nurse and CNA went in to ask resident, resident confirmed he has been smoking weed, we asked him to turn it over, he declined, resident educated about the implication of that, he was told his action will be reported to management. Describe any interventions attempted: Resident told he will be reported to management Effectiveness of Interventions: Resident will continue to be monitored. 12-20-24 7:24 a.m. (documentation time). Note Text: 4:10 am (time of actual observation) Writer notified of patient lethargic in dining room. Writer into dining room, patient seen with his head (laid backward supine fashion) behind wheelchair, lethargic and hard to arouse. Obtained vitals at 4:13 am 65/40, 56, 16, 100% RA (oxygen saturation on room air alone), BS 140 (blood sugar). Called resident several times, he responded and said, I'm high as a bitch. Writer asked resident several times what he had taken, he refused to say. 911 called made per his nurse. 911 into building. Assessed patient, resident remained with a low BP and heart rate. EMTs encouraged resident to go to hospital. Resident refused. Educated the resident on the importance of going to the hospital to monitor low BP and heart rate, resident continued to refuse. Multiple nurses from units educated the patient on the importance of his health. Encouraged resident to go with EMT to be seen at hospital. Resident then became aggressive saying he wasn't going to the hospital because there was nothing wrong with him. EMTs left building. Writer and nurse attempted to take resident to his room, he refused. Resident remained in dining room area. MD (physician) note - 12-20-24 - [Resident #130 name redacted] was found asleep in in his wheelchair. He reported that he was high. He was difficult to arouse, BPs were in the 60-70s systolic. EMS was called. Upon arrival his BP was still low, but he refused to go the hospital. He is at baseline this morning when I see him. All reports reviewed and spoke with staff about the incident. I am holding his BP meds over the weekend. No reports of fever, chills, chest pain, shortness of breath, nausea, vomiting, or diarrhea. ' 1-3-25 - 10:22 pm. Note Text: Nurse went to resident door, there was strong smell of weed in room, coming right to the hallway. Nurse supervisor notified. A review of Resident #130's care plan revealed the following entry regarding the use of illicit drugs and or alcohol: FOCUS: The Resident is at risk of complications due to a history of illicit drug use. Revision on: 12-16-24. GOAL: The Resident will not have any adverse reaction to alcoholism thru review period. Date Initiated: 12-16-2024. Target Date: 3-16-25. INTERVENTIONS: (3) 1. Observe Resident for signs and symptoms of intoxication or withdrawal from drugs such as tremors nausea/vomiting (severe) sweating and notify MD (doctor) as indicated. Date Initiated: 12-16-2024. 2. Administer medication as ordered. Date Initiated: 12-16-2024. 3. Vitals as needed. Date Initiated: 12-16-2024. On 1-7-25 at 11:14 am nursing progress notes documented Verbal spat with roommate .both parties speaking in elevated tones, no physical contact noted both parties separated. On 1-7-25 at 12:23 pm Resident #15 agreed to a room change, and his spouse was notified. Adult Protective Services (APS) was called by an anonymous caller at the facility and the incident of sexual abuse was reported to them. The caller stated in the APS report of 1-7-25 that the facility Administration did not notify police, and they (the Administration) stated the reason as that can't happen (because) is that Resident (Resident #131 victim) would be charged with assault for pushing Resident (#130 aggressor) out of the doorway so that Resident (#131) could escape. This note indicated that there was physical contact known by staff at the time which was denied in the 1-7-25 nursing note. It was also alleged by the caller to APS that Resident #130 had been making sexual advances toward Resident #131 and wanted to get in his pants. It was also alleged that Resident #131 was asked by facility staff Why can't you just go home? The caller went on to state that Resident #131 had been moved 4 times for different assaults, verbal and such, but this was the only sexual assault. This assertion of frequent moves was found to be true as Resident #131's census in the facility documented those moves. The APS caller stated that on this day (1-7-25) the situation escalated and Resident #130 blocked the door of the room and told Resident #131 you are going to let me F K you. The caller stated that Resident #130 proceeded to touch, molest, and sexually assault Resident #131 who began yelling and screaming, and pushed Resident #130 out of the doorway into the hallway to escape when staff came to see what the commotion was about. Resident #131 told them immediately what had happened. On 1-9-25 at 1:00 pm, an interview was conducted with LPN A who stated that they are aware of the Residents going out on LOA (Leave of Absence) and coming back high, also stating but we cannot be with them at all times and cannot stop them leaving the facility. When asked what is done if they catch them smoking or drinking or using drugs in the facility, she stated, We document in the chart, notify the supervisor and educate them, that is all we can really do. When asked if the care plan should reflect the behaviors and interventions, she stated that it should. On 1-9-25 (the second day of survey) at 3:00 pm, Resident #130 was interviewed during an investigation involving Resident drug, alcohol, and weapons abuses that were found to be actively occurring in the facility. This Resident was found to be involved in drug abuse while a Resident. The Resident was asked about an altercation with his roommate which was documented in the nursing progress notes as having occurred on 1-7-25. Resident #130 stated he bought Resident #131 cigarettes and Resident #131 refused to pay him for them. He stated he had indeed used drugs but not in the facility, only outside. This statement was found to be false as staff stated they had removed drugs and drug paraphernalia from his room, and documented that at 4:00 AM on 12-20-24 the Resident was found in the dining room after using drugs in the facility, and was also using in the facility on 9-19-24, and 1-3-25. On 1-9-25 at 3:30 pm, Resident #131 in person, and his spouse by phone were interviewed. They both stated that Resident #130 had made advances toward Resident #131, however, Resident #131 stated he made it Clear that I am straight, married, and got no interest in no [NAME]. Resident #131 stated he would ask me to dress in front of him to see my chest, and I didn't care about that, because he said he would get me some cigarettes, but when he cornered me in the room and wouldn't let me leave the room and grabbed my D k and said I'm gonna F k you in the A , that was it! I screamed for help and pushed him through the door and the nurses almost got knocked down coming in, they heard it all just ask them. Resident #131 stated the temp agency nurse (name) and the other nurse who works here all the time (name) came. Resident #131 stated He (#130 name) and (Resident #106 name) smoke stuff in the room and have overdosed sometimes. I just want out of here. Resident #131 was asked if he had reported the sexual abuse, and he stated I told the nurses, they saw it happen! I told the Administrator who said I would be arrested for pushing him if I called the police, and I've told everybody, but they just moved me to another room. On 1-9-25 A copy of all Facility Reported Incidents (FRI's) for the prior 6 months were requested. Nine (9) were provided by the Administrator, and all 9 followed the standardized format and documentation included notification of the state agency the Virginia Department of Health Office of Licensure and Certification (VDH/OLC), the state Long Term Care Ombudsman, and Adult Protective Services (APS). The 9 completed FRI's were all prior to 9-20-24. On 1-9-25 at 4:00 pm the facility Administrator was asked for any investigation from 1-7-25 involving Residents #130, and #131. On 1-10-25 at 5:00 pm Resident #130 was interviewed by surveyors and stated I feel as though I'm being targeted by a staff member. The Director of Nursing (DON) she don't like me and wants me out of here. She believes anything anyone tells her. He continued to say, Yes I smoke weed but not on the property and I use heroin sometimes, not a lot. The surveyor asked how do you use it, and he replied, I smoke it. The surveyor asked if he received it from someone in the facility. He replied, No I get it outside. He was asked where do you use it? His response was I use it at the bus stop, I go out almost every day. He was asked if he was caught by staff in the facility with drugs or alcohol, and he replied, No they said I was smoking weed in my room, but I won't. He was questioned about the accusations from his roommate, and he stated, I bought him cigarettes, I didn't touch that [NAME] I didn't ask him for no sex. He didn't give me money for the cigarettes he is a liar. They gave me a notice to leave but I got nowhere to go. On 1-10-25, the Administrator delivered a 2-page document dated 1-10-25 entitled Facility Reported Incident (FRI), Date reported 1-10-25, and was signed by the current Administrator. The synopsis was a simple typed document on a clean white unlined sheet of copy paper, and did not state that it was an initial FRI, nor a 5 day follow up. The document described a portion of the incident of 1-7-25, and the fact that Resident #131 alleged that his roommate (Resident #130) had made sexual advances to him and had attempted to block the doorway to keep him (Resident #131) from leaving the room. This was the third time that the allegation of abuse was made to someone in the facility, and to others. The first being the day of the occurrence to staff witnesses, the second to APS who reported it to the facility, to police, and the state agency, and the third on this day 1-10-25. The document reported that Resident #131 had moved Resident #130 out of the way and exited the room. The document included that Resident #131 stated again he was tired of his roommate (Resident #130) making sexual advances at him and he wanted to be out of that room. Resident #131 also stated he wanted to be discharged . The Administrator documented on 1-10-25 that Resident #130 denied the allegation of sexual abuse, and that the facility had concluded that the allegation was unsubstantiated, and was first reported to them on this day. These assertions are incorrect as staff were aware and present on 1-7-25 when the abuse was alleged to have occurred and was first documented. Further the Resident stated to the Administrator (as written in the above portion of the Administrators document) that he was blocked from leaving by his roommate, he was tired of his roommate (Resident #130) making sexual advances at him and he wanted to be out of that room. Sexual abuse and sexual harassment are both crimes. By the facility staff's documentation, and own admission this was reported repeatedly to them, observed by floor baseline staff when it occurred, reported to APS by a complainant, and they continued to report it as unsubstantiated. The facility Resident Protections from abuse policy failures included all of the following 4 areas; 1. The facility was expected to complete background checks on all employees to protect the Resident population from abuse, also training was to be conducted annually for staff. (Training) 2. The Abuse policy document also stated that Residents would be protected if an allegation of abuse was made, and the police involved if that allegation alleged that a crime had happened. (Protection) 3. The Abuse policy document also stated that a comprehensive investigation would be conducted. (Investigation) 4. The document further stated that the state agency and other stake holders would be notified within 24 hours of an allegation of abuse, and that the report would occur within 2 hours if injury occurred. Then the initial report would be followed by a five day follow up report which would be sent to the state agency after the facility investigated to reveal their findings. (Reporting) The facility staff failed to conduct required education for staff, failed to complete background checks in compliance with regulations. The facility staff failed to report the allegation of abuse to the state agency until the state agency reported it to them again 3 days after the allegation was made to, and witnessed by, staff. Police were not called after an allegation that a crime had occurred which was requested by the Resident and his spouse, and a comprehensive investigation was not conducted until the state agency asked for one 3 days after the allegation of abuse was known by staff. The facility Abuse policies were not implemented specifically involving and including the following evidence; TRAINING failure: Protections from Abuse and other annual training records in the facility were reviewed and revealed that Certified Nursing Assistants (CNA's) 12 hours of required annual training was not completed for 4 of the 6 employees reviewed, and background checks for staff were also found to be deficient. PROTECTION failure: Resident #131 was not afforded police intervention, he was protected by a room move, however, there were no other Resident interviews to ascertain if any other Residents in the building had ever experienced this abuse, and if from this abuser. INVESTIGATION failure: None of the staff witnesses of the 1-7-25 incident were interviewed, nor were statements received, and Resident #4's previous and current roommates were not interviewed. The spouse of Resident #131 was not interviewed, and other Residents on the unit were not interviewed. The FRI document stated that on 1-10-25 the first notification by the Resident was obtained. This was incorrect, as staff witnessed the incident partially, if not fully, and documented it. A witness to the incident called APS on 1-7-25. The Resident was blockaded from leaving his room which was witnessed by staff, as he was told police would arrest him for pushing his aggressor, proving involuntary seclusion/kidnapping, and he screamed for help which resulted in staff intervention. Further the Resident wanted a room change because of the allegation which was made by Resident #131 to staff. The allegation of abuse was alleged by a witness to APS, alleged by the Resident's spouse, alleged by the Resident, and by Administration in their synopsis/FRI (facility reported incident) to the state agency on 1-10-25. The 1-10-25 initial facility document does not include many of the avenues that were available to the facility for a complete investigation, and thus they were unable to reach a more comprehensive conclusion of events. Initial REPORTING failure: The 1-10-25 FRI document was the first report by the facility after the allegation of a sexual abuse that facility staff were made aware of on 1-7-25. This document was derived on 1-10-25 only after surveyors requested documentation of it, and 3 days after the abuse occurred. Any allegation of abuse is mandated to be reported within 24 hours if no serious injury occurred to the state agency (VDH/OLC) Virginia Department of Health/Office of Licensure and Certification. The Department of Social Services office of Adult protective Services (APS) were not notified by the facility, and the police were not called by the facility as was requested by Resident #131 and his spouse on the day of the occurrence. INVESTIGATION follow up RESULTS failure: The 5-day mandated follow up reporting after a full investigation; The Administrator's synopsis on 1-10-25 alleges that the abuse was unsubstantiated. A review of all the above evidence by the state agency reveals it to be substantiated, in part, or in all. A police investigation would have been appropriate in this case, as both Residents were alert, and oriented to person, place, time, and situation, however, this was not afforded to Resident #131. On 1-10-25 Two nursing staff members spoke to surveyors on agreement of anonymity as they feared retaliation if it were known that they had spoken to surveyors. The two Nursing staff members worked on the units where Residents #131, and #130 were housed and both agreed that Resident #130 bought cigarettes for Resident #131, however, they stated that they had never known of a problem with that as no one complained about it, and they agreed that Resident #131 always went outside to smoke and had not created an issue. One was an agency nurse who worked in the facility, and one was a facility employee. Both stated they were aware of the incident involving Residents #130, and #131, and stated they wondered when the situation would blow up because Resident #130 was obviously grooming and pursuing Resident #131 (name), with the cigarettes, and Resident #131 (name) was married. The nurses were asked if the Administration was aware and they both stated yeah they knew, we all knew. During interview on 1-29-25 and review of the clinical record, it was found that the Social Worker had only been there a short time, however, was aware of the incident with Resident's #131, and #130. She stated that Resident #131 (name) had been discharged on 1-23-25 to a group home in (name) closer to family a near by county. She also stated that Resident #130 would be discharging on 1-29-25 to a different group home closer to the facility. At that time the Administrator was informed that the investigation was incomplete, and no FRI was ever received at the state agency VDH/OLC for the first allegation of abuse. She was further notified they had not implemented their policies on abuse. The allegations were never reported to the state agency until the day after surveyors asked for an investigation. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any added staff supervision for Resident #130 to prevent the abuse from continuing with another Resident. No staff ever reported the suspicion of a crime, and no police report was ever filed. The first alleged report by the Administrator was incomplete and had errors in information giving the appearance of a verbal altercation and that the victim was not touched. APS, was not notified of the alleged abuse by facility Administration, and was instead notified by a complainant resulting in an investigation being opened by the state agency. On 1-30-25 at approximately 4:00 p.m., the facility Administrator, Corporate Registered Nurse, and DON were notified of the findings. They stated they had no further information or documentation to offer. The facility's staff failed to report allegations of abuse or self-harm within a timely manner for Resident #7. 2. Resident #7 while in psychosis and having suicidal ideation was admitted to the hospital was found to have a switch blade in her bedside table on 1/26/25, on the same day was re-admitted to the facility on [DATE]. The facility staff failed to report the above allegation within the required time frame of 2 hours to the State Survey Agency. Resident #7 was originally admitted to the facility 12/04/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Schizoaffective Disorder and Bipolar Disorder Unspecified. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/16/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #7 cognitive abilities for daily decision making were intact. In sectionG(Functional Status) the resident was coded as requiring supervision of one person with transfers, bed mobility, eating and toileting. The Care Plan dated 12/05/23 read that Resident #7 has a mood problem related to: schizoaffective disorder, depression, anxiety and bipolar disorder. The resident has a history of hospitalization through suicidal ideation. The goal for the resident was that the resident will have improved mood state through the next review date. Interventions for the resident are to monitor medications as ordered and Behavioral consults as needed. During the initial tour an interview was conducted to Resident #7 concerning hospitalizations. Resident #7 said that she went to the hospital recently for having a cough but was recently admitted back to the facility. A change of condition note dated on 01/26/2025 at 5:34 PM., Resident alerted writer that she was actively SI (Suicidal Ideation) with plan to cut herself. Resident admitted to having switchblade in her bedside drawer. Writer entered residents' room to find carpenter knife in her top drawer on the right-hand side. Resident states the staff put it in her drawer. Writer notified provider on call, resident refused to take any medications at this time, stating I need to go to the hospital if you don't call 911 I will. Writer informed provider of this who advised writer to send her to the ER for further evaluation. 911 called, charge nurse notified, residents POA contacted with no answer, will try to call again. VSS 137/69, 18RR, 97.6T, 70HR, 96%RA. Resident is A&OX3. An interview was conducted on 02/05/25 at approximately 2:57 PM., with Licensed Practical Nurse (LPN) H. LPN H said that while working the 3-11 shift, Resident #7 said that she was feeling suicidal, wanted to go to the hospital and was going to use the switch blade in top drawer on the right side of her bed. LPN H also said that she grabbed the weapon the knife and the resident told her to hurry up and call the police. LPN H said that the police confiscated the weapon from her. On 02/05/25 at approximately 2:28 PM., an interview was conducted with LPN J concerning Resident #7. LPN J said that she was called up stairs by the facility staff informing her that Resident #7 had a Swiss knife. LPN J said that once she saw the Swiss knife it looked like something a [NAME] would use to clean fish, it had a wine cork remover, a screwdriver and a nail file attached to it. Once I came upstairs and entered the resident's room, she informed me that it (Swiss knife) was in her drawer, but the nurse had informed me that she took it. resident said that she wanted to kill herself. the resident was sent out for psych eval. she told EMTS that it was in her drawer. On 2/04/25 at approximately 4:20 PM., an end of day meeting was conducted with Administrator, the Director of Nursing (DON)., the Regional/Corporate staff, Regional Risk Management, the Regional Nurse Consultant and with the [NAME] President of Clinical Services concerning Resident #7. They were asked if an incident report or facility synopsis had been documented concerning the above incident involving a knife. The Administrator said that no facility synopsis had been filed but a soft file should have been completed instead. The administrator also mentioned that witnessed statements were received today as well as staff interviews. The above staff were also asked if death or harm could have been caused if the resident had used the Swiss Knife to cut herself. No comments were made. Swiss Army knife The Swiss Army knife is a pocketknife, generally multi-tooled. The term Swiss Army knife was coined by American soldiers after World War II because they had trouble pronouncing the German word Offiziersmesser, meaning officer's knife. The Swiss Army knife generally has a drop-point main blade plus other types of blades and tools, such as a screwdriver, a can opener, a saw blade, a pair of scissors, and many others. These are folded into the handle of the knife through a pivot point mechanism. https://en.wikipedia.org/wiki/Swiss_Army_knife. 3. Resident #39. The facility staff failed to report allegations of abuse in a timely manner to the State Survey Agency after resident alleged being physically abused by a staff member. Resident #39 was originally admitted to the facility 11/09/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Depression, Unspecified. The 5-day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/17/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #39 cognitive abilities for daily decision making were moderately impaired. In sectionGG(Functional Abilities Goals) the resident was coded as requiring partial/moderate assistance with eating, oral hygiene. Resident coded as dependent in lower body dressing, personal hygiene and rolling left and right. The care plan dated 11/22/23 read that Resident #39 had an Activities of Daily Living (ADL) self-care performance deficit related to multiple sclerosis, rheumatoid arthritis, spinalstenosis, right foot drop, morbid obesity, osteoarthritis, bilateral hand contractures and personality disorder. The Goal was to have the resident participate in as much of her ADL care as possible. The intervention for the resident requires total dependance by 2 staff members for toileting and requires max assist to total dependance by 2 staff members for bed mobility, transfers and one person assist for mobility in wheelchair. A review of a nursing note dated 2/04/25 at 12:33 PM., read: State surveyors question this writer about concerns that resident stating that there was an incident with a cna handling her roughly during incontinent care, when this writer spoke with resident concerning this incident, resident denied speaking to surveyor about incident, stating it never happened. Progress note on 2/05/25 at 12 Midnight: Patient with h/o depression, on no psychotropics. She was seen on 9.18.24 and no change was made to her treatment regimen. She is being seen today at the staff request because she reported to the department of health that a CNA was rough with her during care in early 2024. She is found in bed today; she is alert, calm and pleasant. She says she is doing well. She says this incident took place in April 2024. She says a CNA who was caring for her pushed her too far towards the wall. She felt this person was too rough with me. She says she reported this to the unit manager immediately and this individual never cared for her again. She says she also reported this to the VDH because she felt she needed they needed to know. She says she is surprised it took until today for someone from the VDH to come see her. She says she was told this CNA is no longer here but the reason for her living is not related to her incident with her. She says nothing like that happened to her ever again and she feels safe here. A review of Facility Reported Synopsis dated 2/05/25 read that Resident #39 alleged she was handled roughly by staff during incontinent care. The incident occurred April or May of 2024. The alleged staff member is no longer employed with the facility. On 01/28/25 at approximately 3:48 PM., during the initial tour Resident #39 alleged that a Certified Nurses Aide was rough with her while turning her onto her side to provide incontinent care. On 2/05/25 at approximately 7:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The Abuse/Neglect/Misappropriation/Crime Policy reads dated 10/17/23 reads: There is zero tolerance for abuse, neglect, misappropriation of property, or any crime against a patient of the Health and Rehabilitation Center. Procedure: Any suspected or witnessed incidents of patient abuse, neglect, theft against a patient should be reported to the administration, an internal investigation conducted, appropriate and timely reporting to the State Survey Agency and other legally designated agencies, as well as staff corrective action, suspension, and/or termination as necessary. Failure for an employee to report any suspected or witnessed incident of mistreatment, abuse, neglect against a patient will result in corrective action. Immediately upon notification of any alleged violations involving, abuse, neglect or exploitation the administrator will immediately report to the [TRUNCATED]

Based on resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to allow resident to manage financial affairs for 1 of 38 residents (Resident #135), in the survey sample. The findings included: Resident #135 was originally admitted to the facility 9/10/24. The current diagnoses included Non-ST-elevation Myocardial Infarction, muscle weakness, type 2 diabetes mellitus with hyperglycemia, and essential hypertension. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/17/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #135's cognitive abilities for daily decision making were intact. An interview was conducted on 5/21/25 at 1:45 PM with Resident #135. Resident #135 stated, the facility is trying to kick me out because I owe them money. Resident #135 also stated, a payment plan has been set up with the Business Office Manager but they are still trying to make me leave the facility. A review of a facility document: Form SSA-11-BK (Request To Be Selected As Payee) read that the Business Office Manager applied to have Forest Hill Health and Rehabilitation as the Payee regarding Resident #135's social security benefits. An interview was conducted on 5/22/25 at 1:30 PM with the Business Office Manager. The Business Office Manager stated that on 4/29/25 the facility applied to have Forest Hill Health and Rehabilitation as the Payee regarding Resident #135's social security benefits using Form SSA-11-BK (Request To Be Selected As Payee). The Business Office Manager also stated that Form SSA-787 (Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits) was completed by the Nurse Practitioner (NP) on 4/25/25. The Business Office Manager further stated that the NP answered that Resident #135 is able to manage funds or direct others how to manage them, as well as being able to manage funds in the future on the Form SSA-787 (Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits). A review of Form SSA-787 (Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits) dated 4/25/25 read: Do you believe the patient is capable of managing or directing the management of benefits in his or her own best interest? Yes Do you expect the patient to be able to manage funds in the future? Yes An interview was conducted on 5/22/25 at 2:50 PM with Resident #135. Resident #135 stated he is able to manage his own financial affairs. Resident #135 also stated that he never gave permission to the Business Office Manager or the facility to make a request to the Social Security Administration to be selected as the payee regarding his benefits. The facility's Business Office/Collection Policy with an effective date of 1/1/25 read: For unpaid Patient Liability balances, the Business Office Manager must notify the resident/POA/Guardian/RP that due to the unpaid balance and refusal to pay we will be filing for Rep Payee. The Business Office Manager must initiate a Rep Payee application to be completed, signed by physician, and submitted to social security before end of month, or must have a signed RFMS agreement authorizing direct deposit. On 5/22/25 at approximately 7:00 p.m., a final interview was conducted with the Administrator, Director of Nursing, two (2) Corporate Nursing Consultants, Minimum Data Set Consultant, Regional Maintenance Director, and Regional Human Resource Director. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to protect one Resident from abuse by a room mate with known illicit drug and alcohol abuse in their shared room for 1 Resident (Residents #131) in a survey sample size of 63 residents. The findings included: Resident #131 was exposed to, and not protected from alleged sexual harassment and abuse, and facility known illicit drug and alcohol abuse in their shared room by his room mate (Resident #130). Resident #131 (victim) was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Traumatic Brain Injury (TBI) after a motor vehicle accident, diplopia, muscle weakness, unsteadiness on feet, abnormal gait and mobility, wheelchair use, and cognitive communication deficit, although there was no communication deficit noted at the time of survey. Resident #131's most recent Minimum Data Set with an Assessment Reference Date of 1-23-25 was coded as a discharge assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and his own responsible party. The Resident required touch assistance from one staff member for transferring and was wheelchair bound at times and was able to stand or walk independently for short distances. He required set up or touch assistance only with hygiene and bathing. The Resident denied complaints against any other staff or Residents since his admission on [DATE]. The Resident was discharged to a group home on 1-23-25 to be closer to family and to the least restrictive environment. Resident #130 (aggressor of victim #131) was admitted to the facility on [DATE]. Hospital discharge records indicated that the Resident was alert and oriented to person, place and time, and was ambulatory. Diagnoses included but were not limited to: Major depressive disorder, recurrent anxiety, Chronic hepatitis C, type two diabetes, nicotine dependence, fractured left heel with infected wound sepsis due to Methicillin Susceptible Staphylococcus Aureus, enhanced barrier precautions, and history of infectious parasitic disease. Resident #130's most recent Minimum Data Set with an Assessment Reference Date of 12-17-24 was coded as a significant change assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicated no cognitive impairment. The Resident was his own responsible party. The Resident required partial to moderate assistance from one staff member for hygiene and bathing. Resident #130 was observed during survey as ambulating without assistance or device. Resident #130 went out of the facility daily using the public city bus transportation and repeatedly returned under the influence of drugs and alcohol. Instances of this were recorded in the nursing progress notes to include the following most recent to survey. 9-19-24 6:43 am Resident room noted with a strong odor of weeds [sic] by (Certified Nursing Assistant) CNA, nurse and CNA went in to ask resident, resident confirmed he has been smoking weed, we asked him to turn it over, he declined, resident educated about the implication of that, he was told his action will be reported to management. Describe any interventions attempted: Resident told he will be reported to management Effectiveness of Interventions: Resident will continue to be monitored. 12-20-24 7:24 a.m. (documentation time). Note Text: 4:10 am (time of actual observation) Writer notified of patient lethargic in dining room. Writer into dining room, patient seen with his head (laid backward supine fashion) behind wheelchair, lethargic and hard to arouse. Obtained vitals at 4:13 am 65/40, 56, 16, 100% RA (oxygen saturation on room air alone), BS 140 (blood sugar). Called resident several times, he responded and said, I'm high as a bitch. Writer asked resident several times what he had taken, he refused to say. 911 called made per his nurse. 911 into building. Assessed patient, resident remained with a low BP and heart rate. EMTs encouraged resident to go to hospital. Resident refused. Educated the resident on the importance of going to the hospital to monitor low BP and heart rate, resident continued to refuse. Multiple nurses from units educated the patient on the importance of his health. Encouraged resident to go with EMT to be seen at hospital. Resident then became aggressive saying he wasn't going to the hospital because there was nothing wrong with him. EMTs left building. Writer and nurse attempted to take resident to his room, he refused. Resident remained in dining room area. MD (physician) note - 12-20-24 - [Resident #130 name redacted] was found asleep in in his wheelchair. He reported that he was high. He was difficult to arouse, BPs were in the 60-70s systolic. EMS was called. Upon arrival his BP was still low, but he refused to go the hospital. He is at baseline this morning when I see him. All reports reviewed and spoke with staff about the incident. I am holding his BP meds over the weekend. No reports of fever, chills, chest pain, shortness of breath, nausea, vomiting, or diarrhea. ' 1-3-25 - 10:22 pm. Note Text: Nurse went to resident door, there was strong smell of weed in room, coming right to the hallway. Nurse supervisor notified. A review of Resident #130's care plan revealed the following entry regarding the use of illicit drugs and or alcohol: FOCUS: The Resident is at risk of complications due to a history of illicit drug use. Revision on: 12-16-24. GOAL: The Resident will not have any adverse reaction to alcoholism thru review period. Date Initiated: 12-16-2024. Target Date: 3-16-25. INTERVENTIONS: (3) 1. Observe Resident for signs and symptoms of intoxication or withdrawal from drugs such as tremors nausea/vomiting (severe) sweating and notify MD (doctor) as indicated. Date Initiated: 12-16-2024. 2. Administer medication as ordered. Date Initiated: 12-16-2024. 3. Vitals as needed. Date Initiated: 12-16-2024. On 1-7-25 at 11:14 am nursing progress notes documented Verbal spat with roommate .both parties speaking in elevated tones, no physical contact noted both parties separated. On 1-7-25 at 12:23 pm Resident #15 agreed to a room change, and his spouse was notified. Adult Protective Services (APS) was called by an anonymous caller at the facility and the incident of sexual abuse was reported to them. The caller stated in the APS report of 1-7-25 that the facility Administration did not notify police, and they (the Administration) stated the reason as that can't happen (because) is that Resident (Resident #131 victim) would be charged with assault for pushing Resident (#130 aggressor) out of the doorway so that Resident (#131) could escape. This note indicated that there was physical contact known by staff at the time which was denied in the 1-7-25 nursing note. It was also alleged by the caller to APS that Resident #130 had been making sexual advances toward Resident #131 and wanted to get in his pants. It was also alleged that Resident #131 was asked by facility staff Why can't you just go home? The caller went on to state that Resident #131 had been moved 4 times for different assaults, verbal and such, but this was the only sexual assault. This assertion of frequent moves was found to be true as Resident #131's census in the facility documented those moves. The APS caller stated that on this day (1-7-25) the situation escalated and Resident #130 blocked the door of the room and told Resident #131 you are going to let me F K you. The caller stated that Resident #130 proceeded to touch, molest, and sexually assault Resident #131 who began yelling and screaming, and pushed Resident #130 out of the doorway into the hallway to escape when staff came to see what the commotion was about. Resident #131 told them immediately what had happened. On 1-9-25 at 1:00 pm an interview was conducted with LPN A who stated that they are aware of the Residents going out on LOA (Leave of Absence) and coming back high, also stating but we cannot be with them at all times and cannot stop them leaving the facility. When asked what is done if they catch them smoking or drinking or using drugs in the facility, she stated, We document in the chart, notify the supervisor and educate them, that is all we can really do. When asked if the care plan should reflect the behaviors and interventions, she stated that it should. On 1-9-25 (the second day of survey) at 3:00 pm, Resident #130 was interviewed during an investigation involving Resident drug, alcohol, and weapons abuses that were found to be actively occurring in the facility. This Resident was found to be involved in drug abuse while a Resident. The Resident was asked about an altercation with his roommate which was documented in the nursing progress notes as having occurred on 1-7-25. Resident #130 stated he bought Resident #131 cigarettes and Resident #131 refused to pay him for them. He stated he had indeed used drugs but not in the facility, only outside. This statement was found to be false as staff stated they had removed drugs and drug paraphernalia from his room, and documented that at 4:00 AM on 12-20-24 the Resident was found in the dining room after using drugs in the facility, and was also using in the facility on 9-19-24, and 1-3-25. On 1-9-25 at 3:30 pm, Resident #131 in person, and his spouse by phone were interviewed. They both stated that Resident #130 had made advances toward Resident #131, however, Resident #131 stated he made it Clear that I am straight, married, and got no interest in no [NAME]. Resident #131 stated he would ask me to dress in front of him to see my chest, and I didn't care about that, because he said he would get me some cigarettes, but when he cornered me in the room and wouldn't let me leave the room and grabbed my D k and said I'm gonna F k you in the A , that was it! I screamed for help and pushed him through the door and the nurses almost got knocked down coming in, they heard it all just ask them. Resident #131 stated the temp agency nurse (name) and the other nurse who works here all the time (name) came. Resident #131 stated He (#130 name) and (Resident #106 name) smoke stuff in the room and have overdosed sometimes. I just want out of here. Resident #131 was asked if he had reported the sexual abuse, and he stated I told the nurses, they saw it happen! I told the Administrator who said I would be arrested for pushing him if I called the police, and I've told everybody, but they just moved me to another room. On 1-9-25 A copy of all Facility Reported Incidents (FRI's) for the prior 6 months were requested. 9 were provided by the Administrator, and all 9 followed the standardized format and documentation included notification of the state agency the Virginia Department of Health Office of Licensure and Certification (VDH/OLC), the state Long Term Care Ombudsman, and Adult Protective Services (APS). The 9 completed FRI's were all prior to 9-20-24. On 1-9-25 at 4:00 pm the facility Administrator was asked for any investigation from 1-7-25 involving Residents #130, and #131. On 1-10-25 at 5:00 pm Resident #130 was interviewed by surveyors and stated I feel as though I'm being targeted by a staff member. The Director of Nursing (DON) she don't like me and wants me out of here. She believes anything anyone tells her. He continued to say, Yes I smoke weed but not on the property and I use heroin sometimes, not a lot. The surveyor asked how do you use it, and he replied, I smoke it. The surveyor asked if he received it from someone in the facility. He replied, No I get it outside. He was asked where do you use it? His response was I use it at the bus stop, I go out almost every day. He was asked if he was caught by staff in the facility with drugs or alcohol, and he replied, No they said I was smoking weed in my room, but I won't. He was questioned about the accusations from his roommate, and he stated, I bought him cigarettes, I didn't touch that [NAME] I didn't ask him for no sex. He didn't give me money for the cigarettes he is a liar. They gave me a notice to leave but I got nowhere to go. On 1-10-25 The Administrator delivered a 2-page document dated 1-10-25 entitled Facility Reported Incident (FRI), Date reported 1-10-25, and was signed by the current Administrator. The synopsis was a simple typed document on a clean white unlined sheet of copy paper, and did not state that it was an initial FRI, nor a 5 day follow up. The document described a portion of the incident of 1-7-25, and the fact that Resident #131 alleged that his roommate (Resident #130) had made sexual advances to him and had attempted to block the doorway to keep him (Resident #131) from leaving the room. This was the third time that the allegation of abuse was made to someone in the facility, and to others. The first being the day of the occurrence to staff witnesses, the second to APS who reported it to the facility, to police, and the state agency, and the third on this day 1-10-25. The document reported that Resident #131 had moved Resident #130 out of the way and exited the room. The document included that Resident #131 stated again he was tired of his roommate (Resident #130) making sexual advances at him and he wanted to be out of that room. Resident #131 also stated he wanted to be discharged . The Administrator documented on 1-10-25 that Resident #130 denied the allegation of sexual abuse, and that the facility had concluded that the allegation was unsubstantiated, and was first reported to them on this day. These assertions are incorrect as staff were aware and present on 1-7-25 when the abuse was alleged to have occurred and was first documented. Further the Resident stated to the Administrator (as written in the above portion of the Administrators document) that he was blocked from leaving by his roommate, he was tired of his roommate (Resident #130) making sexual advances at him and he wanted to be out of that room. Sexual abuse and sexual harassment are both crimes. By the facility staff's documentation, and own admission this was reported repeatedly to them, observed by floor baseline staff when it occurred, reported to APS by a complainant, and they continued to report it as unsubstantiated. The facility Resident Protections from abuse policy failures included all of the following 4 areas; 1. The facility was expected to complete background checks on all employees to protect the Resident population from abuse, also training was to be conducted annually for staff. (Training) 2. The Abuse policy document also stated that Residents would be protected if an allegation of abuse was made, and the police involved if that allegation alleged that a crime had happened. (Protection) 3. The Abuse policy document also stated that a comprehensive investigation would be conducted. (Investigation) 4. The document further stated that the state agency and other stake holders would be notified within 24 hours of an allegation of abuse, and that the report would occur within 2 hours if injury occurred. Then the initial report would be followed by a five day follow up report which would be sent to the state agency after the facility investigated to reveal their findings. (Reporting) The facility staff failed to conduct required education for staff, failed to complete background checks in compliance with regulations. The facility staff failed to report the allegation of abuse to the state agency until the state agency reported it to them again 3 days after the allegation was made to, and witnessed by, staff. Police were not called after an allegation that a crime had occurred which was requested by the Resident and his spouse, and a comprehensive investigation was not conducted until the state agency asked for one 3 days after the allegation of abuse was known by staff The facility Abuse policies were not implemented specifically involving and including the following evidence; TRAINING failure: Protections from Abuse and other annual training records in the facility were reviewed and revealed that Certified Nursing Assistants (CNA's) 12 hours of required annual training was not completed for 4 of the 6 employees reviewed, and background checks for staff were also found to be deficient. PROTECTION failure: Resident #131 was not afforded police intervention, he was protected by a room move, however, there were no other Resident interviews to ascertain if any other Residents in the building had ever experienced this abuse, and if from this abuser. INVESTIGATION failure: None of the staff witnesses of the 1-7-25 incident were interviewed, nor were statements received, and Resident #4's previous and current roommates were not interviewed. The spouse of Resident #131 was not interviewed, and other Residents on the unit were not interviewed. The FRI document stated that on 1-10-25 the first notification by the Resident was obtained. This was incorrect, as staff witnessed the incident partially, if not fully, and documented it. A witness to the incident called APS on 1-7-25. The Resident was blockaded from leaving his room which was witnessed by staff, as he was told police would arrest him for pushing his aggressor, proving involuntary seclusion/kidnapping, and he screamed for help which resulted in staff intervention. Further the Resident wanted a room change because of the allegation which was made by Resident #131 to staff. The allegation of abuse was alleged by a witness to APS, alleged by the Resident's spouse, alleged by the Resident, and by Administration in their synopsis/FRI (facility reported incident) to the state agency on 1-10-25. The 1-10-25 initial facility document does not include many of the avenues that were available to the facility for a complete investigation, and thus they were unable to reach a more comprehensive conclusion of events. Initial REPORTING failure: The 1-10-25 FRI document was the first report by the facility after the allegation of a sexual abuse that facility staff were made aware of on 1-7-25. This document was derived on 1-10-25 only after surveyors requested documentation of it, and 3 days after the abuse occurred. Any allegation of abuse is mandated to be reported within 24 hours if no serious injury occurred to the state agency (VDH/OLC) Virginia Department of Health/Office of Licensure and Certification. The Department of Social Services office of Adult protective Services (APS) were not notified by the facility, and the police were not called by the facility as was requested by Resident #131 and his spouse on the day of the occurrence. INVESTIGATION follow up RESULTS failure: The 5-day mandated follow up reporting after a full investigation; The Administrator's synopsis on 1-10-25 alleges that the abuse was unsubstantiated. A review of all the above evidence by the state agency reveals it to be substantiated, in part, or in all. A police investigation would have been appropriate in this case, as both Residents were alert, and oriented to person, place, time, and situation, however, this was not afforded to Resident #131. On 1-10-25 Two nursing staff members spoke to surveyors on agreement of anonymity as they feared retaliation if it were known that they had spoken to surveyors. The two Nursing staff members worked on the units where Residents #131, and #130 were housed and both agreed that Resident #130 bought cigarettes for Resident #131, however, they stated that they had never known of a problem with that as no one complained about it, and they agreed that Resident #131 always went outside to smoke and had not created an issue. One was an agency nurse who worked in the facility, and one was a facility employee. Both stated they were aware of the incident involving Residents #130, and #131, and stated they wondered when the situation would blow up because Resident #130 was obviously grooming and pursuing Resident #131 (name), with the cigarettes, and Resident #131 (name) was married. The nurses were asked if the Administration was aware and they both stated yeah they knew, we all knew. During interview on 1-29-25 and review of the clinical record, it was found that the Social Worker had only been there a short time, however, was aware of the incident with Resident's #131, and #130. She stated that Resident #131 (name) had been discharged on 1-23-25 to a group home in (name) closer to family a near by county. She also stated that Resident #130 would be discharging on 1-29-25 to a different group home closer to the facility. At that time the Administrator was informed that the investigation was incomplete, and no FRI was ever received at the state agency VDH/OLC for the first allegation of abuse. She was further notified they had not implemented their policies on abuse. The allegations were never reported to the state agency until the day after surveyors asked for an investigation. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any added staff supervision for Resident #130 to prevent the abuse from continuing with another Resident. No staff ever reported the suspicion of a crime, and no police report was ever filed. The first alleged report by the Administrator was incomplete and had errors in information giving the appearance of a verbal altercation and that the victim was not touched. APS, was not notified of the alleged abuse by facility Administration, and was instead notified by a complainant resulting in an investigation being opened by the state agency. On 1-30-25 at approximately 4:00 p.m., the facility Administrator, Corporate Registered Nurse, and DON were notified of the findings. They stated they had no further information or documentation to offer.

Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff discouraged one Resident from communication with external local entities/police during an abuse allegation, and did not allow evidence from a police report of the abuse situation for 2 Residents (Residents #131, and #130) in a survey sample size of 63 residents. The findings included: The facility failures described above resulted in the sexual abuse/harassment of Resident #131 by Resident #130, without police protection. Resident #131 (victim) was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Traumatic Brain Injury (TBI) after a motor vehicle accident, diplopia, muscle weakness, unsteadiness on feet, abnormal gait and mobility, wheelchair use, and cognitive communication deficit, although there was no communication deficit noted at the time of survey. Resident #131's most recent Minimum Data Set with an Assessment Reference Date of 1-23-25 was coded as a discharge assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and his own responsible party. The Resident required touch assistance from one staff member for transferring and was wheelchair bound at times and was able to stand or walk independently for short distances. He required set up or touch assistance only with hygiene and bathing. The Resident denied complaints against any other staff or Residents since his admission on [DATE]. The Resident was discharged to a group home on 1-23-25 to be closer to family and to the least restrictive environment. Resident #130 (aggressor of victim #131) was admitted to the facility on [DATE]. Hospital discharge records indicated that the Resident was alert and oriented to person, place and time, and was ambulatory. Diagnoses included but were not limited to: Major depressive disorder, recurrent anxiety, Chronic hepatitis C, type two diabetes, nicotine dependence, fractured left heel with infected wound sepsis due to Methicillin Susceptible Staphylococcus Aureus, enhanced barrier precautions, and history of infectious parasitic disease. Resident #130's most recent Minimum Data Set with an Assessment Reference Date of 12-17-24 was coded as a significant change assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicated no cognitive impairment. The Resident was his own responsible party. The Resident required partial to moderate assistance from one staff member for hygiene and bathing. Resident #130 was observed during survey as ambulating without assistance or device. Resident #130 went out of the facility daily using the public city bus transportation and repeatedly returned under the influence of drugs and alcohol. Instances of this were recorded in the nursing progress notes to include the following most recent to survey. 9-19-24 6:43 am Resident room noted with a strong odor of weeds [sic] by (Certified Nursing Assistant) CNA, nurse and CNA went in to ask resident, resident confirmed he has been smoking weed, we asked him to turn it over, he declined, resident educated about the implication of that, he was told his action will be reported to management. Describe any interventions attempted: Resident told he will be reported to management Effectiveness of Interventions: Resident will continue to be monitored. 12-20-24 7:24 a.m. (documentation time). Note Text: 4:10 am (time of actual observation) Writer notified of patient lethargic in dining room. Writer into dining room, patient seen with his head (laid backward supine fashion) behind wheelchair, lethargic and hard to arouse. Obtained vitals at 4:13 am 65/40, 56, 16, 100% RA (oxygen saturation on room air alone), BS 140 (blood sugar). Called resident several times, he responded and said, I'm high as a bitch. Writer asked resident several times what he had taken, he refused to say. 911 called made per his nurse. 911 into building. Assessed patient, resident remained with a low BP and heart rate. EMTs encouraged resident to go to hospital. Resident refused. Educated the resident on the importance of going to the hospital to monitor low BP and heart rate, resident continued to refuse. Multiple nurses from units educated the patient on the importance of his health. Encouraged resident to go with EMT to be seen at hospital. Resident then became aggressive saying he wasn't going to the hospital because there was nothing wrong with him. EMTs left building. Writer and nurse attempted to take resident to his room, he refused. Resident remained in dining room area. MD (physician) note - 12-20-24 - [Resident #130 name redacted] was found asleep in in his wheelchair. He reported that he was high. He was difficult to arouse, BPs were in the 60-70s systolic. EMS was called. Upon arrival his BP was still low, but he refused to go the hospital. He is at baseline this morning when I see him. All reports reviewed and spoke with staff about the incident. I am holding his BP meds over the weekend. No reports of fever, chills, chest pain, shortness of breath, nausea, vomiting, or diarrhea. ' 1-3-25 - 10:22 pm. Note Text: Nurse went to resident door, there was strong smell of weed in room, coming right to the hallway. Nurse supervisor notified. A review of Resident #130's care plan revealed the following entry regarding the use of illicit drugs and or alcohol: FOCUS: The Resident is at risk of complications due to a history of illicit drug use. Revision on: 12-16-24. GOAL: The Resident will not have any adverse reaction to alcoholism thru review period. Date Initiated: 12-16-2024. Target Date: 3-16-25. INTERVENTIONS: (3) 1. Observe Resident for signs and symptoms of intoxication or withdrawal from drugs such as tremors nausea/vomiting (severe) sweating and notify MD (doctor) as indicated. Date Initiated: 12-16-2024. 2. Administer medication as ordered. Date Initiated: 12-16-2024. 3. Vitals as needed. Date Initiated: 12-16-2024. On 1-7-25 at 11:14 am nursing progress notes documented Verbal spat with roommate .both parties speaking in elevated tones, no physical contact noted both parties separated. On 1-7-25 at 12:23 pm Resident #15 agreed to a room change, and his spouse was notified. Adult Protective Services (APS) was called by an anonymous caller at the facility and the incident of sexual abuse was reported to them. The caller stated in the APS report of 1-7-25 that the facility Administration did not notify police, and they (the Administration) stated the reason as that can't happen (because) is that Resident (Resident #131 victim) would be charged with assault for pushing Resident (#130 aggressor) out of the doorway so that Resident (#131) could escape. This note indicated that there was physical contact known by staff at the time which was denied in the 1-7-25 nursing note. It was also alleged by the caller to APS that Resident #130 had been making sexual advances toward Resident #131 and wanted to get in his pants. It was also alleged that Resident #131 was asked by facility staff Why can't you just go home? The caller went on to state that Resident #131 had been moved 4 times for different assaults, verbal and such, but this was the only sexual assault. This assertion of frequent moves was found to be true as Resident #131's census in the facility documented those moves. The APS caller stated that on this day (1-7-25) the situation escalated and Resident #130 blocked the door of the room and told Resident #131 you are going to let me F K you. The caller stated that Resident #130 proceeded to touch, molest, and sexually assault Resident #131 who began yelling and screaming, and pushed Resident #130 out of the doorway into the hallway to escape when staff came to see what the commotion was about. Resident #131 told them immediately what had happened. On 1-9-25 at 1:00 pm an interview was conducted with LPN A who stated that they are aware of the Residents going out on LOA (Leave of Absence) and coming back high, also stating but we cannot be with them at all times and cannot stop them leaving the facility. When asked what is done if they catch them smoking or drinking or using drugs in the facility, she stated, We document in the chart, notify the supervisor and educate them, that is all we can really do. When asked if the care plan should reflect the behaviors and interventions, she stated that it should. On 1-9-25 (the second day of survey) at 3:00 pm, Resident #130 was interviewed during an investigation involving Resident drug, alcohol, and weapons abuses that were found to be actively occurring in the facility. This Resident was found to be involved in drug abuse while a Resident. The Resident was asked about an altercation with his roommate which was documented in the nursing progress notes as having occurred on 1-7-25. Resident #130 stated he bought Resident #131 cigarettes and Resident #131 refused to pay him for them. He stated he had indeed used drugs but not in the facility, only outside. This statement was found to be false as staff stated they had removed drugs and drug paraphernalia from his room, and documented that at 4:00 AM on 12-20-24 the Resident was found in the dining room after using drugs in the facility, and was also using in the facility on 9-19-24, and 1-3-25. On 1-9-25 at 3:30 pm, Resident #131 in person, and his spouse by phone were interviewed. They both stated that Resident #130 had made advances toward Resident #131, however, Resident #131 stated he made it Clear that I am straight, married, and got no interest in no [NAME]. Resident #131 stated he would ask me to dress in front of him to see my chest, and I didn't care about that, because he said he would get me some cigarettes, but when he cornered me in the room and wouldn't let me leave the room and grabbed my D k and said I'm gonna F k you in the A , that was it! I screamed for help and pushed him through the door and the nurses almost got knocked down coming in, they heard it all just ask them. Resident #131 stated the temp agency nurse (name) and the other nurse who works here all the time (name) came. Resident #131 stated He (#130 name) and (Resident #106 name) smoke stuff in the room and have overdosed sometimes. I just want out of here. Resident #131 was asked if he had reported the sexual abuse, and he stated I told the nurses, they saw it happen! I told the Administrator who said I would be arrested for pushing him if I called the police, and I've told everybody, but they just moved me to another room. On 1-9-25 A copy of all Facility Reported Incidents (FRI's) for the prior 6 months were requested. 9 were provided by the Administrator, and all 9 followed the standardized format and documentation included notification of the state agency the Virginia Department of Health Office of Licensure and Certification (VDH/OLC), the state Long Term Care Ombudsman, and Adult Protective Services (APS). The 9 completed FRI's were all prior to 9-20-24. On 1-9-25 at 4:00 pm the facility Administrator was asked for any investigation from 1-7-25 involving Residents #130, and #131. On 1-10-25 at 5:00 pm Resident #130 was interviewed by surveyors and stated I feel as though I'm being targeted by a staff member. The Director of Nursing (DON) she don't like me and wants me out of here. She believes anything anyone tells her. He continued to say, Yes I smoke weed but not on the property and I use heroin sometimes, not a lot. The surveyor asked how do you use it, and he replied, I smoke it. The surveyor asked if he received it from someone in the facility. He replied, No I get it outside. He was asked where do you use it? His response was I use it at the bus stop, I go out almost every day. He was asked if he was caught by staff in the facility with drugs or alcohol, and he replied, No they said I was smoking weed in my room, but I won't. He was questioned about the accusations from his roommate, and he stated, I bought him cigarettes, I didn't touch that [NAME] I didn't ask him for no sex. He didn't give me money for the cigarettes he is a liar. They gave me a notice to leave but I got nowhere to go. On 1-10-25 The Administrator delivered a 2-page document dated 1-10-25 entitled Facility Reported Incident (FRI), Date reported 1-10-25, and was signed by the current Administrator. The synopsis was a simple typed document on a clean white unlined sheet of copy paper, and did not state that it was an initial FRI, nor a 5 day follow up. The document described a portion of the incident of 1-7-25, and the fact that Resident #131 alleged that his roommate (Resident #130) had made sexual advances to him and had attempted to block the doorway to keep him (Resident #131) from leaving the room. This was the third time that the allegation of abuse was made to someone in the facility, and to others. The first being the day of the occurrence to staff witnesses, the second to APS who reported it to the facility, to police, and the state agency, and the third on this day 1-10-25. The document reported that Resident #131 had moved Resident #130 out of the way and exited the room. The document included that Resident #131 stated again he was tired of his roommate (Resident #130) making sexual advances at him and he wanted to be out of that room. Resident #131 also stated he wanted to be discharged . The Administrator documented on 1-10-25 that Resident #130 denied the allegation of sexual abuse, and that the facility had concluded that the allegation was unsubstantiated, and was first reported to them on this day. These assertions are incorrect as staff were aware and present on 1-7-25 when the abuse was alleged to have occurred and was first documented. Further the Resident stated to the Administrator (as written in the above portion of the Administrators document) that he was blocked from leaving by his roommate, he was tired of his roommate (Resident #130) making sexual advances at him and he wanted to be out of that room. Sexual abuse and sexual harassment are both crimes. By the facility staff's documentation, and own admission this was reported repeatedly to them, observed by floor baseline staff when it occurred, reported to APS by a complainant, and they continued to report it as unsubstantiated. The facility Resident Protections from abuse policy failures included all of the following 4 areas; 1. The facility was expected to complete background checks on all employees to protect the Resident population from abuse, also training was to be conducted annually for staff. (Training) 2. The Abuse policy document also stated that Residents would be protected if an allegation of abuse was made, and the police involved if that allegation alleged that a crime had happened. (Protection) 3. The Abuse policy document also stated that a comprehensive investigation would be conducted. (Investigation) 4. The document further stated that the state agency and other stake holders would be notified within 24 hours of an allegation of abuse, and that the report would occur within 2 hours if injury occurred. Then the initial report would be followed by a five day follow up report which would be sent to the state agency after the facility investigated to reveal their findings. (Reporting) The facility staff failed to conduct required education for staff, failed to complete background checks in compliance with regulations. The facility staff failed to report the allegation of abuse to the state agency until the state agency reported it to them again 3 days after the allegation was made to, and witnessed by, staff. Police were not called after an allegation that a crime had occurred which was requested by the Resident and his spouse, and a comprehensive investigation was not conducted until the state agency asked for one 3 days after the allegation of abuse was known by staff The facility Abuse policies were not implemented specifically involving and including the following evidence; TRAINING failure: Protections from Abuse and other annual training records in the facility were reviewed and revealed that Certified Nursing Assistants (CNA's) 12 hours of required annual training was not completed for 4 of the 6 employees reviewed, and background checks for staff were also found to be deficient. PROTECTION failure: Resident #131 was not afforded police intervention, he was protected by a room move, however, there were no other Resident interviews to ascertain if any other Residents in the building had ever experienced this abuse, and if from this abuser. INVESTIGATION failure: None of the staff witnesses of the 1-7-25 incident were interviewed, nor were statements received, and Resident #4's previous and current roommates were not interviewed. The spouse of Resident #131 was not interviewed, and other Residents on the unit were not interviewed. The FRI document stated that on 1-10-25 the first notification by the Resident was obtained. This was incorrect, as staff witnessed the incident partially, if not fully, and documented it. A witness to the incident called APS on 1-7-25. The Resident was blockaded from leaving his room which was witnessed by staff, as he was told police would arrest him for pushing his aggressor, proving involuntary seclusion/kidnapping, and he screamed for help which resulted in staff intervention. Further the Resident wanted a room change because of the allegation which was made by Resident #131 to staff. The allegation of abuse was alleged by a witness to APS, alleged by the Resident's spouse, alleged by the Resident, and by Administration in their synopsis/FRI (facility reported incident) to the state agency on 1-10-25. The 1-10-25 initial facility document does not include many of the avenues that were available to the facility for a complete investigation, and thus they were unable to reach a more comprehensive conclusion of events. Initial REPORTING failure: The 1-10-25 FRI document was the first report by the facility after the allegation of a sexual abuse that facility staff were made aware of on 1-7-25. This document was derived on 1-10-25 only after surveyors requested documentation of it, and 3 days after the abuse occurred. Any allegation of abuse is mandated to be reported within 24 hours if no serious injury occurred to the state agency (VDH/OLC) Virginia Department of Health/Office of Licensure and Certification. The Department of Social Services office of Adult protective Services (APS) were not notified by the facility, and the police were not called by the facility as was requested by Resident #131 and his spouse on the day of the occurrence. INVESTIGATION follow up RESULTS failure: The 5-day mandated follow up reporting after a full investigation; The Administrator's synopsis on 1-10-25 alleges that the abuse was unsubstantiated. A review of all the above evidence by the state agency reveals it to be substantiated, in part, or in all. A police investigation would have been appropriate in this case, as both Residents were alert, and oriented to person, place, time, and situation, however, this was not afforded to Resident #131. On 1-10-25 Two nursing staff members spoke to surveyors on agreement of anonymity as they feared retaliation if it were known that they had spoken to surveyors. The two Nursing staff members worked on the units where Residents #131, and #130 were housed and both agreed that Resident #130 bought cigarettes for Resident #131, however, they stated that they had never known of a problem with that as no one complained about it, and they agreed that Resident #131 always went outside to smoke and had not created an issue. One was an agency nurse who worked in the facility, and one was a facility employee. Both stated they were aware of the incident involving Residents #130, and #131, and stated they wondered when the situation would blow up because Resident #130 was obviously grooming and pursuing Resident #131 (name), with the cigarettes, and Resident #131 (name) was married. The nurses were asked if the Administration was aware and they both stated yeah they knew, we all knew. During interview on 1-29-25 and review of the clinical record, it was found that the Social Worker had only been there a short time, however, was aware of the incident with Resident's #131, and #130. She stated that Resident #131 (name) had been discharged on 1-23-25 to a group home in (name) closer to family a near by county. She also stated that Resident #130 would be discharging on 1-29-25 to a different group home closer to the facility. At that time the Administrator was informed that the investigation was incomplete, and no FRI was ever received at the state agency VDH/OLC for the first allegation of abuse. She was further notified they had not implemented their policies on abuse. The allegations were never reported to the state agency until the day after surveyors asked for an investigation. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any added staff supervision for Resident #130 to prevent the abuse from continuing with another Resident. No staff ever reported the suspicion of a crime, and no police report was ever filed. The first alleged report by the Administrator was incomplete and had errors in information giving the appearance of a verbal altercation and that the victim was not touched. APS, was not notified of the alleged abuse by facility Administration, and was instead notified by a complainant resulting in an investigation being opened by the state agency. On 1-30-25 at approximately 4:00 p.m., the facility Administrator, Corporate Registered Nurse, and DON were notified of the findings. They stated they had no further information or documentation to offer.

Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure personal privacy was afforded to three (3) residents (Residents # 123, #2, and # 46) in a survey sample of 63 residents. 1. For Resident # 123, the facility staff failed to provide a curtain to pull around the bed while providing ADL (Activities of Daily Living) Care. Resident # 123 was admitted to the facility on [DATE] with the diagnoses of, but not limited to: Dementia with Agitation, Diabetes, Hypertension, and Legal blindness. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 1/7/2025. Resident # 123's BIMS (Brief Interview for Mental Status) Score was a 13 out of 15, indicating no cognitive impairment. Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025. On 1/29/2025 at approximate 10:40 a.m., a Certified Nursing Assistant was observed providing care to Resident # 123. The Certified Nursing Assistant was helping Resident # 123 get dressed for the day. Resident # 123 was visible to anyone who came into the room. There was no curtain around the bed. The roommate (Resident # 2) was in the room and could see Resident # 123. The Certified Nursing Assistant stated she was an agency employee. The Certified Nursing Assistant stated she pulled the curtain around the roommate (Resident # 2) as far as she could and tried to shield Resident #123 while providing care. She stated it was important to provide privacy. On 2/3/2025 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the residents' to have privacy in their rooms. On 2/4/2025 during the end of day meeting, the Administrator, Corporate Nurse Consultants and Director of Nursing were made aware of the findings. No further information was provided. 2. Resident # 2, the facility staff failed to have a provide a curtain to pull around the bed while providing Activities of Daily Living (ADL) Care. Resident # 2 was admitted on [DATE] with diagnoses including but not limited to: Epilepsy, Seizures, Confirmed Physical Abuse, Confirmed Psychological Abuse, Major Depressive Disorder, Anxiety Disorder, and Neoplasm of the Brain. Resident #2's most recent MDS (Minimum Data Set) was a Quarterly Assessment with an ARD (Assessment Reference Date) of 12/27/2024 coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 13 out of 15 indicating no cognitive impairment. Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025. Observations were made of there being one quarter panel curtain suspended above Resident # 2's bed. The curtain did not extend around the bed to completely provide visual privacy while ADL care was being provided. Resident # 2 had a roommate in the room. The roommate (Resident # 123) was in the room while ADL care was being provided for Resident # 2. The Certified Nursing Assistant stated she was an agency employee. The Certified Nursing Assistant stated she pulled the curtain as far as she could and tried to shield Resident # 2 while providing care. She stated it was important to provide privacy. On 2/3/2025 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the residents' to have privacy in their rooms. On 2/4/2025 during the end of day meeting, the Administrator, Corporate Nurse Consultants and Director of Nursing were made aware of the findings. No further information was provided.3. The facility staff failed to ensure privacy while performing incontinence care for Resident #46. Resident #46 was originally admitted to the facility 1/04/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Chronic Kidney Disease. The annual, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/28/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #46 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities Goals) the resident was coded as requiring supervision with eating, upper body dressing, requires substantial/maximal assistance with toileting hygiene, showers/bathing, lower body dressing and personal hygiene. The care plan dated 7/11/23 read that resident has an ADL self-care performance deficit r/t Weakness, Acute Kidney Failure, history of Falling, Epilepsy and Bipolar Disorder, history of falls. The Goal is the resident will improve current level of function in through the review date (11/21/23). The intervention: Monitor/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function On 01/29/25 at approximately 11:30 AM., while rounding in the hallway on unit 4, Resident #46 was heard yelling for his Certified Nurse's Assistant (CNA) B, by her first name several times. On 01/29/25 at approximately 11:39 AM., CNA B entered Resident #46 room (403B unit 4). The resident had informed her that he had a Bowel Movement (BM). After receiving permission from Resident #46 to observe his care, CNA B began incontinent and ADL care on the resident. There was a partial privacy curtain preventing the resident across from him to seeing the ADL care, the door to room [ROOM NUMBER] B was closed. Visibly from the door the resident could be seen receiving care. A timeline of events: 11:51 AM., there was a knock at the door, two staff quickly entered the room while the resident was exposed, receiving Activities of Daily Living (ADL), incontinent care. 11:54 AM., there was a knock at the door, then quickly, the door opened, entered one staff, resident still exposed, while receiving ADL care. 11:56 AM., there was a knock at the door, the Assistant Director of Nursing (ADON) quickly entered the room and said I'm just rounding. CNA B, said I'm ok. On 02/05/25 at approximately 1:56 PM., an interview was conducted with CNA F concerning the above incident. CNA F said that She shouldn't have walked into the residents' room while he was receiving care. CNA F also said that months ago that she informed a nurse that some of the rooms didn't have privacy curtains. CNA F also said that if the rooms don't have privacy curtains, she will just make sure the door is closed. On 2/03/25 at approximately 4:21 PM., an interview was conducted with the Director of Nursing (DON) concerning the privacy curtains. The DON said after knocking on a resident's closed-door staff should wait to hear what the CNA is saying first before entering. On 02/03/25 at approximately 3:19 PM., an interview was conducted with CNA B concerning Resident #46. CNA B said that no one should walk in the room while care is being provided. CNA B also said that the resident only had a portion of a privacy curtain when care was being rendered. On 2/05/25 at approximately 7:00 PM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to complete an Advanced Beneficiary Notice (ABN) for two (2) Residents, (Residents #192 and #37) in the four (4) sampled residents. The findings included: Residents #192, and #37 were chosen from a list of residents discharged in the previous 6 months. On 2-3-25 at 9:00 AM, the Business Office Manager was asked for a copy of the Advance Beneficiary Notice for 4 Residents. The Director of Nursing (DON) presented 4 forms that she stated were the ABNs. The forms revealed two (2) of the four (4) sampled Residents received Form CMS-10123 NOMNC (Notice of Medicare Non-Coverage) which were signed by the resident or the authorized representative, and included the estimated date of non-coverage, and appeal information. The other two (2) of the four (4) sampled Residents (Resident #192, and #37) received form CMS-R-131 forms which revealed no date when insurance coverage would end, did not specify a cost for the Resident should they elect to pay for continued services, and did not give information on the appeal process available to them. The form for Resident #192 was filled out by an Occupational Therapy Assistant, and documented spoke with (name). Daughter of the Resident. No date, and no time was documented. No letter was sent. The form for Resident #37 was filled out by an Occupational Therapist, and documented Left voicemail w/RP (responsible party) no name given for that individual, no date, and no time was documented. No letter was sent. Neither of these two (2) Residents nor their representatives signed the forms, no estimated cost of continued services was documented, nor were letters sent to instruct on appeal should the Resident's wish to continue the services. An interview was conducted with the newly hired Social Worker who stated she would normally be the person to administer the NOMNC. She stated that she could see the issues with the 2 NOMNC/ABN's received by surveyors, and listed the failures of the documents after reviewing them both. The facility had a history of not having a vetted, acceptable Social worker at times during the past year, and those dates can be found elsewhere in the statement of deficiencies under Federal Tag - 850. During the end of day debriefing on 2-3-25 the Director of Nursing and Administrator were informed of the findings. The facility staff stated they had nothing further to present.

Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to ensure two (2) of 63 residents (Resident #39 and Resident #46) in the survey sample were given the opportunity to formulate an advance directive. The findings included; 1. The facility staff failed to ensure Resident #39 had an opportunity to develop an advanced directive. Resident #39 was originally admitted to the facility 11/09/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Depression, Unspecified. The 5-day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/17/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #39 cognitive abilities for daily decision making were moderately impaired. In sectionGG(Functional Abilities Goals) the resident was coded as requiring partial/moderate assistance with eating, oral hygiene. Resident coded as dependent in lower body dressing, personal hygiene and rolling left and right. The care plan dated 11/22/23 read that Resident #39 had an Activities of Daily Living (ADL) self-care performance deficit related to multiple sclerosis, rheumatoid arthritis, spinal stenosis, right foot drop, morbid obesity, osteoarthritis, bilateral hand contractures and personality disorder. The Goal was to have the resident participate in as much of her ADL care as possible. The intervention for the resident requires total dependance by two (2) staff members for toileting and requires max assist to total dependance by two (2) staff members for bed mobility, transfers and one person assist for mobility in wheelchair. A review of the medical records revealed no advanced directives were available or that the resident had an opportunity to develop one. A review of the Physicians Order Summary (POS) revealed resident had a Full Code Status as of 11/10/2023. On 02/03/25 at approximately 2:33 PM., an interview was conducted with Resident #39 concerning an advanced Directive. Resident #39 said that I'm a full code. I don't think that I have an Advance. Directive. 2. The facility staff failed to ensure Resident #46 had an opportunity to formulate an advanced directive. Resident #46 was originally admitted to the facility 1/04/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Chronic Kidney Disease. The annual, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/28/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #46 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities Goals) the resident was coded as requiring supervision with eating, upper body dressing, requires substantial/maximal assistance with toileting hygiene, showers/bathing, lower body dressing and personal hygiene. The care plan dated 7/11/23 read that resident has an ADL self-care performance deficit r/t Weakness, Acute Kidney Failure, history of Falling, Epilepsy and Bipolar Disorder, history of falls. The Goal is the resident will improve current level of function in through the review date (11/21/23). The intervention: Monitor/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. The Physicians Order Summary for January 2025 reads that Resident has a Full Code status as of 07/15/2024. On 2/04/25 at approximately 1:00 PM., an interview was conducted with the Social Services Director (SSD) concerning advanced Directives. The SSD said that no Advanced Directive were done by Social Services or that he had an opportunity to develop one. On 2/05/25 at approximately 2:30 PM., the nursing staff on unit 4 were asked for the advanced Directive Book but to no book was available. On 2/05/25 at approximately 1:51 PM., an interview was conducted with RN C concerning the advance directives for the above residents. RN C said that they usually keep them in a red folder on the unit (unit 4), but she can't find the folder. On 02/05/25 at approximately 2:09 PM., an interview was conducted with Licensed Practical Nurse (LPN) B. LPN B, said that they did not have an advance directive book on Unit four (4). On 02/05/25 at approximately 2:21 PM., an interview was conducted with the Director of Nursing (DON) concerning the above. The DON also said that upon admission Social Services will complete the advance directive with the resident, family or guardian. The DON also mentioned that on each unit the facility has a code status book. On 2/05/25 at approximately 7:00 PM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure it was clinically appropriate for the self-administration of medications for one (1) resident (Resident # 83) in survey sample of 64 residents. Findings included: For Resident # 83, the facility staff failed to ensure there was a self-administration of medication assessment related to medication found at the bedside. Resident # 83 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to: Chronic Obstructive Pulmonary Disease, Hypertension, Chronic Kidney Disease, Diabetes, Acute Respiratory Failure and Congestive Heart Failure. The most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 12/24/2024. Resident # 83's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Resident # 83 required assistance with Activities of Daily Living. Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025. During the initial tour on 1/28/2025 at approximately 12:10 p.m., a medication bottle was observed on the nightstand by the bed by the window. There were several items cluttered on the nightstand. The resident was lying in bed when the surveyor walked into the room. The label on the bottle stated the medication was Polyethylene Glycol (a laxative) dated February 9, 2024 with no refills. Resident # 83 stated the bottle of medication was a prescription she picked up a long time ago before coming to the facility. On 1/28/2025 at 1:34 p.m., an interview was conducted with Registered Nurse-B who stated medications should not be left at the bedside without self administration assessments and orders from the Physician. Registered Nurse-B stated none of the residents on the unit had assessments with orders for self administration of medications. Registered Nurse-B stated she did not see the medication bottle with on the nightstand when she administered the medications that morning. On 1/28/2025 at 2:39 p.m., an interview was conducted with the other nurse LPN (Licensed Practical Nurse)-D scheduled to pass medications on the unit that day. Licensed Practical Nurse-D stated bottles of medications should not be left at the bedside without an order from the physician. Registered Nurse-B removed the bottle of medication from the nightstand after explaining to the resident that medications could not be left at the bedside without an order. Resident # 83 stated she did not remember the medication was there. Review of the Physicians Orders revealed an active order for the medication Polyethylene Glycol 3350 Oral Powder 17 GM (gram) /Scoop (Polyethylene Glycol 3350) Give 1 scoop by mouth one time a day for constipation. Review of the January 2025 Medication Administration Record revealed scheduled daily administration of the medication Polyethylene Glycol 3350 Oral Powder 17 GM (gram) /Scoop (Polyethylene Glycol 3350) Give 1 scoop by mouth one time a day for constipation. The documentation revealed the medication was administered as ordered. During the end of day debriefings on 2/4/2025, the Administrator, Director of Nursing and Regional Nurse Consultants were informed of the findings. They stated medications should not be left at the bedside unless a resident has been assessed for self administration of medications. A copy of the medication administration policy was requested. Review of the Self-Administration of Medication and Treatments Policy revealed the policy was not dated to indicate when it was implemented or reviewed and revised. The Policy stated Residents have the right to self-administer medications/treatments if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. On 2/5/2025 at 2:12 p.m., an interview was conducted with the Director of Nursing who stated medications should never be left at the bedside unless there has been an assessment by the physician and an order for the medications to be left at the bedside. No further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents are cared for in a manner that promotes maintenance or enhancement of his or her quality of life for one (1) Resident (#24) in a survey sample of 63 Residents. The findings included: For Resident #24 the facility staff failed to adequately bathe, and groom Resident to ensure he was free from body odors and unkempt appearance and failed to dress him in clothing other than a hospital gown and failed to get him out of bed daily so that he may attend activities and have social interaction with peers. Resident #24 was admitted to the facility on [DATE] with diagnoses that include but are not limited to paranoid schizophrenia, diabetes, chronic kidney disease, mild intellectual disabilities, hypertension, hypothyroidism, bipolar disorder, major depressive disorder, severe with psychotic features, and anxiety. The following observations were made of Resident #24. 1/28/25- 2 p.m. observed Resident #24 in bed eyes closed dressed in hospital gown hair greasy and a strong body odor evident. 1/29/25 - 11:30 a.m. Resident #24 in bed watching TV hospital dressed in hospital gown, hair greasy, body odor present. 1/30/25 11:50 a.m. nails long brown substance under nails, in need of shower / bath hair appears greasy Resident has body odor and smells of urine. In bed only in hospital gown and brief. 1/31/25 11:38 AM Resident # 24 in bed dressed in hospital gown nails still appear dirty and hair greasy continues to have body odor. On 1/31/25 at 11:40 a.m., an interview was conducted with Resident #24. When asked does the staff usually get you up and get you dressed, he responded, No not usually, I can't walk. When asked does the staff get you up and put you in the wheelchair, he responded No not unless I have to go somewhere. When asked does the staff get you up and put you in the shower, he stated that they usually bathe him in bed. When asked when the last time is his hair was washed, he stated that he did not know. Excerpts from the Resident Preference Evaluation dated 6/21/24 read: 1. How important is it for you to choose what you wear? (2.) Somewhat important 2. How important is it to you to listen to music you like? (2) Somewhat important 5. How important is it to you to do things with groups of people? (2) Somewhat important 6.How important is it to you to do your favorite activities? (1) Very important 7 How important is it to you to go outside to get fresh air when the weather is good? (2) Somewhat important On 2/5/25 an interview was conducted with CNA B who was asked if Resident #24 has clothing in his room, CNA B answered yes, he has clothing, when asked if they fit him and were in good repair CNA B stated that the clothing was fine and if he did not have clothing the facility would have gotten him some from the clothing drive. When asked why Resident #24 is always wearing a hospital gown instead of his personal clothing CNA B stated he just got out of the shower. On 2/5/25 at approximately 3:00 p.m. an interview was conducted with the unit manager who stated that it is the expectation of the facility that all Residents are kept clean, odor free, and dressed appropriately in their own personal clothing on a daily basis. On 2/5/25 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observation, interview, clinical record review, facility documentation review and in the course of a complaint investigation, the facility staff failed for one of 48 sampled residents (#75) to ensure the Resident received ordered wound physician visits, care, and failed to identify a pressure wound to the heel before it reached an advanced stage. This is harm. The Findings Include: Resident # 75 was admitted to the facility on [DATE], her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 75's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/29/22, coded the Resident as follows: Section G - Resident #75 was coded as requiring #3- Extensive Assistance of #3 - 2 Person Physical Assistance for bed mobility and dressing. For transfers and toileting she was coded as requiring #4 -Total Assistance (requiring a mechanical lift) and #3 - 2 Person Physical Assistance Walking was coded as #8 -Activity did not occur. Resident required a wheelchair for locomotion on and off the unit. Section H - Coded Resident #75 as having and indwelling catheter and being always incontinent Section M - Coded Resident #75 as at risk for developing pressure ulcers. Excerpts from the admission note read as follows: Resident was admitted to the hospital R/T [related to] abuse / neglect. History of diabetes type 2, [CONDITION(S)], has Foley catheter in place, depression, quadriplegic spinal paralysis, . , abrasion to great toe and left foot. Turn every 2 hours, resident needs air mattress. Resident is incontinent. Resident #75 was seen by the wound physician on 5/25/22 for Initial Wound Evaluation and Management. The document did not list any wounds to the heel and included the following: Follow up evaluation by wound care specialist within seven days with further interventions as indicated. Resident #75 was seen again by the wound physician on 6/1/22 (7 days later) and no wounds to the heel were documented. The next time Resident #75 was seen by the wound physician was on 7/8/22 (over 1 month since the last visit) and the following wound was documented: Unstageable Left Heel - Wound size - 6 cm X 8.5 cm X unmeasurable There were no other entries in the Resident's clinical record concerning the wound to the heel. On 7/6/22 an observation of Resident #75's wound was made by Surveyor B. The following was noted: Wound to Left heel and side of foot - 9cm X 10.5cm, open with black necrotic tissue, yellow slough. and active bleeding at the time of observation. A review of the Resident's care plan revealed the following: Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate Date Initiated: 06/02/2022 The Nutrition Evaluation Annual and Significant Change was completed by the dietician on 5/27/22 with recommendations for vitamins and Prostat for wound healing. On 7/12/22 a review of the clinical record revealed that these recommendations were never implemented. On 7/13/22 at approximately 1:50 PM, the Nurse Practitioner (NP) was interviewed and asked if she was aware that the RD had put in a recommendation for Pro-Stat for wound healing. The NP stated that she was not aware. The NP stated they have not been having the meetings where the DON would bring those things to my attention. On 7/14/22 at approximately 945 am, an interview with the Corporate RN was conducted. The Cooperate RN stated that she had looked in the records and could not find consistent documentation of the progression of Resident #75's wound and could not locate consistent accurate weekly skin assessments. She stated that she had only been in the facility a couple of days and did not know what happened to the documentation and did not know why the Resident was only seen once in June. A review of the policies and procedures document WC - 130 Pressure Injury Record revealed the following: Policy: To document the president of skin impairment/new skin impairment related to pressure when first observed and weekly thereafter until the side is resolved. One site will be recorded per page. Procedure: 1. Residents will have a pressure injury record completed for each skin impairment that is related to pressure. 2. Mark the pressure area on the body description identifying the site 3. Enter the date. 4. Enter the stage of the pressure injury. 5. Enter the size of the pressure injury - length X width X depth in centimeters 6. Enter the tissue type in color. 7. Enter the wound edges and drainage 8. Enter the peri-wound information. 9. Licensed nurse to sign the appropriate area. On 7/14/22 the Interim Administrator was made aware and no further information was provided.

Based on resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide a dignified discharge, resulting in psychological harm for one resident (Resident #1) in a survey sample of four residents. The findings included: For Resident #1, facility staff coerced Resident #1 into signing an AMA form. The facility evicted him against his will. The facility staff humiliated him by laughing at him in the lobby of the facility. The facility staff transported him along with his belongings to the front lawn of his sister's apartment. Resident #1 was left alone in an unsafe condition without access to a bathroom, food, water, medication, or access to shade, where he suffered humiliation, anxiety, shame and public embarrassment. Resident #1 was a [AGE] year old, was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a 30-Day Assessment with an Assessment Reference Date of 9/5/19 was reviewed. Resident #1 had a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. In addition, he was coded as not having any mood or behavioral issues. Resident #1 was dependent on a wheelchair for mobility. On 9/26/19 a review was conducted of facility documentation, revealing a complaint that was submitted by Resident #1's sister on 9/24/19. An excerpt read: On 9/19/19 he went to [MEDICAL TREATMENT] and when he came back to the facility, all of his things were packed up in their van and he was told that he was not welcome back into the facility. The facility then took him to her apartment in their van. She came home and her brother was sitting in the yard .her apartment is not equipped for someone that is a double [MEDICAL CONDITION] .she was not notified that he was being discharged to her apartment .he sat in her yard for two hours after having [MEDICAL TREATMENT] earlier that day. On 9/26/19 at 12:30 P.M. an interview was conducted with the facility van driver (Employee F) in the conference room. The driver was asked to describe the circumstances under which she transported Resident #1 to his sister's address. She stated, I was told by the Administrator to drop him off at his sisters' home. He had signed himself out. His stuff was already packed up. He had 3 boxes, an artificial leg, and a cane. He was in a wheelchair. I loaded him up. I took him 6 minutes away. I put boxes down and I left him on the grass in the front. I dropped him off at 1:00 P.M. It was a quiet ride. I have taken people home before. Normally there is someone there. She stated that she knew that his sister was not at home. On 9/27/19 at approximately 10:30 [NAME]M., a telephone interview was conducted with Resident #1, and his sister. Resident #1 stated that on 9/18/19, facility staff gave him an AMA (Against Medical Advice) form to sign while he was lying on a gurney. He was awakened by Emergency Medical Services (EMS), and was being transported out of the facility. He stated that the facility staff did not explain what the form was for, nor the consequences of signing out of the facility AM[NAME] He stated that the EMS personnel asked him why he had called 911. He told them that he was taking a nap, and had not called them. He had no reason to want to go to the hospital. After a few minutes, the facility staff admitted to the EMS that the facility had called 911. Resident #1 stated that the hospital did not treat him, nor perform any tests. (this was confirmed during a review of his hospital records). He stated the hospital informed him that the facility did not want him to return there because he had signed himself out AM[NAME] After several hours, the facility allowed him to return. He stated that upon his return on the evening of 9/18/19, all of his belongings were missing from his room. The staff denied knowing where his belongings were. Resident #1 stated that on the morning of 9/19/19, he went to his regularly scheduled [MEDICAL TREATMENT] appointment. Upon his return, the facility refused to allow him to go past the lobby, or to eat lunch. His belongings had been packed up in boxes and put on the facility van. He stated that while he was in the lobby, A white woman with long hair who was one of the social workers looked at me and laughed at me (Employee J-Social Services Director). I felt humiliated. The van driver asked me for an address to drop me off at. The driver dropped me off in the yard in front of my sister's apartment with my boxes. I was anxious, embarrassed and felt shame sitting out there alone in public. Resident #1 said that the driver knew that his sister was not at home. He stated that the driver left him outside in the sun without any food, water, medication, or access to a bathroom. He stated that he was there alone for at least two hours until his sister came home.

Based on resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff neglected to provide safe discharge services, for one resident (Resident #1) in a survey sample of 4 residents. The findings included: 1. For Resident #1, the facility neglected to implemented procedures to ensure a safe discharge. Resident #1 was a [AGE] year old, was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a 30-Day Assessment with an Assessment Reference Date of 9/5/19 was reviewed. Resident #1 had a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. In addition, he was coded as not having any mood or behavioral issues. Resident #1 was dependent on a wheelchair for mobility. On 9/26/19 a review was conducted of Resident #1's clinical record. According to Resident #1's current physician orders, he was on the following medications: [REDACTED] [MEDICATION NAME] 15 MG by mouth daily Tylenol 325 MG 2 tablets by mouth every 6 hours for pain [MEDICATION NAME] 2 ML inhalation every 4 hours as needed for wheezing Atorvastatin 40 MG 1 tablet by mouth daily [MEDICATION NAME] 160 MCG 2 puffs twice daily [MEDICATION NAME] 0.25 MCG 1 capsule by mouth daily Epoetin Alfa injectable (given at [MEDICAL TREATMENT]) [MEDICATION NAME] 300 MG 1 capsule by mouth at bedtime [MEDICATION NAME] 25 MG 0.5 tablet by mouth every 12 hours [MEDICATION NAME] 30 MG 1 tablet by mouth at bedtime Senna 8.6 MG 2 tablets by mouth at bedtime for constipation [MEDICATION NAME] 50 MG 0.5 tablet by mouth at bedtime Resident #1's Care Plan dated 8/16/19 was reviewed. An excerpt read, has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) bilateral Above knee Amputations, Limited Mobility, shunt, [MEDICAL TREATMENT], Hypertension, [MEDICAL CONDITION]. 15 minute safety checks, cow bell use. On 9/26/19 a review was conducted of facility documentation, revealing a complaint that was submitted by Resident #1's sister on 9/24/19. An excerpt read: On 9/19/19 he went to [MEDICAL TREATMENT] and when he came back to the facility, all of his things were packed up in their van and he was told that he was not welcome back into the facility. The facility then took him to her apartment in their van. She came home and her brother was sitting in the yard .her apartment is not equipped for someone that is a double [MEDICAL CONDITION] .she was not notified that he was being discharged to her apartment .he sat in her yard for two hours after having [MEDICAL TREATMENT] earlier that day. On 9/26/19 at 12:30 P.M. an interview was conducted with the facility van driver (Employee F) in the conference room. The driver was asked to describe the circumstances under which she transported Resident #1 to his sister's address. She stated, I was told by the Administrator to drop him off at his sisters' home. He had signed himself out. His stuff was already packed up. He had 3 boxes, an artificial leg, and a cane. He was in a wheelchair. I loaded him up. I took him 6 minutes away. I put boxes down and I left him on the grass in the front. I dropped him off at 1:00 P.M. It was a quiet ride. I have taken people home before. Normally there is someone there. She stated that she knew that his sister was not at home. On 9/27/19 at approximately 10:30 [NAME]M., a telephone interview was conducted with Resident #1, and his sister. Resident #1 stated that on 9/18/19, facility staff gave him an AMA (Against Medical Advice) form to sign while he was lying on a gurney. He was awakened by Emergency Medical Services (EMS), and was being transported out of the facility. He stated that the facility staff did not explain what the form was for, nor the consequences of signing out of the facility AM[NAME] He stated that the EMS personnel asked him why he had called 911. He told them that he was taking a nap, and had not called them. He had no reason to want to go to the hospital. After a few minutes, the staff admitted that the facility had called 911. Resident #1 stated that the hospital did not treat him, nor perform any tests. (this was confirmed during a review of his hospital records). The hospital informed him that the facility did not want him to return there because he had signed himself out AM[NAME] After several hours, the facility allowed him to return. Upon his return on the evening of 9/18/19, all of his belongings were missing from his room. The staff denied knowing where his belongings were. On the morning of 9/19/19, he went to his regularly scheduled [MEDICAL TREATMENT] appointment. Upon his return, the facility refused to allow him to go past the lobby, or to eat lunch. His belongings had been packed up in boxes and put on the facility van. He stated that while he was in the lobby, A white woman with long hair who was one of the social workers looked at me and laughed at me . I felt humiliated. The van driver asked me for an address to drop me off at. The driver dropped me off in the yard in front of my sister's apartment with my boxes. I was embarrassed and ashamed sitting out there in public. Resident #1 said that the driver knew that his sister was not at home. He stated that the driver left him outside in the sun without any food, water, medication, or access to a bathroom. He stated that he was there alone for at least two hours until his sister came home. Resident #1's sister stated that his friend went to the facility to visit him on 9/19/19 and was informed that he no longer lived there. His friend called her to find out where he was. Resident #1's sister stated that she had not been informed that he would be taken to her apartment. She stated that her apartment was not accessible or appropriate for a double [MEDICAL CONDITION]. She stated that upon her arrival home, she had no immediate way to get him into her home. There was no wheelchair ramp. She stated that she had to get someone to go another location to obtain two wooden boards to get him up over the stairs. In addition, the facility did not obtain his permission to be sent to the hospital. On 9/18/19 at 4:21 P.M., an excerpt from a nursing progress note read, Oxygen sats (saturation) 96%-99%. No behavior problems noted. No education provided. Noted resident poking tissue in nose with a small amount of blood on tissue. NP (Nurse Practitioner) aware. Orders to send resident to the hospital for evaluation. On 9/26/19 at approximately 4:05 P.M., an interview was conducted with the facility Administrator (Employee A) in the conference room. When asked why Resident #1 had been sent to the hospital on [DATE], the Administrator stated that Resident #1 wanted to go to the hospital due to a little bit of blood that came out of his nose earlier that morning. The Administrator further stated that on 9/18/19 the hospital called the facility and stated that the resident was ready for discharge, but were told that he left the facility AM[NAME] She stated that the hospital was upset with the facility and stated, Y'all always say your residents left AM[NAME] The Administrator stated that she then agreed to allow Resident #1 to return that night to the facility. The Administrator was asked why Resident #1 did not voluntarily leave the facility on 9/18/19, when the AMA was dated. She stated that he wanted to go to the hospital. The Administrator further stated that Resident#1 had been issued a 30 Day Discharge Notice on 8/28/19 because a cigarette lighter was found in his room. She stated that the facility officially became smoke-free on (MONTH) 1, 2019. The Administrator stated that she did not have an obligation to wait 30 days. She stated, We don't have to wait 30 days. Every now and then we would take them and make sure they are in a safe place as a courtesy. Because of his BIMS of 15 we can discharge him. He was cognitively aware of his decision to go AM[NAME] We discharged him and delivered him to the address he specified. When asked to show documentation that Resident #1 was transported to a safe, appropriate location, the Administrator reviewed his progress notes, which had been provided to the surveyor. She was unable to find any documentation of such. On 9/26/19 a review was conducted of Resident #1's hospital discharge form dated 9/18/19 at 2:12 P.M. An excerpt read, Stated Complaint: Sent by (facility) for drug addiction XXX[AGE] year old male patient with [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]) on [MEDICAL TREATMENT] with bilateral [MEDICAL CONDITION] was sent by facility for drug screen but does not make urine. Patient denies any medical complaints. Denies any substance use. Will send back to facility. Patient sent for drug screen. Patient unable to make urine due to [MEDICAL CONDITION] on [MEDICAL TREATMENT]. emergency room does not routinely do serum drug testing for screening purposes. discharged at 3:21 P.M. The hospital made multiple calls to the facility to obtain permission the send him back there. At 6:45 P.M., approximately three and one-half hours after the hospital discharged Resident #1, the facility finally agreed to allow him to return. On 9/26/19 a review was conducted of facility documentation, revealing a policy on Leaving Against Medical Advice dated 8/24/17. An excerpt read: Procedure: Attempt to resolve concerns contributing to desire to leave AM[NAME] The resident will be informed of the risks involved, the benefits of staying in the center, and the alternatives to both. Nursing will document this discussion in the nursing section of the medical record. The social services designee will document any discussions held with the resident in the social service section of the medical record. Resident #1's clinical record did not contain any documentation that a nurse informed of the risks involved, or the benefits of staying in the center, or the alternatives, or discussions with the Social Worker. On 9/30/19 at 3:30 P.M. an interview was conducted with the Social Worker (Employee I) in the conference room with 2 surveyors present (Surveyor A, Surveyor B). The Social Worker was asked to describe the circumstances under which Resident #1 signed an AM[NAME] She stated, I was told he wants to go AM[NAME] I gave him the paper. I read what it says. She stated that she was in his room after the EMS had arrived and that he was on his bed. She stated that she told him that the facility could not take care of him if he signed out AMA, and that he said that his girlfriend could take care of him. The Social Worker was asked why the AMA form had not been properly completed, by including the physicians name. She stated that she just put the form down on her desk because she didn't believe he wanted to leave that facility, and she said to the Administrator, we'll see where this goes. The Social worker was asked why she did not try to find other appropriate placement for Resident #1. She stated, she had called one facility, but He did not want to give up his stuff. The Social Worker was unable to show documentation of any further attempts to locate an appropriate, safe living arrangement. The Social Worker had never spoken with Resident #1's sister regarding placement. On 9/30/19 a review was conducted of facility documentation, revealing a policy on Abuse, Neglect, Exploitation & Misappropriation dated 11/28/17. An excerpt read, No employee at any time may commit an act of physical, psychological, or emotional abuse, neglect, mistreatment .Mental abuse if the use of verbal or nonverbal conduct which causes or has to potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Mental and Verbal Abuse include, but are not limited to: Mocking, insulting, ridiculing .

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed for 1 resident (Resident #210) of 63 sampled residents to ensure that they were free of abuse and neglect. Resident #210 was abused by Resident #68, resulting in facial and scalp contusions and being rendered unconscious on the floor. This is harm for Resident #210. The Findings included: Resident #210 was a [AGE] year old who was admitted to the facility on [DATE] and expired at the facility on [DATE]. Resident #210's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of [DATE] was reviewed. Resident #210 was coded as having a Brief Interview of Mental Status Score of 0, indicating severe cognitive impairment. In addition, she was coded as requiring a walker for ambulation. Resident #68 was a [AGE] year old who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of [DATE] was reviewed. Resident #68 was coded as having a Brief Interview of Mental Status Score of 5, indicating moderately impaired cognition. He was coded as being able to understand and be understood by others. According to his clinical record, Resident #68 had a history of [REDACTED]. An excerpt from a Progress Note dated [DATE] read, resident exposed himself to the receptionist downstairs. On [DATE] a review was conducted of facility documentation, revealing an investigation of an altercation between Resident #210 and Resident #68. The witness statement, which was written by Registered Nurse D on behalf of Certified Nursing Assistant I was reviewed. Certified Nursing Assistant (CNA I) was the witness. An excerpt read, I heard (Resident #68) ask (Resident #210) about 5 times to remove her hand off his wheelchair, and when she didn't that's when he hit her. I removed (Resident #68) from the site immediately. (Resident #210) was unresponsive for awhile. On [DATE] an interview was conducted with CNA I in a second floor office. She stated that she thought that Resident #210 was unconscious for ,[DATE] minutes. She said, He (Resident #68) hit her (Resident #210) because she had her hands on his wheelchair. He asked her several times to remove her hands from his wheelchair. She was known to be like that even with other residents, wandering in and out of their rooms. I removed him from the area and I yelled down the hall for someone to come. She laid on the floor for 2 or 3 minutes before anyone came to help her. It happened in the dining room on the secure unit. He (Resident #68) can be a handful to deal with. He is anxious, always talking loud at others. On [DATE] at 11:30 [NAME]M. an interview was conducted in the conference room with Registered Nurse D, who conducted the investigation. She stated, The CNA (CNA I) stated at the time that (Resident #68) hit (Resident #210), and that (Resident #210) was unresponsive on the floor for an unknown amount of time. A nurse's note dated [DATE] was reviewed. An excerpt read, Resident (Resident #210) was holding the handle of another residents (Resident #68) wheelchair, the other resident asked her to leave his chair alone 2 x and then he hit her, resident lost her balance at that time and fell to the floor. Resident (#210) assessed and has a lump to the left side of forehead and complains of a headache. MD notified and resident is being sent to the ER (emergency room ). On [DATE] a review was conducted of facility documentation, revealing a hospital Discharge Summary dated [DATE]. An excerpt read, Facial & Scalp Contusions. 1. Apply Ice packs, 2. take Tylenol 3. apply antibiotic cream The follow-up report to the incident that occurred on [DATE] was reviewed. It read, [DATE]. Findings: Upon completion of the investigation of the allegation of resident to resident abuse between (Resident #68), and (Resident #210), the facility is substantiating these allegations of abuse. In addition the report stated that Resident #68 was placed on 1:1 observation, and staff was educated regarding aggressive behaviors and interventions. On [DATE] an interview was conducted with the facility Administrator (Employee A) in the conference room. She stated that Resident #68's arm went up in the air and hit her, he didn't intentionally do it. The Administrator was asked why then did the facility substantiated the allegation of abuse and put Resident #68 on 1:1 observation, as well as the other interventions, including staff education regarding managing aggressive behaviors. She stated, .I would not have written it that way . The Physical Therapy notes were reviewed. Resident #68 was independent in bed mobility and being able to propel his wheelchair. There was no documentation in his record of a neurological disease that caused involuntary movements such as muscle spasms, twitches, jerking or writhing movements. On [DATE] at 3:00 P.M. an interview was conducted with the Director of Nursing (Employee B). When asked to state her understanding of the therapy notes, she stated, His arms were fine and had full strength. The facility Abuse, Neglect, Exploitation & Misappropriation Policy dated [DATE] was reviewed. An excerpt read, It is inherent in the nature and dignity of each resident that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. No further information was received.

Based on observation, resident interview, staff interview, facility documentation review, Hospital record review, and clinical record review, the facility staff failed ensure an accident and hazard free environment for 1 resident, (Residents #211) of 63 residents in the survey sample, resulting in harm. The findings included: 1. For Resident #211, the facility staff failed to supervise a Resident with a known exit seeking behavior, and failed to secure windows resulting in the Resident falling 10 feet from a window, and fracturing his neck. Resident #211, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #211's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4-16-19 was coded as a full admission. Resident #211 was coded with a BIMS (Brief Interview of Mental Status) score of 7/15 which indicated moderate cognitive impairment. Resident #211 was coded as needing one staff limited assistance for dressing eating and hygiene, and only supervision for transferring, bed mobility and toileting. The Resident was independently ambulatory with a walker. The Director of Nursing (DON), and Administrator were asked for copies of all physician progress notes [REDACTED]. The request was for all documents from the time of admission to the time of discharge. The documents were supplied, and the DON stated this is everything we have. A review of Resident #211's clinical record revealed nursing progress notes documenting that from 4-19-19, the Resident stated he wanted to move to another room, and was agitated with his room mate. The notes stated the Resident was pacing in the hallway. On 4-24-19 the nursing note describes the Resident as making false accusations, however, does not describe what those are, and asks repeated questions about the same topics. From the date of admission to the facility, the Resident's family, and the Resident, requested to be moved back to the tidewater area to be closer to his family. On 4-28-19 the family came to the facility and took the Resident on an outing at 11:30 a.m., and he returned at 2:00 p.m. At 10:30 p.m. that night the Resident stated he did not want his room mate and called his family and wanted to go to the hospital. Staff documented that they told him this was not a valid reason to go to the hospital, and they would pass the concern on to the day shift the next day. The next day on 4-29-19, the nursing notes documented that the Resident talked with his family several times, and that staff had referred him to have a psychiatric evaluation as he stated he was Sad sometimes and wants to go home. Nursing notes documented the following: On 4-30-19 Resident was agitated with room mate and not wanting to be in room. On phone with family throughout the evening. Has been pacing the hallway and sitting in the front lobby. Took belongings in a bag and carried them to the lobby. Encouraged to go back to room, but refused. Currently sitting in lobby with head phones on and eyes closed. At 10:00 p.m., that night the Resident refused his medications. On 5-1-19 at 2:30 p.m., the Resident refused to go to his room and sat in the lobby. At 6:30 p.m. that night the Resident was agitated and wanted to leave the facility, and was placed on 15 minute checks. On 5-2-19 the resident refused his shower and stated he wanted to leave the facility. The Resident tried to exit the building at the beginning of the 3:00 p.m., to 11:00 p.m. shift and was stopped by an employee. The note also documented that the Resident stayed in the lobby the majority of the shift. On 5-3-19 the Resident remained on 15 minute checks and was in the lobby at 7:43 a.m. At 7:26 p.m., the Resident was on 15 minute checks for elopement risk and the Resident was documented as in the hallway for first half of shift, .and then after dinner took a shower and went to bed. Later that night, at 1:23 a.m., (5-4-19) The Resident refused to sleep in his bed, and was sitting in the lobby, and stayed there all night until 6:00 a.m. when he went to bed. On 5-5-19 at 7:55 a.m., that the Resident was agitated and confused and sitting in the lobby on 15 minute elopement checks. At 8:19 p.m., the Resident was sitting in the lobby. At 9:30 p.m. the Resident had opened the window in the first floor day room and threw his walker, coat, and cell phone charger out of the window, and jumped out of the window himself. The staff found him on the ground in the shrubbery beneath the day room window. The Resident arrived via ambulance at the hospital emergency room at 10:22 p.m., and was diagnosed there with traumatic spinal cord injury requiring surgery, and resulted in the previously ambulatory Resident being paralyzed and Quadriplegic. After complications from the injury and surgery, the Resident received a [MEDICAL CONDITION] in his neck to breathe, and a feeding tube, as the Resident could no longer eat. Social work notes were reviewed and revealed no indication that the Resident had agitation, or exit seeking behaviors. There were only 4 notes in the clinical notes in the record and that documented that staff were aware that the family was involved with the Resident's care and that the family and the Resident wanted him moved closer to family. physician progress notes [REDACTED]. On 4-9-19 the physician's note documented consult for psychiatry is indicated, due to diagnoses, and medications. The physician's notes all revealed documentation of no family involvement, no agitation, no anxiety, monitor for changes in mental status, and no depression. The note dated 4-15-19 documented monitor him for falls and impulsive behavior. None of the physician notes indicated that the doctor was ever made aware of the Resident's agitation, statements of sadness, pacing, statements of wanting to go home, desire for a room change, agitation with the Resident's room mate, and exit seeking behaviors. The care plan was reviewed and revealed no care plan for the Resident's feelings of agitation, anxiety, sadness and wanting to move closer to family. No psychiatric evaluation was ever care planned or obtained, after the doctor stated in his progress note that it was indicated. Only 2 areas in the care plan address the Resident's desire to leave the facility, and those follow; 1. F[NAME]US: Resident (name) has a behavior problem related to [MEDICAL CONDITION] and [MEDICAL CONDITION]: history of refusing pneumonia vaccine, false accusations, repetitive questions, pacing the hallway, sitting in the front lobby with belongings, refuses showers. Initiated 4-16-19. The interventions were; Administer medications as ordered. Monitor document for side effects. Anticipate and meet resident needs. Explain all procedures to the resident before starting and allow the resident to adjust to changes. 2. F[NAME]US: Resident (name) is an elopement risk related to pacing the hallway, sitting in the front lobby, Taking belongings in a bag and carrying them to the lobby, 15 minute checks. Initiated 5-1-19. The interventions were; Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, encourage to go back to room for rest/sleep. None of the care plan interventions for behaviors or elopement were ever documented as having been used except for returning the Resident to his room, and no behaviors were ever documented on the medication and administration records for the Resident's stay. A Report of Resident Exit Seeking/Wandering: Missing from Facility, 5 page document was reviewed. The form revealed that the document was completed on 5-6-19, the day after the Resident exited from the window and fell . The document described the Resident as observed outside in the landscape shrubbery beneath a window. Last known location lobby, No security alarm at facility, was assessment for exit seeking/wandering completed before this event yes, was an assessment for exit seeking/wandering completed prior to this event no, an assessment for exit seeking/wandering was completed after this event, no resident monitoring device. The document goes on to say that the doctor and family were made aware of the fall from the window. On 7-24-19 at approximately 2 pm, interviews were conducted with two nursing the maintenance director. The interview with the unit 2 nursing staff revealed that the windows in the day room, at the end of that hall, were not screwed shut until the day after the Resident fell , and could be opened completely before he fell . They went on to say how could a 200 pound grown man push a walker and himself out of a window that would not open. The interview with the maintenance director revealed that the windows were not screwed shut until the day after the Resident fell , as he stated We put the screws in to keep the windows from opening immediately the next day after he fell . No social work support was evident, no monitoring device was applied, physician notes indicated the doctor was unaware of the Residents agitation, sadness, wandering, and exit seeking, supervision was insufficient, and even though the staff knew for many days that the Resident was wandering and exit seeking, the windows on the first floor day room were not made safe from elopement. The windows in the unit 2 day room were examined during survey, and revealed that the windows all had metal screws, screwed into the window frame, so that the windows could not be opened more than 4 inches. The facility Administrator and DON were made aware of the findings on 7-26-19. No further information was provided.

Based on staff interview, clinical record review and facility documentation the facility failed to ensure two Residents were free from significant medication error in a survey sample of 54 Residents. 1. For Resident # 141 the facility failed to ensure Resident received proper dose of medication causing significant medication error and harm resulting in Resident being hospitalized and intubated and placed on Ventilator. 2. For Resident #80, the facility staff repeatedly failed for 90 opportunities (30 consecutive days times every 8 hours), to ensure physician-ordered blood pressure monitoring for a PRN (as needed) low blood pressure medication ([MEDICATION NAME]). The findings include: 1. For Resident # 141 the facility failed to ensure Resident received proper dose of medication causing significant medication error and harm resulting in Resident being hospitalized and intubated and placed on Ventilator. Resident #141 a [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 141's most recent (Minimum Data Set) MDS (a screening tool) coded Resident as having a (Brief Interview of Mental Status) BIMS score of 10 which indicates moderate cognitive impairment. On [DATE] a clinical record review was conducted and it was found that Resident #141 had an appointment at the hospital for an MRI on [DATE]. He had an MRI the previous week at the same hospital on [DATE]. The Resident had an order for [REDACTED]. *[MEDICATION NAME] is used to treat anxiety disorders and panic disorder (sudden, unexpected attacks of extreme fear and worry about these attacks). [MEDICATION NAME] is in a class of medications called benzodiazepines. It works by decreasing abnormal excitement in the brain. According to the Narcotic Count sheet 1 (one) pill (2 MG) was signed out on [DATE] prior to MRI appointment. On [DATE] prior to the MRI appointment the Resident was given 2 (two) pills of [MEDICATION NAME] 2 MG each for a total of 4 MG of [MEDICATION NAME]. According to the hospital documentation the Resident was taken to the hospital by medical transport and was sent back to the facility because he did not need another MRI. According to Nurses Notes dated [DATE] at 11:10 Resident went out to appt this AM and returned from appt as coming in became unresponsive sternal rub slow to respond, BS (blood sugar) 96. O2 (Oxygen) was placed on resident at 2 (Liters per Minute) LPM (nasal cannula) at 98% Resident was assessed by Nursing staff code called. 911 activated arrived at the time of incident to pick up another resident for appt they resumed over resident 0 CPR initiated d/t resident having pulse and respirations. Resident transported to (hospital name) for eval. MD aware RP (RP Name) aware was coming in to facility a time. Bed hold renewed. According to hospital record on [DATE] Resident #141 a [AGE] year old male with developmental delay, [MEDICAL CONDITION] disorder, admitted to the ICU (Intensive Care Unit) intubated (artificial airway placed to provide oxygen for patient unable to breathe spontaneously) The story is not very clear sounds as though he was sent her from his NH (Name of Facility) for a head CT. In order to tolerate the scan was given 4 MG of [MEDICATION NAME] (wrong medication entered should have been [MEDICATION NAME]) prior to transport. On arrival was told he did not need the CT as he had just had an MRI last week (for which 2 MG of [MEDICATION NAME] was given) (again medication should have said [MEDICATION NAME]) EMS came to pick him back up and bring him back to his NH and he was noted to be lethargic. There is some report that a sheet (?) had to be tied around him. At some point started to become cyanotic and brought back to the ER (emergency room ) where he was intubated for airway protection. Not long after this he started to wake up and follow commands so was extubated (tube removed) in the ER, However within 15 minutes of extubation was once again obtunded and reintubated. Is now in ICU on vent and unable to provide and subjective history. The Resident was admitted to the hospital with [REDACTED]. The Resident was discharged from the hospital on [DATE] and returned to the facility. On [DATE] an interview was conducted with the DON who stated she was not present at the time of the incident however she felt in her opinion whoever took or transcribed the order should have had it clarified the order had no parameters to show when to give the second pill it only stated (MONTH) give second pill if necessary. DON was asked if 4 MG was a usual dose of [MEDICATION NAME] for anxiety for a Resident prior to a procedure. She stated that it seemed like a high dose. She further stated that in her opinion as an RN and a DON an accidental overdose resulting in being intubated and hospitalized in the ICU for 5 days constituted harm. On [DATE] in an interview with the Administrator she stated I meant no [MEDICATION NAME] harm when I wrote in the FRI sustained no harm, of course he was harmed by the administration of the medicine and had to be intubated but I mean there were not [MEDICATION NAME] effects from it. NOTE: This investigation is the result of a (Facility Reported Incident) FRI submitted to the OLC on [DATE]. The FRI stated that On [DATE] Resident #141 was administered and extra dose of [MEDICATION NAME] prior to a procedure. He was sent to the hospital and admitted . He suffered no harm as a result of the incident and has since returned to the facility and is doing well. The facility Administrator stated that they had self-identified the deficient practice prior to survey and presented the survey team with a Plan of Correction and requested a consideration for Past Non-Compliance, however the deficient practice of medication errors continued during the survey and thus the Past Non-Compliance was not accepted by the survey team. 2. For Resident #80, the facility staff repeatedly failed for 90 opportunities (30 consecutive days times every 8 hours), to ensure physician-ordered blood pressure monitoring for a PRN (as needed) low blood pressure medication ([MEDICATION NAME]). Resident #80 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #80's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of [DATE], coded Resident #80 as having severely impaired cognition. On [DATE], a review was conducted of Resident #80's clinical record, revealing the following signed physician's orders [REDACTED]. Give 1 tablet by mouth every 8 hours as needed for systolic blood pressure less than 95 mmhg/[MEDICAL CONDITION]. The clinical record contained the Medication Administration Record [REDACTED]. The nurses' notes did not contain documentation of the blood pressure monitoring on any shift, nor the administration, if needed of the medication. On [DATE], a review was conducted of facility documentation, revealing a Medication Administration Policy dated [DATE]. It read: Chart on Medication Administration Record [REDACTED]. On [DATE] at 2:15 P.M. the Assistant Director of Nursing (Employee C) was interviewed. When asked about the importance of monitoring blood pressure, she stated, The importance of monitoring the blood pressure is that if it is low then we administer the PRN order for [MEDICATION NAME]. If you're not monitoring the blood pressure you wouldn't know when to give it. I expect the nurses to document administration as soon as they give it. On [DATE] at approximately 4:00 P.M., the facility Administrator (Employee A) was informed of the findings. No further information was received.

Based on staff interview, clinical record review and facility documentation the facility failed to provide care in accordance with accepted standards of practice for 1 Resident (Resident #144) in a survey sample of 54 Residents. For Resident # 141, the facility failed to clarify an ambiguous order from a physician resulting in an overdose of [MEDICATION NAME] and subsequent harm. The findings include: Resident #141 a [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 141's most recent (Minimum Data Set) MDS (a screening tool) coded Resident as having a (Brief Interview of Mental Status) BIMS score of 10 which indicates moderate cognitive impairment. On [DATE] a clinical record review was conducted and it was found that Resident #141 had an appointment at the hospital for an MRI on [DATE]. He had an MRI the previous week at the same hospital on [DATE]. The Resident had an order for [REDACTED]. *[MEDICATION NAME] is used to treat anxiety disorders and panic disorder (sudden, unexpected attacks of extreme fear and worry about these attacks). [MEDICATION NAME] is in a class of medications called benzodiazepines. It works by decreasing abnormal excitement in the brain. According to the Narcotic Count sheet 1 (one) pill (2 MG) was signed out on [DATE] prior to MRI appointment. On [DATE] prior to the MRI appointment the Resident was given 2 (two) pills of [MEDICATION NAME] 2 MG each for a total of 4 MG of [MEDICATION NAME]. According to the hospital documentation the Resident was taken to the hospital by medical transport and was sent back to the facility because he did not need another MRI. According to Nurses Notes dated [DATE] at 11:10 Resident went out to appt this AM and returned from appt as coming in became unresponsive sternal rub slow to respond, BS (blood sugar) 96. O2 (Oxygen) was placed on resident at 2 (Liters per Minute) LPM (nasal cannula) at 98% Resident was assessed by Nursing staff code called. 911 activated arrived at the time of incident to pick up another resident for appt they resumed over resident 0 CPR initiated d/t resident having pulse and respirations. Resident transported to (hospital name) for eval. MD aware RP (RP Name) aware was coming in to facility a time. Bed hold renewed. According to hospital record on [DATE] Resident #141 a [AGE] year old male with developmental delay, [MEDICAL CONDITION] disorder, admitted to the ICU (Intensive Care Unit) intubated (artificial airway placed to provide oxygen for patient unable to breathe spontaneously) The story is not very clear sounds as though he was sent her from his NH (Name of Facility) for a head CT. In order to tolerate the scan was given 4 MG of [MEDICATION NAME] (wrong medication entered should have been [MEDICATION NAME]) prior to transport. On arrival was told he did not need the CT as he had just had an MRI last week (for which 2 MG of [MEDICATION NAME] was given) (again medication should have said [MEDICATION NAME]) EMS came to pick him back up and bring him back to his NH and he was noted to be lethargic. There is some report that a sheet (?) had to be tied around him. At some point started to become cyanotic and brought back to the ER (emergency room ) where he was intubated for airway protection. Not long after this he started to wake up and follow commands so was extubated (tube removed) in the ER, However within 15 minutes of extubation was once again obtunded and reintubated. Is now in ICU on vent and unable to provide and subjective history. The Resident was admitted to the hospital with [REDACTED]. The Resident was discharged from the hospital on [DATE] and returned to the facility. According to Perry & Potter 9th edition chapter 32 box ,[DATE] entitled Steps to take to Prevent Medication Errors Box ,[DATE] Steps To Take to Prevent Medication Errors o Prepare medications for only one patient at a time. o Follow the six rights of medication administration. o Be sure to read labels at least 3 times (comparing Medication Administration Record [REDACTED]. o Use at least two patient identifiers and review the patient's allergies [REDACTED]. o Do not allow any other activity to interrupt administration of medication to a patient (e.g., phone call, pager, discussion with other staff) (Hopkinson and Jennings, 2013). o Double check all calculations and other high risk medication administration processes (e.g., patient-controlled [MEDICATION NAME], Insulin) and verify with another nurse. o Do not interpret illegible handwriting; clarify with health care provider. o Question unusually large or small doses. On [DATE] an interview was conducted with the DON who stated she was not present at the time of the incident however she felt in her opinion whoever took or transcribed the order should have had it clarified the order had no parameters to show when to give the second pill it only stated (MONTH) give second pill if necessary. DON was asked if 4 MG was a usual dose of [MEDICATION NAME] for anxiety for a Resident prior to a procedure. She stated that it seemed like a high dose. She further stated that in her opinion as an RN and a DON an accidental overdose resulting in being intubated and hospitalized in the ICU for 5 days constituted harm. On [DATE] in an interview with the Administrator she stated I meant no [MEDICATION NAME] harm when I wrote in the FRI sustained no harm, of course he was harmed by the administration of the medicine and had to be intubated but I mean there were not [MEDICATION NAME] effects from it. NOTE: This investigation is the result of a (Facility Reported Incident) FRI submitted to the OLC on [DATE]. The FRI stated that On [DATE] Resident #141 was administered and extra dose of [MEDICATION NAME] prior to a procedure. He was sent to the hospital and admitted . He suffered no harm as a result of the incident and has since returned to the facility and is doing well. The facility Administrator stated that they had self-identified the deficient practice prior to survey and presented the survey team with a Plan of Correction and requested a consideration for Past Non-Compliance, which is as follows: 1. Resident #141 no longer resides at the facility 2. DON/Designee conducted a Quality Review of Physician orders [REDACTED]. 3. DON/Designee provided re-education to licensed nurses. 4. DON/Designee to Quality improvement monitoring on all physician orders 5. Date of compliance [DATE] Past non-compliance

Based on observation, staff interview, clinical record review and facility documentation review the facility staff failed to 1a) ensure 1 resident (Resident #37) of 51 residents in the survey sample was free from a choking hazards resulting in immediate jeopardy and 1b) failed to supervise Resident #37 resulting in falls with injury resulting in harm. 2) the facility staff failed to mitigate a fall hazard for 1 resident (Resident #64) in a 51 resident sample. 1a. Resident #37, who had [DIAGNOSES REDACTED]. total dependence on staff for eating, was observed sitting alone in her room for at least 30 minutes wearing a beaded silicone necklace. She was observed to stuff the necklace into her mouth. She was also observed to bite down on the beads with her teeth and forcefully pull the necklace with her hands. This resulted in Immediate Jeopardy 1b. Resident #37 fell on [DATE] requiring an emergency room visit and six sutures to the head. She fell again without injury on 3/16/18 as a result of being left unattended in a standing position by staff. She fell a third time on 6/7/18 requiring an emergency room visit and three sutures to the head. This is harm. 2) Resident #64 had multiple falls. After a therapy screen, the facility did not implement using colored tape on the call bell as a visual reminder to use his call bell for assistance. The findings included: 1a. Resident #37, who had [DIAGNOSES REDACTED]. total dependence on staff for eating, was observed sitting alone in her room for at least 30 minutes wearing a beaded silicone necklace. She was observed to stuff the necklace into her mouth. She was also observed to bite down on the beads with her teeth and forcefully pull the necklace with her hands. This resulted in Immediate Jeopardy Resident #37, a [AGE] year old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident had her own teeth. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 4/28/18. Resident #37 was coded with severely impaired cognitive skills. She required extensive assistance with activities of daily living and was coded as a 4/2 (total dependence, one person assistance) for eating. On 7/17/18 at 11:35 a.m., Resident #37 was observed in her room seated in a wheelchair. There were no staff present in the room. Resident #37 was wearing a beaded necklace around her neck. The necklace included two types of beads: round approximately the size of a nickel and flat approximately an inch long. The resident was observed to chew on the necklace and also stuff the necklace into her mouth. She was observed from 11:35 a.m. until 11:55 a.m. by this surveyor. She was observed by Surveyor 2 from 11:25 a.m. until 11:35 a.m. No staff entered the room during the 30 minute observation. At this time, a family member of Resident #37's roommate was in the room. The family member stated she was a nurse and she was extremely concerned that Resident #37 was going to choke on the necklace because she stuffed in her mouth. The family member stated she had alerted the staff of the concern. On 7/17/18 at 11:55 a.m., Licensed Practical Nurse B (LPN B), Unit Manager, was asked to observe Resident #37 with this surveyor. Upon entrance to the room, Resident #37 had the necklace beads in her mouth. LPN B was asked if it was ok that Resident #37 was wearing the necklace and putting it in her mouth. LPN B stated that the resident had a [DIAGNOSES REDACTED].#37 was care planned to have the teething ring. It was reviewed with LPN B that Resident #37 had been stuffing the necklace in her mouth for the last 30 minutes. LPN B was asked if the facility was concerned that Resident #37 would choke on the necklace LPN B stated that the resident was supervised when wearing the necklace. It was reviewed with LPN B that Resident #37 had not been supervised while wearing the necklace for the last 30 minutes. LPN B was asked to describe the type of supervision that was supposed to be provided. LPN B stated that the staff usually sat Resident #37 at the nursing station. On 7/17/18 at 12:20 p.m., Resident #37 was observed at the nursing station holding the necklace, no staff were in sight. On 7/18/18 at 9:00 a.m., Resident #37 was in the dining room alternating between chewing on the necklace as she held it in her hand and inserting the necklace in her mouth. The Speech Therapist (ST) was on the unit and she was asked to look at the necklace. She stated that she had never seen the necklace before, as it was not a device that had been recommended or provided by the therapy department. She stated that therapy would recommend a product called a chewy tube. The ST stated she had worked with Resident #37 previously. The ST stated that Resident #37 needed constant supervision and was a 1:1 for feeding. The ST was asked to provide the product information for the chewy tube. On 7/18/18 at 9:25 a.m., the ST provided a product book depicting the chewy tube. The product had a D shape to it. When asked if she considered the necklace to be a choking hazard, the ST hesitated to answer and then stated she has not assessed the resident so she could not say. This conversation was held at the nursing station desk. While not directly part of the discussion, LPN B was seated at the nursing station desk during the conversation with the ST. On 7/18/18 at 1:00 p.m.- 1:12 p.m., Resident #37 was observed in the dining room. She was seated at the table waiting for lunch. There were seven residents in the dining room. Staff varied from one or two staff. They were removing trays from the meal cart and setting up the trays for the residents in the room. At this time, Resident #37 held the necklace in her hand. The ends were not clasped and the necklace was a long strand of beads approximately 30 inches long. The resident alternated between inserting the beads in her mouth from the middle of the strand, the end of the strand (4 beads) and chewing on her hands. Resident #37 was also observed to bite down on the beads with her teeth and pull forcefully with her hands. The staff did not redirect Resident #37's actions at any time. The care plan dated 12/5/17 read, Behaviors related to, Attempts to bite, cognitive loss, ineffective impulse control, insufficient safety awareness with the intervention dated 6/20/18 have an object acceptable for mouth. The care plan read, (Resident #37) has the potential for injury r/t (related to) pica, dementia, poor communication/ comprehension, poor safety awareness, impaired mobility. An intervention dated 9/7/17 read, Monitor resident for chewing and inappropriate items in mouth. The care plan read, The resident has the potential for imbalanced nutrition r/t (related to) dementia, hx (history) etoh (alcohol) use, dx (diagnosis) dysphagia, hx (history) burns. Hx (history) significant weight change. Interventions dated 9/26/17 read, Redirect resident to discourage consumption of non food items and Remove potentially hazardous items & debris from environment. On 7/18/18 at 1:42 p.m., IJ was called. On 7/18/18 at 1:51 p.m., a meeting was held with the Administrator, Director of Nursing (DON) and Corporate Nurse. At this time, the facility was notified that Resident #37 was observed unsupervised in her room for 30 minutes alternating between chewing on the beaded necklace and stuffing it in her mouth. They were notified that Immediate Jeopardy had been called regarding Resident #37. At this time, the DON stated that the necklace was a teething necklace for a baby. At 2:05 p.m., the DON provided Resident #37's necklace to the survey team. The beads of the necklace were strung on a string. Knots were tied between every bead. Two beads were observed missing from the necklace. The facility presented a plan of correction on 7/18/18 at 3:11 p.m., and IJ was abated. The facility plan of correction is as follows: July 18, (YEAR) 1. Resident identified with necklace beads. Necklace beads have been removed and given to surveyor. Speech therapy evaluation has been requested by Physician. 2. No other residents have been identified as using the necklace beads. Residents with oral PICA [DIAGNOSES REDACTED]. 3. Residents with oral PICA [DIAGNOSES REDACTED]. Current in-house licensed nurses will receive education regarding oral PICA and adaptive devices by 1 pm on 7/19/18. Education will be provided by Regional Nurse Consultant. 4. Identified residents will be monitored daily using PI tool to ensure appropriate oral devices have been assessed by speech therapy. 5. Any new recommendations will be discussed in monthly QAPI meeting. On 7/18/18 at 5:30 p.m., the DON, Corporate Nurse and Administrator provided the packaging for the teething necklace. The necklace was a Nuby Teething Necklace. Product information included in the packaging read, Teething Trends Silicone Jewelry is fashion forward for mom and provides comfort to baby's gums. A variety of colors captivate your baby while the soft silicone provides stimulation to gums and emerging teeth. The product was found on the Nuby website in the Teethers section. The website https://www.nuby.com/usa/en/teethers was accessed on 7/24/18 at 9:35 a.m. The Teethers section read Teething is one of the most difficult stages of early development. Our teethers are designed to make it easier on both of you with soft silicone that soothes those sore gums and calms fussy babies. The DON stated that she purchased the necklace on the recommendation of the psychology nurse practitioner. The DON stated that a mother wears the necklace around her neck and the baby chews on the necklace while the mother holds the baby. It was reviewed with the DON that the mother is with the baby, supervising the baby at the time of use. The DON stated that Resident #37 was supervised while wearing the necklace and she does not wear it at night. It was reviewed that Resident #37 was unsupervised, as she was in her room alone for at least 30 minutes wearing the necklace. The DON stated that Resident #37 was not supposed to be left alone with the necklace. The DON stated she was supposed to be supervised. It was reviewed with the DON, Corporate Nurse and Administrator that Resident #37's admitting nursing note documented that the resident was admitted with a teething ring. It was reviewed that a teething ring and a beaded teething necklace are different devices. A teething ring can not be swallowed. On 7/19/18 at 9:05 a.m. an interview was held with the DON. When asked how the facility decided to provide the teething necklace, the DON stated that it was decided during a phone conversation with the psychology nurse practitioner. The DON stated they were trying to find something appropriate Resident #37 could put in her mouth to address her constant chewing behavior. They decided on the teething necklace which was purchased at the store by the DON. The following information about the eating disorder Pica was accessed at the National Eating Disorders website on 7/24/18 at 12:39 p.m. at https://www.nationaleatingdisorders.org/learn/by-eating-disorder/other/pica EVALUATION & DIAGNOSIS · There are no laboratory tests for pica. Instead, the [DIAGNOSES REDACTED]. · Diagnosing pica should be accompanied by tests for [MEDICAL CONDITION], potential intestinal blockages, and toxic side effects of substances consumed (i.e., lead in paint, bacteria or parasites from dirt). WARNING SIGNS & SYMPTOMS OF PICA · The persistent eating, over a period of at least one month, of substances that are not food and do not provide nutritional value. · The ingestion of the substance(s) is not a part of culturally supported or socially normative practice (e.g., some cultures promote eating clay as part of a medicinal practice). · Typical substances ingested tend to vary with age and availability. They may include paper, soap, cloth, hair, string, wool, soil, chalk, talcum powder, paint, gum, metal, pebbles, charcoal, ash, clay, starch, or ice. · The eating of these substances must be developmentally inappropriate. In children under two years of age, mouthing objects-or putting small objects in their mouth-is a normal part of development, allowing the child to explore their senses. Mouthing may sometimes result in ingestion. In order to exclude developmentally normal mouthing, children under two years of age should not be diagnosed with [REDACTED]. · Generally, those with pica are not averse to ingesting food. RISK FACTORS · Pica often occurs with other mental health disorders associated with impaired functioning (e.g., intellectual disability, autism spectrum disorder, [MEDICAL CONDITION]). · Iron-deficiency [MEDICAL CONDITION] and malnutrition are two of the most common causes of pica, followed by pregnancy. In these individuals, pica is a sign that the body is trying to correct a significant nutrient deficiency. Treating this deficiency with medication or vitamins often resolves the problems. · A medical professional should assess if the behavior is sufficiently severe to warrant independent clinical attention (e.g., some people may eat nonfood items during pregnancy, but their doctor may determine that their actions do not indicate the need for separate clinical care). Nurse Practitioner notes were reviewed. Notes were documented as follows: 9/6/17 The plan section read, 3. Pica- h/o (history of) GI (gastrointestinal) bleed and 5. Dysphagia (difficulty swallowing)- SP (speech therapy) 9/12/17 Patient with history of dementia which has been worsening. The hypomagnesium (low magnesium) is not an acute finding but has been worsening she is in her bed resting today. 9/26/17 Patient is seen today regarding her multiple vitamin/ mineral deficiencies. She has a noted magnesium level of 1.3, which is critically low. Yesterday afternoon, she began biting herself and 'gnawing at her fingers' per psychiatry and nursing staff. I asked her to be sent to the ER (emergency room ) for IV (intravenous) [MEDICATION NAME], hydration and full assessment. Per staff, she returned later last night with a [DIAGNOSES REDACTED]. Staff called the ER and were told (per Wing 4 charge nurse) that 'her magnesium levels were normal and that lab was almost 4 days old'. The ER did not return any lab results or other notes with her. We will request these as well as repeat her labs stat (Magnesium and CBC (complete blood count) since these were her most critically low readings). I have already written for a hematology consult to assess her reasons for malabsorption. The plan section read, PICA: Psychiatry feels this is related to her deficiency of multiple vitamins/ minerals not an underlying psychiatric issue. Dementia does cause further complication of this. Will address the underlying deficiencies and follow from there. 10/5/17 Her dementia appears stable and her PICA has slightly improved. She does tend to continue to bite on anything she has in her mouth. The plan section read, PICA: Has improved slightly. Will continue supplements and continue to monitor. 10/13/17 Of note, patient has also gained weight and her PICA has improved. The plan section read, PICA: Improved with diet and weight gain. Continue to monitor. 12/8/17 She has been noted by staff to have started 'eating things again' including on nurse reporting that she was 'biting at her own arm'. The plan read 2. DEMENTIA: She exhibits continued cognitive decline. Continue monitoring and medications as ordered. 3. PICA: Continue monitoring and labs are obtained. Likely related to deficiency. Will assess labs and adjust treatment as indicated. 12/23/17 Past Medical History included dysphagia and dementia, multifactorial. The plan read Dementia: Resident continues to decline unresponsive to therapy. and Dysphagia: Aspiration precautions. Weekly weights. Close observation with food ingestion. Sit up right in chair. 1/22/18- no mention of PICA 5/22/18 She is wheelchair and bed bounds at this time and is total assist. She may follow some commands at the time, but for the most part, she is symptoms of severe dementia. No mention of PICA. Labs ordered. 6/20/18 Diet: pureed Plan: PICA: labs ordered Speech Therapy notes were reviewed. Notes were documented as follows: Speech Therapy note from hospital stay prior to admittance to the facility on [DATE]. The hospital Speech Therapy note read strict aspiration & reflux precautions. 4/24/18 The Speech Therapy Initial Eval note read, Patient Referral and Historysection: Pt (patient) with fast rate of intake and needs supervision, verbal cues to slow rate. The Clinical Impressions section read, Due to ongoing decline in cognitive abilities, patient is currently a dependent feed and demonstrates good potential for diet advance with caregiver assist to follow safe swallowing precautions. 7/18/18 Short-term goals read, Patient will demonstrate safe oral manipulation of a non nutritive resistive chewing device (i.e. Chewy Tube, Y-Chews, Etc) for up to 15 minutes without s/s (signs/symptoms) aspiration, gagging or distress. Long-Term Goals read, Patient will demonstrate a reduced risk of ingesting inedible objects and inflicting self harm via safe use of a non-nutritive chewing device between meals. The Clinical Impressions/ Recommendations section read, Caregivers are independent and compliant with previous recommendations to follow aspiration precautions. Patient does present with behaviors associated with Pica most evident between meals including biting/chewing/ingesting inedible objects and biting/chewing on self. To reduce frequency of these behaviors, patient would benefit from speech therapy to conduct a trial using non nutritive resistive chewing devices such as a Chewy-tube or Y-Chews device to determine the safest and most effective intervention to reduce frequency of behavior and to decrease risk of aspiration, accidental ingestion of a non food item and self harm. The description of Aspiration precautions was accessed on 7/24/18 at 11:34 p.m. at the website https://www.drugs.com/cg/aspiration-precautions.html. Aspiration precautions: Aspiration means that foods or fluids get into your airway. This can lead to trouble breathing or lung infections such as pneumonia. Aspiration precautions are practices that help prevent these problems. The recommendation for aspiration precautions and/or swallowing precautions was documented in Resident #37's clinical record in all three speech therapy notes and the 12/23/17 nurse practitioner note. The facility was asked on multiple occasions to provide the aspiration policy or protocol used at the facility. On 7/23/18 at 1:40 p.m., the DON stated that the facility did not have an aspiration protocol. Nursing notes were reviewed. Notes were documented as follows: 9/4/17 Patient arrived with a childs teething ring + pacifiers as she bites anything + places it in her mouth. 9/15/17 Resident continues to enter other residents' rooms, grabbing everything (trash, diapers, papers etc to eat) 12/7/17 Resident keeps biting her arms and hands The wound on her left forearm bigger and bigger. Resident took dressing off. Writer apply a new dressing and wrap with Kerlix on her left arm to prevent Resident biting her wound again. Continue to monitor. 12/7/17 Resident continues to bite on her hands, arms and noted to be chewing on side rail to wheelchair (arm of chair). Pillow case wrapped around arm of chair. redirecting resident frequently. Notified NP (Nurse Practitioner) 12/8/17 Resident alert. confusion. Still keeps bit things including her hand and arm. 6/20/18 Res. obs. chewing on table. Res given an object acceptable for chewing 6/21/18 Continues to chew on object provided by nursing. In summary, Resident #37 was known to have severe dementia, have a swallowing difficulty and known to repeatedly place non food items in her mouth. She was observed alone in her room for at least 30 minutes alternating between stuffing a beaded necklace into her mouth and gripping the beads with her teeth and forcefully pulling the necklace with her hands. She was observed in the dining room stuffing the beads into her mouth. She was not redirected by staff. Speech Therapy had never seen the necklace. Speech Therapy did not recommend, evaluate or provide the beaded necklace. When the necklace was given to the survey team, two beads were observed to be missing. The DON stated Resident #37 should not have been left alone with the necklace. 1b) Resident #37 fell on [DATE] requiring an emergency room visit and sutures to the head. She fell again without injury on 3/16/18 as a result of being left unattended in a standing position by staff. She fell a third time on 6/7/18 requiring an emergency room visit and sutures to the head. Resident #37's three falls are listed below: 1. 12/10/17 fall The Fall Root Cause Investigation Report read, -Breakfast up to floor @ 10 AM- resident in day room -Approx 11 AM CNA (certified nursing assistant) informed writer resident on floor in day room - Resident on knees in floor with head on floor trying to bite cord to box fan beside her blood noted on side of fan probably hit her head on side of fan. w/c (wheelchair) over backside of resident locked. - Blood (fresh) from laceration to forehead + L temple appears to need stitches- area cleansed + bandage applied- resident put in w/c and ambulance called- No RP (responsible party)- NP (nurse practitioner) (name) called + informed- resident out to ER (emergency room ) @ 11:15 AM. 12/10/17 Discharge Instructions from the ER visit read, Sutured Wound Care Your cut has been cleaned and closed with stitches. The instructions also read, Wound Care- Facial Laceration You have been treated for [REDACTED]. A laceration is a cut through the skin. This will usually require stitches if it is deep. A Weekly Skin Integrity Review form was included in the clinical record. On 12/15/17, documentation in the Current skin condition section read, 6 sutures to forehead. 2. 3/16/18 fall The Fall Root Cause Investigation Report documented that the resident was toileting prior to the fall or at the time of the fall. Attached was a witness statement which read, I, (name), was assigned to (resident name): I was in the process of changing her: she had been playing in feces: I stood her up and she held on to the night table: I went to the sink to wet a towel to clean her up: before I got back t her she lost her Balance and Feel (sic): (she slightly hit her left side of head on her wheel chair. The most recent Minimum Data Set assessment completed prior to the fall had an assessment reference date of 12/28/17. She was coded as a 4/3 (total assistance/ 2 persons) for Transfers between surfaces and standing position. On 3/16/18, a Fall Risk Evaluation was completed. Resident #37 scored a 10, indicating high risk for potential falls. 3. 6/7/18 fall 6/7/18, 3:10 p.m. nursing note read, Resident was found on the floor in her bedroom. Before the event occur the resident was lying bed. The resident have a deep laceration to the L forehead. The laceration was cleaned a dressing was applied. Resident was sent out to (hospital) for eval. 6/7/18, 8:00 p.m. nursing note read, Call ER (emergency room to get information on how many sutures, wasn't in the chart @ the hospital on how many. Upon assessment it look to be 3 sutures on the left side of forehead. The hospital emergency provider report stated complaint read, Head Pain. Diagnostic tests included CT (computerized tomography) scan of the head and spine. Both had negative findings. The hospital discharge summary read, suture care. Resident #37's care plan initially dated 9/7/17 was reviewed. There was no focus area specific to fall prevention. The focus (Resident name) has the potential for injury r/t (related to) pica, dementia, poor communication/ comprehension, poor safety awareness, impaired mobility included safety interventions. Interventions included 9/15/17 revised 5/4/18: be sure call light is within reach 9/15/17 revised 5/4/18: ensure appropriate footwear 9/15/17 revised 5/4/18: Follow facility fall protocol 9/7/17: keep needed items, water, etc, in reach The care plan interventions were not reviewed and revised after each fall. On 7/19/18 at the end of day meeting, Resident #37's falls with injury and lack of supervision were reviewed with the Administrator and Director of Nursing. They were also notified that it did not appear that the care plan interventions were updated. All information regarding the falls was accepted and reviewed. No information was provided about the care plan. COMPLAINT DEFICIENCY 2) Resident #64 had multiple falls. After a therapy screen, the facility did not implement using colored tape on the call bell as a visual reminder to use his call bell for assistance. Resident #64 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #64's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 5-15-18 coded Resident #64 with severe cognitive impairment. The MDS was completed as a quarterly assessment. The resident required extensive assistance with ADL's (activities of daily living such as bed mobility and toileting) of one to two staff members. The resident could feed himself. The resident was incontinent of bowel and bladder. The resident was coded as having two falls since the last assessment with no injury. On 2/26/18, the SBAR (situation, background, appearance, resident evaluation) recorded, Found resident sat (sic) on floor many times with no injury. On 5/25/18, the SBAR report documented a fall. No specifics documented. On 6/29/18, the resident was found sitting on bedside mat. No injuries were noted. A rehabilitation referral was reviewed with a date of 7-2-18 . It included to add bright color to call bell. On 7/18/18 at 9:14 AM, Resident #64 was observed in his room, in a wheelchair. The call bell was on the bed. There was no tape or color added to the call bell. When asked if he had fallen before, he stated he had fallen before and hit his head. There was a fall mat on the floor beside the bed and the bed was against a wall. On 7/19/18 11:00 AM: Surveyor requested the rehabilitation referral copy yesterday, have not received. On room check, the resident now has colored tape on his call bell. The rehabilitation form was provided. Review of the care plan dated 5-23-18 revealed the resident had a potential for injury related falls, unsteady gait, [MEDICAL CONDITION] medication and tremors. On 7/18/18, an intervention was added to the care plan to add color to call bell. On 7/19/18 at 4:10 PM, the facility Administrator and Director of Nursing were notified of above findings.

Based on staff interview, facility documentation, clinical and hospital record review, and in the course of a complaint deficiency, the facility staff failed to for one resident, Resident #611, in a survey sample of 51 residents, to notify the physician of a change in condition, resulting in harm. 1. Resident #611's physician was not notified of the worsening of the resident's pressure wounds, resulting in wound infection, pain and resulted in both wounds deteriorating to stage 4 pressure ulcers. In addition, the physician was not notified of the inability of the facility to provide a [DEVICE] for treatment. This resulted in harm. The findings included: 1. Resident #611's physician was not notified of the worsening of the resident's pressure wounds, resulting in wound infection, pain and resulted in both wounds deteriorating to stage 4 pressure ulcers. In addition, the physician was not notified of the inability of the facility to provide a [DEVICE] for treatment. This resulted in harm. Resident #611 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Resident #611's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 1/16/18 coded Resident #611 with severe cognitive impairment. The MDS was completed as a quarterly assessment. The resident required extensive to total care with all ADL's (activities of daily living such as bed mobility and toileting) of one to two staff members. The resident was incontinent of bowel and bladder. There was one wound documented on the MDS which was coded as a stage 3 with the measurements of 4.5 cm (centimeters) by 3.3 cm with a depth of 0.3 cm. The wound bed had slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous). During this look back period, according to the clinical record, the resident actually had two stage three pressure ulcers. The NPUAP (national pressure ulcer advisory panel) describes a stage 3 ulcer as a Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. NPUAP describes a stage 4 ulcer as a Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Review of the clinical record for the resident's right buttock, also documented as sacral and right ischial wound revealed the following: There was no wound tracking, weekly measurements, treatment documentation, wound care orders upon review of the clinical record. There was documentation of at least one time that the resident received a treatment that was ordered for the right posterior thigh. The physician was not notified of decline in the wound for a change in treatment. On 12/13/17, the nurse's notes documented a dressing change to right buttocks. There was no documentation that the physician was notified and orders given to treat the wound. On 12/18/17, the nurse's notes read, Treatment to right buttock (pressure). Area is stage 3 . some yellow slough . NS, Alginate, [MEDICATION NAME]. Incidentally, this was the treatment for [REDACTED]. There is no documentation that the MD was notified of the deterioration of the wound. 12/21/17, the nurse's notes read: Wound is malodorous, and appears to have bloody drainage. Resident shouted in pain upon dressing application . resident is still grimacing and vocalized his pain. There was no documentation the physician was notified of the pain. Pain medication was ordered on 1-18-18. On 12/27/17, the nurse's notes read: Resident threw up after lunch. There is no documentation that the MD was notified. On 12/28/17, the NP (nurse practitioner) recorded: On assessment, patient had a dressing to his right hip, when uncovered, there was about 3.5 by 3.5 inch wound with bloody, purulent drainage noted Nurse called to bedside to assess the site. A culture and sensitivity was ordered, but was canceled on 1-2-18. Antibiotic therapy with Keflex was initiated. On 12/29/17, the nurse's notes read: Treatment provided. Some discomfort . Area is improving, healing nicely. Measurements- inner dimensions 2.9 by 2.7. There is no indication which wound was being assessed and there is no depth recorded. There is no documentation that the MD was notified. On 1/3/18, the nurses notes read: Wound has developed yellowish-gray slough on wound bed with an odor, however wound is reducing in size and depth. No measurements were taken and it is unclear which wound was being assessed. On 1/5/18, the nurse's notes read: Treatment performed . Area is improving slowly, the area of the wound is hard to heal, in middle of buttock cheek, very close to anus. On 1/12/18, the nurses note read: Treatment completed on sacral/right posterior buttocks. Measures 4.5 by 3.3 by 0.3. There is no documentation the physician was notified of the worsening of the wound. On 1/15/18, the nursing notes read: Treatment completed, area is sore, there is stool in the wound, needs an irrigation with saline, to help clear wound. There is no documentation the physician was notified of the observation and no new physician orders. On 1/25/18, the notes read: Sacral wound dressing changed, moderate drainage noted. Area malodorous. No measurements documented. There is no documentation that the MD was notified. On 2/7/18 at 4:30 AM, Resident O2 sat 88%, placed on O2 sat up to 95%. The resident did go out for an appointment with the wound clinic. The treatment orders per the wound care physician read: Right ischial (hip) wound stage 3-4, measurements 4.3 cm by 3.0 cm with a depth of 3.8 cm. PT (physical therapy) wound care with pulsed lavage 1000 cc (cubic centimeters) 0.9 % NS 4.8 PSI (pounds square inch) 100 mm (millimeters) mercury [DEVICE] treatment) to right ischial wound. Dressing [MEDICATION NAME], packed with [MEDICATION NAME], 4 by 4 and [MEDICATION NAME] border. There is no documentation that the wound treatment or PT referral was done as ordered. On 2/12/18, after the resident returned from the wound clinic (no wound documentation available), according to the nurse's notes, Family came to the nurses and wanted resident to be sent to the ER (emergency room ) for an evaluation because he is more lethargic to them. NP (nurse practitioner) present and assessed resident and stated that we could treat him here. But they still wanted to go. The resident was transferred to the hospital and did not return to the facility. Review of the care plan dated 2/21/18 revealed there was no documentation of the right buttock/sacrum/hip wounds. It also included to notify the physician for change in condition. On 7/19/18 at 4:10 PM, the DON (director of nursing) stated, The nurses should call the MD and get an order for [REDACTED]. On 7/19/18 at 5:20 PM, the facility Regional Clinical Director stated, We don't do [DEVICE].

Based on facility documentation and clinical record review, and in the course of a complaint investigation, the facility staff failed to for three residents (Resident #611, #612, #361) in a survey sample of 51 residents in the survey sample, to develop a care plan. 1. Resident #611 sustained a sacral wound that was discovered at a stage 3,that was not care planned for the treatment, continued assessment, interventions and evaluation of the acquired stage 3, resulting in infection and deterioration of the wound to a stage 4. This is harm. 2. Resident #612's history of fecal impaction was not care planned. The resident had no documentation of no bowel movements (BM) for 4 days, resulting in nausea and distended abdomen. At autopsy, the resident had both the large and small intestine distended with air, and the large intestine contained an abundant amount of stool. 3. For Resident # 361, the facility staff failed to ensure a comprehensive care plan included the focus of refusal of care. The findings included: 1. Resident #611 sustained a sacral wound that was discovered at a stage 3,that was not care planned for the treatment, continued assessment, interventions and evaluation of the acquired stage 3, resulting in infection and deterioration of the wound to a stage 4. This is harm. Resident #611 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Resident #611's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of [DATE] coded Resident #611 with severe cognitive impairment. The MDS was completed as a quarterly assessment. The resident required extensive to total care with all ADL's (activities of daily living such as bed mobility and toileting) of one to two staff members. The resident was incontinent of bowel and bladder. There was one wound documented on the MDS which was coded as a stage 3 with the measurements of 4.5 cm (centimeters) by 3.3 cm with a depth of 0.3 cm. The wound bed had slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous). During this look back period, according to the clinical record, the resident actually had two stage three pressure ulcers. The NPUAP (national pressure ulcer advisory panel) describes a stage 3 ulcer as a Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. NPUAP describes a stage 4 ulcer as a Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. [DATE]: Nurses notes recorded: Resident's wound to right buttock showing signs of improvement. There were no measurements. On [DATE], the nurses notes read: Wound has developed yellowish-gray slough on wound bed with an odor, however wound is reducing in size and depth. No measurements were taken and it is unclear which wound was being assessed. On [DATE], the nurse's notes read: Treatment performed . Area is improving slowly, the area of the wound is hard to heal, in middle of buttock cheek, very close to anus. On [DATE], Area on right posterior buttocks measures 2.4 by 1.9 by 0.2. On [DATE], a low air loss mattress was ordered. On [DATE], the nurses note read: Treatment completed on sacral/right posterior buttocks. Measures 4.5 by 3.3 by 0.3. There is no documentation the physician was notified of the worsening of the wound. On [DATE], the nursing notes read: Treatment completed, area is sore, there is stool in the wound, needs an irrigation with saline, to help clear wound. There is no documentation the physician was notified of the observation and no new physician orders. On [DATE], in the nurse's notes: New order to culture right lower buttocks, do aerobe (sic) and anerobic and do surgical consult on right lower buttock pressure. On [DATE], the nurse's notes revealed: New order for Bactrim DS (antibiotic). On [DATE], the notes read: Sacral wound dressing changed, moderate drainage noted. Area malodorous. No measurements documented. On [DATE] at 4:30 AM, Resident O2 sat 88%, placed on O2 sat up to 95%. The resident did go out for an appointment with the wound clinic. The treatment orders per the wound care physician read: Right ischial (hip) wound stage ,[DATE], measurements 4.3 cm by 3.0 cm with a depth of 3.8 cm. PT (physical therapy) wound care with pulsed lavage 1000 cc (cubic centimeters) 0.9 % NS 4.8 PSI (pounds square inch) 100 mm (millimeters) mercury to right ischial wound. Dressing [MEDICATION NAME], packed with [MEDICATION NAME], 4 by 4 and [MEDICATION NAME] border. There is no documentation that the wound treatment or PT referral was done as ordered. On [DATE], after the resident returned from the wound clinic (no wound documentation available), according to the nurse's notes, Family came to the nurses and wanted resident to be sent to the ER (emergency room ) for an evaluation because he is more lethargic to them. NP (nurse practitioner) present and assessed resident and stated that we could treat him here. But they still wanted to go. The resident was transferred to the hospital and did not return to the facility. Review of the care plan dated [DATE] revealed there was no documentation of the right buttock/sacrum/hip wound. 2. Resident #612's history of fecal impaction was not care planned. The resident had no documentation of no bowel movements (BM) for 4 days, resulting in nausea and distended abdomen. At autopsy, the resident had both the large and small intestine distended with air, and the large intestine contained an abundant amount of stool. Resident #612 was admitted to the facility on [DATE] and discharged to the hospital on [DATE], where he expired. [DIAGNOSES REDACTED]. Resident #612's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of [DATE] coded Resident #612 with no cognitive impairments. The MDS was completed as an admission assessment. The resident required extensive care with all ADL's (activities of daily living such as bed mobility and toileting) of one to two staff members. The resident was frequently incontinent of bowel and bladder. The resident was coded as having a weight loss not prescribed by the physician. Review of the closed record revealed: On [DATE]: The resident was admitted to the facility. [MEDICATION NAME] 4 mg (milligrams) for nausea was ordered and stat chest X-Ray. Complained of nausea at 10:54 PM and on the ,[DATE] shift. No documentation of [MEDICATION NAME] being administered for nausea. On [DATE]: All shifts charted lungs clear. No complaints of nausea or vomiting documented. The physician note read: admitted to (name of hospital) after being admitted for hematuria, fecal impaction. On [DATE], the physician notes for this day documented moderate distention (abdomen), hypoactive bowel sounds, non tender, no guarding. Review of Resident #612's care plan dated [DATE] revealed no care plan for history of fecal impaction and nausea or interventions to address bowel function and nausea. An autopsy was done [DATE]. The results were: Final anatomic Diagnosis: [REDACTED]. Pleural effusion, bilateral. Focal active [MEDICAL CONDITION], with acute and chronic inflammation and focal degeneration of bowel wall. Probable early acute appendicitis is seen. [MEDICATION NAME] cavities were filled with approximately 1000 ml (one liter) of serosanguinous fluid in both the left and right sides. The large and small intestine were both distended with air, and the large intestine contains an abundant amount of stool. The microscopic examination revealed acute and chronic inflammation of the large intestine (acute [MEDICAL CONDITION]). Vermiform appendix shows autolysis of appendiceal mucosa with focal early acute appendicitis. 3. For Resident # 361, the facility staff failed to ensure a comprehensive care plan included the focus of refusal of care. Resident #361 was admitted to the facility on [DATE] for skilled services in nursing and therapy related to altered mental status and [MEDICAL CONDITION]. [DIAGNOSES REDACTED]. Review of the Resident # 361's closed clinical record revealed the most recent MDS (Minimum Data Set) was an Admission Assessment with an ARD (Assessment Reference Date) of [DATE]. Resident # 361 was coded as having a BIMS (Brief Interview of Mental Status) of ,[DATE] indicating no cognitive impairment. The resident was coded as requiring extensive assistance of one staff member for ADLs (activities of daily living) including bathing except for eating, where he was coded as independent and requiring set up only. Resident # 361 was coded as always incontinent of bowel and bladder. Review of the closed clinical record was conducted on [DATE] and [DATE]. Review of an interdisciplinary note dated [DATE] revealed documentation of bilateral heel unstageable pressure ulcers deteriorated per wound report ,[DATE]. Discussed with unit manager who reports refusal of care. Notably resident reports 'not feeling well' per nurse note ,[DATE], although no fever no pain .Resident refused to be weighed for weekly weights, however last week weight 201 pounds, stable since admission, BMI (Body Mass Index) 22. Recommend d/c (discontinue) Cardiac restriction to encourage adequate intake for wound healing. Will continue to monitor and f/u (follow up) per protocol Review of Nurses Notes revealed documentation: [DATE] (no time written) Resting upon rounds combative at times, refuses care at times. Chart check [DATE] 1505 (3:05 PM) LOA (Leave of Absence) with friend in manual wheelchair no skin issues noted at this time-can be uncooperative [DATE] 2:15 PM . Resident stated 'He didn't want to get up doesn't feel well,' Writer asked what wrong (sic) Resident stated 'Lady leave me alone. I just don't feel well. Resident has new order to obtain Complete Blood count, comprehensive Metabolic Profile and urinalysis and culture and sensitivity [DATE] Review of the care plan revealed focus areas of At risk for impaired skin integrity, Has an infection Urinary tract infection, Altered bladder elimination, impaired cognition and/or thought processes related to Parkinson, impaired decision making, potential for alteration in pain/discomfort, actual and potential ADL (Activities of Daily Living) deficits, Potential for injury related to decrease mobility, fluid imbalance, Activities, Rehab potential , Full Code, Mood State, Nutritional Status, Psychosocial Well being, Potential for imbalanced nutrition related to Hypertension Thorough review of the care plan revealed no documentation of the concern or focus of refusal of care along with measurable objectives and interventions to reach a goal. During the end of day debriefing on [DATE], the facility Administrator, Director of Nursing and Corporate Consultant stated care plans should reflect the residents' focus areas along with objectives, interventions and goals. No further information was provided. COMPLAINT DEFICIENCY

Based on staff interview, clinical record review and facility documentation review the facility staff failed for 1 resident (Resident #361) of 51 residents in the survey sample to report an allegation of Neglect to the state agency. Resident #361 did not receive treatments as ordered by the physician for two consecutive days 9/16/2017 and 9/17/2017. Maggots were found in the wounds on his heels. The nurse signed the Treatment Administration Record indicating the treatments were done. The nurse later admitted she did not do the treatments to the heels for those two days. A FRI (Facility Reported Incident ) was not submitted until a new administrator was hired in (MONTH) (YEAR). The findings included: Resident #361 was admitted to the facility on [DATE] for skilled services in nursing and therapy related to altered mental status and [MEDICAL CONDITION]. [DIAGNOSES REDACTED]. Review of the Resident # 361's closed clinical record revealed the most recent MDS (Minimum Data Set) was an Admission Assessment with an ARD (Assessment Reference Date) of 8/9/2017. Resident # 361 was coded as having a BIMS (Brief Interview of Mental Status) of 13/15 indicating no cognitive impairment. The resident was coded as requiring extensive assistance of one staff member for ADLs (activities of daily living) including bathing except for eating, where he was coded as independent and requiring set up only. Resident # 361 was coded as always incontinent of bowel and bladder. Review of the closed clinical record was conducted on 7/18/2018 and 7/19/2018. Review of the FRI (Facility Reported Incident submitted to the state agency on 2/15/2018 reported an allegation of neglect that occurred on 9/18/17. The FRI stated a nurse LPN (Licensed Practical Nurse) H failed to provide wound care to Resident # 361 resulting in resident being sent to the emergency room for further evaluation. It was noted that maggots were in his wound located on his right heel. The hospital sent resident back to the facility on [DATE] and requested that the resident have a wound consult. Resident did return with orders for antibiotic treatment. Resident was sent back to hospital on [DATE] and did not return. LPN H was suspended and during the investigation, LPN H verbally admitted that she did not provide wound care as ordered by the physician during her assigned shift. She was terminated and she was reported to the Department of Health Professions-Enforcement Division. Review of the closed clinical record was conducted on 7/18/2018 and 7/19/2018. An interview was conducted with the Administrator on 7/18/2018 regarding reporting the allegation of neglect for Resident # 361. The Administrator stated that he heard rumors about the allegation of neglect soon after he was employed at the facility in (MONTH) (YEAR). He stated he searched but could not find any documentation that the allegation of neglect had been reported to the State Agency by the previous administrator so he completed the FRI (Facility Reported Incident). The Administrator stated it was the right thing to do. The Administrator stated that once an allegation was made, he would report to the State Agency immediately and begin the investigation. The DON stated that she would report to the state agency immediately but no later than 2 hours after the allegation is made. The facility abuse policy Abuse: Neglect, Exploitation and Misappropriation, Under Reporting/Response was reviewed. Page 7, read Any employee is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause thee allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the Administrator and to other officials in accordance with State law On 7/19/18 at 4:00 p.m., the Administrator and DON were asked to submit any information they would like to have reviewed regarding the issue. Both stated that no other information was able to be found. The Administrator and DON were not employed at the facility at the time of the allegation of Neglect. The nurse was terminated on 9/18/2017. No further information was provided. COMPLAINT DEFICIENCY

Based on staff interview, clinical record and facility documentation, staff interview and in the course of a complaint investigation, the facility staff failed to for two Residents, Resident #611 and Resident #361, in a survey sample of 51 residents, to prevent neglect, resulting in harm for both residents. In addition, the facility staff maintain supplies needed for resident care. 1) Resident #611 sustained a sacral wound that was discovered at a stage 3, was not treated or monitored, which progressed to a stage 4, requiring hospitalization . The resident also acquired a stage 3 pressure ulcer to the right posterior upper thigh which progressed to a stage 4 and became infected. This is harm 2) For Resident #361, the facility staff failed to ensure neglect did not occur. Treatments were not done as ordered by the physician. Resident #361 was transported to the hospital with maggots in his wounds. This is harm 3) The facility failed to maintain supplies needed for resident care. The findings included: 1) Resident #611 sustained a sacral wound that was discovered at a stage 3, was not treated or monitored, which progressed to a stage 4, requiring hospitalization . The resident also acquired a stage 3 pressure ulcer to the right posterior upper thigh which progressed to a stage 4 and became infected. This is harm. Resident #611 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Resident #611's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 1/16/18 coded Resident #611 with severe cognitive impairment. The MDS was completed as a quarterly assessment. The resident required extensive to total care with all ADL's (activities of daily living such as bed mobility and toileting) of one to two staff members. The resident was incontinent of bowel and bladder. There was one wound documented on the MDS which was coded as a stage 3 with the measurements of 4.5 cm (centimeters) by 3.3 cm with a depth of 0.3 cm. The wound bed had slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous). During this look back period, according to the clinical record, the resident actually had two stage three pressure ulcers. The NPUAP (national pressure ulcer advisory panel) describes a stage 3 ulcer as a Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. NPUAP describes a stage 4 ulcer as a Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Review of the closed clinical record revealed on 8-27-17 an SBAR- Situation/Background/Evaluation/ Appearance/Review revealed a red, irritated area to buttock, likely related to soiled pamper. Barrier cream was applied. Review of the clinical record revealed on 11/22/17: Assess resident right upper thigh for bleeding. Minimal bleeding noted. Appears to be excoriation and has been a recurring incident. RP/MD (responsible party/physician) notified. On 12/6/17, the treatment was changed to [MEDICATION NAME] and a dry dressing. On 12/8/17, the treatment was changed to cleaning the wound with normal saline, skin prep, Alginate, cover with [MEDICATION NAME]. The wound was documented as a stage 2-3. The area measured 4 cm by 4 cm with a 0.3 depth. There were no further notes or wound tracking of this wound until 2-1-18. The treatment remained the same until 1-17-18. On 1/10/18 a low air loss mattress was in place. On 1/17/18, the nurses notes documented, Right lower posterior thigh . area tender to touch, resident cringes when touched measures 3.5 cm by 2 cm with a depth 1.4 cm . wound has an odor drainage covers 80 % of dressing. The treatment was changed to Maxsorb, Alginate (for drainage) and Santyl (to debride dead tissue). On 1/18/18, the resident received an order for [REDACTED]. On 1/22/18, there was a new physician's order for Bactrim DS (an antibiotic) [DIAGNOSES REDACTED]. On 2/1/18, the nurse's notes documented went out to the wound clinic for consult right thigh. VS (vital signs) 97.4, 82, 12 (respirations), blood pressure 92/50. Oxygen (O2) saturation 87 % (normal above 92 %). Staff called the wound clinic to recheck oxygen sats 87%. MD notified , new order for oxygen 2 liters per minute via nasal cannula for O2 less than 95%. The wound treatment was changed to cleanse right thigh with 1/4 strength Dakins, rinse with NS (normal saline) apply [MEDICATION NAME] 4 by 4 and ABD (absorbent dressing). The pain medication orders were changed to [MEDICATION NAME] 5 mg (milligrams) every six hours for pain. On 2/7/18 at 4:30 AM, Resident O2 sat 88%, placed on O2 sat up to 95%. The resident did go out for an appointment with the wound clinic. On 2/10/18, the nurses notes read: Wound care provided. Facial grimacing noted during wound care. On 2/12/18, after the resident returned from the wound clinic, according to the nurse's notes, Family came to the nurses and wanted resident to be sent to the ER (emergency room ) for an evaluation because he is more lethargic to them. NP (nurse practitioner) present and assessed resident and stated that we could treat him here. But they still wanted to go. The resident was transferred to the hospital and did not return to the facility. Review of the clinical record for the resident's right buttock, also documented as sacral and right ischial wound revealed the following: There was no wound tracking, weekly measurements, treatment documentation, wound care orders upon review of the clinical record. There was documentation of at least one time that the resident received treatment that was ordered for the right posterior thigh. The physician was not notified of decline in the wound for a change in treatment. On 12/13/17, the nurse's notes documented a dressing change to right buttocks. On 12/18/17, the nurse's notes read, Treatment to right buttock (pressure). Area is stage 3 . some yellow slough . NS, Alginate, [MEDICATION NAME]. Incidentally, this was the treatment for [REDACTED]. 12/21/17, the nurse's notes read: Wound is malodorous, and appears to have bloody drainage. Resident shouted in pain upon dressing application . resident is still grimacing and vocalized his pain. There was no documentation the physician was notified of the pain. Pain medication was ordered on 1-18-18. On 12/27/17, the nurse's notes read: Resident threw up after lunch. There is no documentation that the MD was notified. On 12/28/17, The NP recorded: On assessment, patient had a dressing to his right hip, when uncovered, there was about 3.5 by 3.5 inch wound with bloody, purulent drainage noted Nurse called to bedside to assess the site. A culture and sensitivity was ordered, but was canceled on 1-2-18. Antibiotic therapy with Keflex was imitated. On 12/29/17: The nurse's notes read: Treatment provided. Some discomfort . Area is improving, healing nicely. Measurements- inner dimensions 2.9 by 2.7. There is no indication which wound was being assessed and there is no depth recorded. 12/31/17: Nurses notes recorded: Resident's wound to right buttock showing signs of improvement. There were no measurements. On 1/3/18, the nurses notes read: Wound has developed yellowish-gray slough on wound bed with an odor, however wound is reducing in size and depth. No measurements were taken and it is unclear which wound was being assessed. On 1/5/18, the nurse's notes read: Treatment performed . Area is improving slowly, the area of the wound is hard to heal, in middle of buttock cheek, very close to anus. On 1/8/18, Area on right posterior buttocks measures 2.4 by 1.9 by 0.2. On 1-10-18, a low air loss mattress was ordered. On 1/12/18, the nurses note read: Treatment completed on sacral/right posterior buttocks. Measures 4.5 by 3.3 by 0.3. There is no documentation the physician was notified of the worsening of the wound. On 1/15/18, the nursing notes read: Treatment completed, area is sore, there is stool in the wound, needs an irrigation with saline, to help clear wound. There is no documentation the physician was notified of the observation and no new physician orders. On 1/17/18, in the nurse's notes: New order to culture right lower buttocks, do aerobe (sic) and anerobic and do surgical consult on right lower buttock pressure. On 1/22/18, the nurse's notes revealed: New order for Bactrim DS (antibiotic). On 1/25/18, the notes read: Sacral wound dressing changed, moderate drainage noted. Area malodorous. No measurements documented. On 2/7/18 at 4:30 AM, Resident O2 sat 88%, placed on O2 sat up to 95%. The resident did go out for an appointment with the wound clinic. The treatment orders per the wound care physician read: Right ischial (hip) wound stage 3-4, measurements 4.3 cm by 3.0 cm with a depth of 3.8 cm. PT (physical therapy) wound care with pulsed lavage 1000 cc (cubic centimeters) 0.9 % NS 4.8 PSI (pounds square inch) 100 mm (millimeters) mercury to right ischial wound. Dressing [MEDICATION NAME], packed with [MEDICATION NAME], 4 by 4 and [MEDICATION NAME] border. There is no documentation that the wound treatment or PT referral was done as ordered. On 2/12/18, after the resident returned from the wound clinic (no wound documentation available), according to the nurse's notes, Family came to the nurses and wanted resident to be sent to the ER (emergency room ) for an evaluation because he is more lethargic to them. NP (nurse practitioner) present and assessed resident and stated that we could treat him here. But they still wanted to go. The resident was transferred to the hospital and did not return to the facility. Review of the care plan dated 2/21/18 revealed there was no documentation of the right buttock/sacrum/hip wounds. It also included to notify the physician for change in condition. Review of the skin evaluations done by nursing from 10/3/17 to 1/6/18 revealed no markings on the body diagram or notations of the right buttock/sacral/ wound. The facility policy (clinical guideline) was reviewed. The policy read: * Licensed nurse to complete skin evaluations weekly and document in the clinical record. * CNA (certified nursing assistant) to complete skin observations and report changes to Licensed nurse. * Licensed nurse to document presence of skin impairment/ new skin impairment when observed and weekly until resolved. * Licensed nurse to report changes in skin integrity to the physician/ practitioner and resident/responsible party and document in the medical record * Develop individualized goals and interventions and document on care plan and the CNA Kardex * Monitor resident's response to treatment and modify treatment as indicated * Refer to therapy as indicated * Evaluate the effectiveness of interventions and progress towards goals during the care management meeting and as needed. On 7/19/18 at 4:10 PM, the DON (director of nursing) stated, The nurses should call the MD and get an order for [REDACTED]. On 7/19/18 at 5:20 PM, the facility Regional Clinical Director stated, We don't do [DEVICE]. 2) For Resident #361, the facility staff failed to ensure neglect did not occur. Treatments were not done as ordered by the physician. Resident #361 was transported to the hospital with maggots in his wounds. This is harm. Resident #361 was admitted to the facility on [DATE] for skilled services in nursing and therapy related to altered mental status and [MEDICAL CONDITION]. [DIAGNOSES REDACTED]. Review of the Resident # 361's closed clinical record revealed the most recent MDS (Minimum Data Set) was an Admission Assessment with an ARD (Assessment Reference Date) of 8/9/2017. Resident # 361 was coded as having a BIMS (Brief Interview of Mental Status) of 13/15 indicating no cognitive impairment. The resident was coded as requiring extensive assistance of one staff member for ADLs (activities of daily living) including bathing except for eating, where he was coded as independent and requiring set up only. Resident # 361 was coded as always incontinent of bowel and bladder. Review of the FRI (Facility Reported Incident submitted to the state agency on 2/15/2018 reported an allegation of neglect that occurred on 9/18/17. The FRI stated a nurse LPN (Licensed Practical Nurse) H failed to provide wound care to Resident # 361 resulting in resident being sent to the emergency room for further evaluation. It was noted that maggots were in his wound located on his right heel. The hospital sent resident back to the facility on [DATE] and requested that the resident have a wound consult. Resident did return with orders for antibiotic treatment. Resident was sent back to hospital on [DATE] and did not return. LPN H was suspended and during the investigation, LPN H verbally admitted that she did not provide wound care as ordered by the physician during her assigned shift. She was terminated and she was reported to the Department of Health Professions-Enforcement Division. Review of the closed clinical record was conducted on 7/18/2018 and 7/19/2018. Review of the Physicians Orders revealed orders written on 8/31/2017 for: Cleanse right heel with Normal Saline apply Santyl and dry dressing every day and PRN (as needed). Cleanse left heel with Normal Saline apply Santyl and dry dressing every day and PRN (as needed). Review of the TAR (Treatment Administration Record) for (MONTH) (YEAR) revealed documentation of treatments to the right heel and left heel being signed off as having been administered every day in (MONTH) (YEAR) from 9/1/2017-9/18/2017. There were no missing signatures or circled signatures indicating treatments had not been administered. Review of the Facility Investigation and Sworn Statement revealed that when questioned by the Director of Clinical Services about whether treatments had been completed over the weekend of 9/16-9/17/2017, the nurse, LPN (Licensed Practical Nurse) H, admitted that she did not do treatments on Resident # 361 on 9/16/2017 and 9/17/2017. When the Director of Clinical Services asked why the treatments had not been completed, LPN H stated Resident # 361 told her he was not in the mood on that Saturday, 9/16/17 and Sunday someone came and got him by the time I went back in there he was already gone. (sic) LPN H stated no, I probably did not when asked if she told another nurse that the wound care needed to be completed. LPN H admitted that it was possible she signed off the treatments on the TAR because I do sign my stuff and then go to the patient. Review of the (MONTH) TAR in the Investigation packet had yellow highlights on those two dates: (MONTH) 16, (YEAR) and (MONTH) 17, (YEAR). Review of the hospital emergency room notes dated 9/18/17 at 5:23 PM revealed documentation of Chronic ulcerations to bilateral heels. Left heel has maggot visible in wound. Left heel ulceration appears to reach the bone. Review of the facility policy on Abuse, Neglect, Exploitation and Misappropriation dated 11/30/2014 and revision date 11/28/2017 stated Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. During the end of day debriefing on 7/19/2018, the facility Administrator, Director of Nursing and Corporate Consultant were informed of the findings. All stated that nurses should follow physicians orders. No further information was provided. COMPLAINT DEFICIENCY 3) The facility failed to maintain supplies needed for resident care. Resident #31 was admitted to the facility on [DATE]. Her most recent Minimum Data Set (MDS) Assessment was a Quarterly Assessment with an Assessment Reference Date (ARD) of 4/23/2018. Her active [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) assessed her at 15, indicating no impairment. Resident #31 required extensive assistance of two persons for transfers and bed mobility, required extensive assistance of 1 person for dressing and hygiene, and was totally dependent on 1 person for toileting. On 7/17/18 an initial tour of the facility was conducted. During the tour, at 12:30p.m., an interview was conducted with Resident #31 in her room. Resident #31 was asked how long she had been living at the facility, and she replied about 7 years. Resident #31 was asked to describe her time at the facility. Resident #31 stated that she felt the facility had gone downhill during her time there. When asked to explain what she meant, Resident #31 offered several examples. She offered several examples of issues that she stated had gotten more common over time. These included a lack of supplies for staff to provide care, such as linens, towels, gowns, and washcloths. Resident #31 stated that sometimes residents with soiled linens have to wait linens to be washed before they are cleaned up because there are no clean linens available. In addition, Resident #31 stated that she has asked for a shower, only to be told she has to wait because no towels are available. On 7/18/18 at 2:00p.m., a meeting was conducted with the Resident Council. When asked about concerns related to having enough linens or other supplies, 4 residents stated that there were frequently not enough linens or towels. When asked to elaborate, the Residents stated that sometimes when they asked for a bath or shower, staff would tell them they had to wait for laundry to finish, because there were not enough clean towels. On 7/18/2018 at 2:25p.m., an interview was conducted with Employee A, the Environmental Services Manager. He was asked to describe how each unit is stocked with linens. Employee A stated that each unit has both a linen cart, located in the hall, as well as a linen closet. He went on to state that nursing staff will first check the linen cart for needed supplies, then check the unit closet. The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 7/18/18. No further information was provided.

Based on staff interview, facility documentation and clinical record review, and in the course of a complaint investigation, the facility staff failed to assess appropriately, treat and/or monitor pressure ulcers for four Residents (Residents #611, #361, #100, #37) in a survey sample of 51 residents. 1. Resident #611 sustained a sacral wound that was discovered at a stage 3, was not treated or monitored, which progressed to a stage 4, requiring hospitalization . The resident also acquired a stage 3 pressure ulcer to the right posterior upper thigh which progressed to a stage 4 and became infected. This resulted in harm. 2. For Resident #361, the facility staff failed to prevent the worsening of a pressure ulcer to the left heel and failed to treat the pressure ulcers on the right and left heel resulting in harm. 3. For Resident # 100, the facility staff failed to document the administration of treatments to wounds in (MONTH) (YEAR). 4. For Resident #37, the facility staff failed to identify three abdominal wounds prior to the stage where necrotic tissue was developed resulting in harm. The findings included: Resident #611 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Resident #611's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 1/16/18 coded Resident #611 with severe cognitive impairment. The MDS was completed as a quarterly assessment. The resident required extensive to total care with all ADL's (activities of daily living such as bed mobility and toileting) of one to two staff members. The resident was incontinent of bowel and bladder. There was one wound documented on the MDS which was coded as a stage 3 with the measurements of 4.5 cm (centimeters) by 3.3 cm with a depth of 0.3 cm. The wound bed had slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous). During this look back period, according to the clinical record, the resident actually had two stage three pressure ulcers. The NPUAP (national pressure ulcer advisory panel) describes a stage 3 ulcer as a Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. NPUAP describes a stage 4 ulcer as a Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Review of the closed clinical record revealed on 8-27-17 an SBAR- Situation/Background/Evaluation/ Appearance/Review revealed a red, irritated area to buttock, likely related to soiled pamper. Barrier cream was applied. Review of the clinical record revealed on 11/22/17: Assess resident right upper thigh for bleeding. Minimal bleeding noted. Appears to be excoriation and has been a recurring incident. RP/MD (responsible party/physician) notified. On 12/6/17, the treatment was changed to [MEDICATION NAME] and a dry dressing. On 12/8/17, the treatment was changed to cleaning the wound with normal saline, skin prep, Alginate, cover with [MEDICATION NAME]. The wound was documented as a stage 2-3. The area measured 4 cm by 4 cm with a 0.3 depth. There were no further notes or wound tracking of this wound until 2-1-18. The treatment remained the same until 1-17-18. On 1/10/18 a low air loss mattress was in place. On 1/17/18, the nurses notes documented, Right lower posterior thigh . area tender to touch, resident cringes when touched measures 3.5 cm by 2 cm with a depth 1.4 cm . wound has an odor drainage covers 80 % of dressing. The treatment was changed to Maxsorb, Alginate (for drainage) and Santyl (to debride dead tissue). On 1/18/18, the resident received an order for [REDACTED]. On 1/22/18, there was a new physician's orders [REDACTED]. On 2/1/18, the nurse's notes documented went out to the wound clinic for consult right thigh. VS (vital signs) 97.4, 82, 12 (respirations), blood pressure 92/50. Oxygen (O2) saturation 87 % (normal above 92 %). Staff called the wound clinic to recheck oxygen sats 87%. MD notified , new order for oxygen 2 liters per minute via nasal cannula for O2 less than 95%. The wound treatment was changed to cleanse right thigh with 1/4 strength Dakins, rinse with NS (normal saline) apply [MEDICATION NAME] 4 by 4 and ABD (absorbent dressing). The pain medication orders were changed to [MEDICATION NAME] 5 mg (milligrams) every six hours for pain. On 2/7/18 at 4:30 AM, Resident O2 sat 88%, placed on O2 sat up to 95%. The resident did go out for an appointment with the wound clinic. On 2/10/18, the nurses notes read: Wound care provided. Facial grimacing noted during wound care. On 2/12/18, after the resident returned from the wound clinic, according to the nurse's notes, Family came to the nurses and wanted resident to be sent to the ER (emergency room ) for an evaluation because he is more lethargic to them. NP (nurse practitioner) present and assessed resident and stated that we could treat him here. But they still wanted to go. The resident was transferred to the hospital and did not return to the facility. Review of the clinical record for the resident's right buttock, also documented as sacral and right ischial wound revealed the following: There was no wound tracking, weekly measurements, treatment documentation, wound care orders upon review of the clinical record. There was documentation of at least one time that the resident received treatment that was ordered for the right posterior thigh. The physician was not notified of decline in the wound for a change in treatment. On 12/13/17, the nurse's notes documented a dressing change to right buttocks. On 12/18/17, the nurse's notes read, Treatment to right buttock (pressure). Area is stage 3 . some yellow slough . NS, Alginate, [MEDICATION NAME]. Incidentally, this was the treatment for [REDACTED]. 12/21/17, the nurse's notes read: Wound is malodorous, and appears to have bloody drainage. Resident shouted in pain upon dressing application . resident is still grimacing and vocalized his pain. There was no documentation the physician was notified of the pain. Pain medication was ordered on 1-18-18. On 12/27/17, the nurse's notes read: Resident threw up after lunch. There is no documentation that the MD was notified. On 12/28/17, The NP recorded: On assessment, patient had a dressing to his right hip, when uncovered, there was about 3.5 by 3.5 inch wound with bloody, purulent drainage noted Nurse called to bedside to assess the site. A culture and sensitivity was ordered, but was canceled on 1-2-18. Antibiotic therapy with Keflex was imitated. On 12/29/17: The nurse's notes read: Treatment provided. Some discomfort . Area is improving, healing nicely. Measurements- inner dimensions 2.9 by 2.7. There is no indication which wound was being assessed and there is no depth recorded. 12/31/17: Nurses notes recorded: Resident's wound to right buttock showing signs of improvement. There were no measurements. On 1/3/18, the nurses notes read: Wound has developed yellowish-gray slough on wound bed with an odor, however wound is reducing in size and depth. No measurements were taken and it is unclear which wound was being assessed. On 1/5/18, the nurse's notes read: Treatment performed . Area is improving slowly, the area of the wound is hard to heal, in middle of buttock cheek, very close to anus. On 1/8/18, Area on right posterior buttocks measures 2.4 by 1.9 by 0.2. On 1/10/18, a low air loss mattress was ordered. On 1/12/18, the nurses note read: Treatment completed on sacral/right posterior buttocks. Measures 4.5 by 3.3 by 0.3. There is no documentation the physician was notified of the worsening of the wound. On 1/15/18, the nursing notes read: Treatment completed, area is sore, there is stool in the wound, needs an irrigation with saline, to help clear wound. There is no documentation the physician was notified of the observation and no new physician orders. On 1/17/18, in the nurse's notes: New order to culture right lower buttocks, do aerobe (sic) and anerobic and do surgical consult on right lower buttock pressure. On 1/22/18, the nurse's notes revealed: New order for Bactrim DS (antibiotic). On 1/25/18, the notes read: Sacral wound dressing changed, moderate drainage noted. Area malodorous. No measurements documented. On 2/7/18 at 4:30 AM, Resident O2 sat 88%, placed on O2 sat up to 95%. The resident did go out for an appointment with the wound clinic. The treatment orders per the wound care physician read: Right ischial (hip) wound stage 3-4, measurements 4.3 cm by 3.0 cm with a depth of 3.8 cm. PT (physical therapy) wound care with pulsed lavage 1000 cc (cubic centimeters) 0.9 % NS 4.8 PSI (pounds square inch) 100 mm (millimeters) mercury to right ischial wound. Dressing [MEDICATION NAME], packed with [MEDICATION NAME], 4 by 4 and [MEDICATION NAME] border. There is no documentation that the wound treatment or PT referral was done as ordered. On 2/12/18, after the resident returned from the wound clinic (no wound documentation available), according to the nurse's notes, Family came to the nurses and wanted resident to be sent to the ER (emergency room ) for an evaluation because he is more lethargic to them. NP (nurse practitioner) present and assessed resident and stated that we could treat him here. But they still wanted to go. The resident was transferred to the hospital and did not return to the facility. Review of the care plan dated 2/21/18 revealed there was no documentation of the right buttock/sacrum/hip wounds. It also included to notify the physician for change in condition. Review of the skin evaluations done by nursing from 10/3/17 to 1/6/18 revealed no markings on the body diagram or notations of the right buttock/sacral/ip wound. The facility policy (clinical guideline) was reviewed. The policy read: * Licensed nurse to complete skin evaluations weekly and document in the clinical record. * CNA (certified nursing assistant) to complete skin observations and report changes to Licensed nurse. * Licensed nurse to document presence of skin impairment/ new skin impairment when observed and weekly until resolved. * Licensed nurse to report changes in skin integrity to the physician/ practitioner and resident/responsible party and document in the medical record * Develop individualized goals and interventions and document on care plan and the CNA Kardex * Monitor resident's response to treatment and modify treatment as indicated * Refer to therapy as indicated * Evaluate the effectiveness of interventions and progress towards goals during the care management meeting and as needed. On 7/19/18 at 4:10 PM, the DON (director of nursing) stated, The nurses should call the MD and get an order for [REDACTED]. On 7/19/18 at 5:20 PM, the facility Regional Clinical Director stated, We don't do [DEVICE]. 2. For Resident #361, the facility staff failed to prevent the worsening of a pressure ulcer to the left heel and failed to treat the pressure ulcers on the right and left heel resulting in harm. Resident #361 was admitted to the facility on [DATE] for skilled services in nursing and therapy related to altered mental status and [MEDICAL CONDITION]. [DIAGNOSES REDACTED]. Review of the Resident # 361's closed clinical record revealed the most recent MDS (Minimum Data Set) was an Admission Assessment with an ARD (Assessment Reference Date) of 8/9/2017. Resident # 361 was coded as having a BIMS (Brief Interview of Mental Status) of 13/15 indicating no cognitive impairment. The resident was coded as requiring extensive assistance of one staff member for ADLs (activities of daily living) including bathing except for eating, where he was coded as independent and requiring set up only. Resident # 361 was coded as always incontinent of bowel and bladder. Review of the FRI (Facility Reported Incident) submitted to the state agency on 2/15/2018 reported an allegation of neglect that occurred on 9/18/17. The FRI stated a nurse LPN (Licensed Practical Nurse) H failed to provide wound care to Resident # 361 resulting in resident being sent to the emergency room for further evaluation. It was noted that maggots were in his wound located on his right heel. The hospital sent the resident back to the facility on [DATE] and requested that the resident have a wound consult. Resident #361 did return with orders for antibiotic treatment. The resident was sent back to hospital on [DATE] and did not return. LPN H was suspended and during the investigation, LPN H verbally admitted that she did not provide wound care as ordered by the physician during her assigned shift. Review of the closed clinical record was conducted on 7/18/2018 and 7/19/2018. Review of the Physicians Orders revealed orders written on 8/31/2017 for: Cleanse right heel with Normal Saline apply Santyl and dry dressing every day and PRN (as needed). Cleanse left heel with Normal Saline apply Santyl and dry dressing every day and PRN (as needed). Review of the TAR (Treatment Administration Record) for (MONTH) (YEAR) revealed documentation of treatments to the right heel and left heel being signed off as having been administered every day in (MONTH) (YEAR) from 9/1/2017-9/18/2017. There were no missing signatures or circled signatures indicating treatments had not been administered. Review of the Facility Investigation and Statement revealed that when questioned by the Director of Clinical Services about whether treatments had been completed over the weekend of 9/16/2017-9/17/2017, the nurse, LPN (Licensed Practical Nurse) H, admitted that she did not do treatments on Resident # 361 on 9/16/2017 and 9/17/2017. When the Director of Clinical Services asked why the treatments had not been completed, LPN H stated Resident # 361 told her he was not in the mood on that Saturday, 9/16/17 and Sunday someone came and got him by the time I went back in there he was already gone. (sic) LPN H stated no, I probably did not when asked if she told another nurse that the wound care needed to be completed. LPN H admitted that it was possible she signed off the treatments on the TAR because I do sign my stuff and then go to the patient. Review of the (MONTH) TAR in the Investigation packet had yellow highlights on those two dates: (MONTH) 16, (YEAR) and (MONTH) 17, (YEAR). Review of the hospital emergency room notes dated 9/18/17 at 5:23 PM revealed documentation of Chronic ulcerations to bilateral heels. Left heel has maggot visible in wound. Left heel ulceration appears to reach the bone. Review of the SBAR (Situation, Background, Appearance, Review and Notify) Communication Form dated 9/18/2018 revealed documentation of the Situation being a change in condition of a wound. Background-under # 8 Skin evaluation was written-wound-odor/drainage, # 9-Pain Evaluation-Does resident have pain- yes, Is the pain new was checked, location was described as heel The non-verbal signs of pain were listed as Yes-moaning, guarding foot Appearance-noted with infestation to his heel Review and Notify-Primary Care Clinician Notified-nurse practitioner was notified 9/18/17-(no time was listed) Other-Send to ER (emergency room ) Nurses Notes-Resident assessed noted with infestation to his right heel. NP (nurse practitioner) in observed N.O. (new order) to send to ER for eval. (evaluation) Review of Physicians Orders revealed order on 8/15/17 for: Skin prep to right heel every shift and as needed. Skin prep to bottom of left foot every shift 8/21/17- 3 PM- Cleanse right heel with normal saline pat dry, apply Santyl and cover with 4 X 4 Kling and tape 8/22/17 10 AM- Order Clarified Cleanse right heel with Normal Saline or wound cleanser Apply Santyl and dry dressing every day and as need 8/25/2017-Cleanse left heel with Normal Saline or wound cleanser Apply Santyl 4 X 4's Kling every day and as needed (4 X 4) 8/28/17- Resident from Physical Therapy Review of (MONTH) (YEAR) TAR Treatment Administration Record revealed documentation on 8/28/2017 of treatments not being administered to the right and left heel for the reason off unit The order was for daily treatments and as needed. The treatments were listed on the TAR as scheduled for 7-3 shift. There was no documentation of the next shift (3-11) administering the treatment on 8/28/2017. The next documentation of providing treatments to the right and left heels was 8/29/2017. Review of the new admission assessment on 7/28/2017 revealed documentation of no problems with Resident # 361's heels upon admission. The documentation stated skin intact, several old surgical scars. There were three documented foot problems listed on the Admission assessment: a scab on the left great toe, an old surgical scar on the bottom of the left foot, and a dark hard calloused area on the side of the right foot. Review of the Daily Skilled Nurse's notes revealed documentation: 8/10/17-9:30 AM- . in to assess right heel small amt (amount) blood observed on sock and heel. skin tough, intact small pinpoint opening no drainage. new order skin prep every shift. 8/15/2017-9 AM- . in to do treatment resident has boggy heel observed right heel 4 X 4 order for skin prep continues, no odor or drainage . resident has callous area to bottom of left foot skin prep added. MD (medical doctor) and RP (Responsible Party) aware will continue to monitor for changes. Resident has Prevalon Boots in place and continues in therapy caseload. 8/21/2017-Late Entry: at 3 PM was called to residents room by therapy. Resident observed having some leakage on sock. Sock was removed. Observed open area to right heel Stage 2, area was cleaned with normal saline, pat dry and Santyl was applied and covered. Resident own RP made aware. MD was called and made aware obtained new orders for treatment. {note was written after a note written 8/21/2017 at 10:25 PM by the 3-11 shift} 8/22/2017-8:10 AM Resident discussed 8/18/17 for wounds right heel 4 x 4 x 0 black blistery eschar wound edges firm no drainage no odor. Heel center boggy. Resident utilizes wheelchair for mobility on rehab caseload. All IDT (Interdisciplinary) members present. continue skin prep to heel and left bottom for small callous intact no drainage. Treatment indicated skin prep no pain expressed. Will continue to monitor for changes. MD and RP aware. 8/25/2017 12 PM Resident discussed at Wound meeting for areas to right heel 4 X 4 eschar present no drainage no odor intact and left heel 4 x 4 eschar Santyl treatment indicated no complaints of pain Prevalon boots in place. MD and RP aware. will continue to monitor. 8/25/2017 12:05 PM Resident also presents with callous to bottom left foot intact no drainage, skin prep only no pain. MD and RP aware 8/27/2017 2:45 PM- dressing to heels intact. 8/31/2017 (no time written) Orders clarified to change cleanse right and left heel wounds with Normal Saline only and dry dressing MD and RP aware. 9/7/17 7 PM- transferred from Unit 1 .Prevalon Boots to bilateral intact will monitor. 9/12/2017 (no time written) Resting upon rounds combative at times, refuses care at times. Chart check 9/12/17 1505 (3:05 PM) LOA (Leave of Absence) with friend in manual wheelchair no skin issues noted at this time-can be uncooperative 9/13/2017 2:15 PM . Resident stated 'He didn't want to get up doesn't feel well,' Writer asked what wrong (sic) Resident stated 'Lady leave me alone. I just don't feel well. Resident has new order to obtain Complete Blood count, comprehensive Metabolic Profile and urinalysis and culture and sensitivity 9/14/18 9/18/17 1 PM Called to resident room by nurse manager. Resident left heel note with eschar, thick dark drainage. no odor. NP (nurse practitioner made aware. N.O. (new order) to send to ER for evaluation. Review of the care plan revealed documentation of the Focus: At risk for impaired skin integrity with interventions which included: Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing weekly . Float heels Monitor changes in skin status appearance, color, wound healing signs and symptoms of infection, wound size and/or stage The facility policy titled Clinical Guidelines-Skin and Wound dated 4/1/2017 was reviewed. The Process read Overview: To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. Process: On Admission/re-admission the resident's skin will be evaluated for baseline skin condition and documented in the medical record. Braden Risk Evaluation to be completed on admission/re-admission, weekly for 4 weeks from admission, quarterly and with a significant change in condition. Licensed Nurse to complete skin evaluation weekly and prior to transfer/discharge and document in the medical record. CNA (Certified Nursing Assistant) to complete skin observations and report changes to Licensed Nurse Licensed Nurse to report changes in skin integrity to the physician/practitioner and resident/responsible party and document in the medical record Develop individualized goals and interventions and document on the care plan and in the CNA Kardex Refer to therapy as indicated Monitor residents' response to treatments and modify treatment as indicated. Evaluate the effectiveness of interventions and progress towards goals during the care management meeting and as needed QAPI: Patterns and trends of newly developed and/or worsening skin conditions will be reviewed by the QAPI team In summary, Resident # 361 was admitted to the facility with no wounds on the left or right heel. Resident # 361 was described on Admission as weight bearing. Treatments were not administered as ordered by the physician. Resident # 361 was sent to the ER with maggots in his heel wounds and according to the ER documentation, the Left heel was open to the bone. During the end of day debriefing on 7/19/2018, the facility Administrator, Director of Nursing and Corporate Consultant were informed of the findings. No further information was provided. 3. For Resident # 100, the facility staff failed to document the administration of treatments to wounds in (MONTH) (YEAR). Resident # 100 was a [AGE] year old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a Significant Change assessment with an Assessment Reference Date (ARD) of 5/29/18. The MDS coded Resident # 100 with a BIMS (Brief Interview for Mental Status) of 15/15 indicating no cognitive impairment; the resident required extensive to total assistance with activities of daily living including extensive help in bathing; always incontinent of bowel and bladder. Review of the clinical record was conducted on 7/18/2018. Review of the (MONTH) (YEAR) Treatment Administration Record revealed missing documentation of administration of treatments as listed below: Cleanse both feet and heels with warm water and soap, pat dry, and apply skin prep twice daily for scaly skin- not documented 4/12/2018 3-11 shift 4/29/2018 7-3 shift [MEDICATION NAME] to sacral area change every 3 days -not documented 4/27/18-( resulting in 6 days between treatments to the sacral area.) Wound observation was done on 7/18/2018 at 10:22 with the wound care doctor and wound care nurse. Valid physicians orders were evident. During the end of day debriefing, the Administrator, Director of Nursing and Corporate Nurse were informed of the findings. All stated treatments should be administered as ordered by the physician. No further information was provided. COMPLAINT DEFICIENCY 4. For Resident #37, the facility staff failed to identify three abdominal wounds prior to the stage where necrotic tissue was developed resulting in harm. A review of the clinical record revealed that Resident #37 had an abdominal wound. A nursing note dated 5/9/18, 9:35 a.m. read, Nursing Aid reported areas on abdomen to writer observed 3 circular necrotic(dead tissue) areas surrounded by redness directly under adult diaper line, nursing aid was providing AM (morning) care when areas were found. Resident shows no s/s (signs/symptoms) of pain MD (doctor) made aware/ wound doctor made aware. N.O. (new order) clean with NS (normal saline), apply Santyl cover with ABD pad + secure with tape per wound doctor request in which MD (doctor) Jennings agreed to tx (treatment) order. On 5/9/18 at 11:15 a.m., the wound doctor wrote out and signed the above treatment order on a telephone order sheet. A Skin Evaluation flow sheet used to document weekly skin checks was identified in the clinical record. The flow sheet began with the date 5/11/18. On 5/11/18, the current skin condition was described as 3 narc areas with three X marks drawn on the abdomen of the body diagram. The CNA (Certified Nursing Assistant) -ADL (Activities of Daily Living) Tracking Form for (MONTH) (YEAR) was reviewed. The Bathing section was reviewed. Resident #37 was coded to have received a partial bath from 5/4/18-5/7/18. On 5/8/18, a 4/2 (total dependence/ one person assist) was documented for the 3-11 but the type of bath provided was not documented. The Treatment Administration Record for (MONTH) (YEAR) was provided. The treatment to the abdomen was completed as ordered from 5/9/18-5/28/18. A note written by the wound care doctor on 5/23/18 documented that the abdominal wound Resolved on 5/23/18. Wound Progress read [MEDICATION NAME] and Resolved. No other wound care doctor notes were located in the clinical record or provided by the facility. The care plan dated 9/6/17 was reviewed. The focus read, (Resident) has the potential for impaired skin integrity r/t (related to) incontinence, fragile skin. The interventions date 9/6/17 read, administer treatments as ordered, encourage adequate nutrition, identify causative factors and eliminate where possible, incontinence are post episode, keep skin dry, weekly skin checks. The facility staff were asked to provide any skin and wound management protocols used at the facility. The Wound Classification Guide was provided. The Stage III wound description read, Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. The Stage IV wound description read, Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. The Unstageable wound description read, Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/ or eschar (tan, brown or black) in the wound bed. The following information was accessed on 7/25/18 at 10:20 a.m. at the website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 05/ Necrotic tissue, slough, and eschar The wound bed may be covered with necrotic tissue (non-viable tissue due to reduced blood supply), slough (dead tissue, usually cream or yellow in colour), or eschar (dry, black, hard necrotic tissue). Such tissue impedes healing. According to the above descriptions, the necrotic tissue in Resident #37's wound was either slough or eschar, indicating her wounds would be staged at a III, IV or unstageable when first identified. On 7/18/18 at the end of day meeting, the Administrator, Director of Nursing (DON) and Corporate Nurse were notified of the concerns regarding the abdominal wounds. They were asked to provide all documentation related to the abdominal wound. The facility provided information on 7/19/18. No information regarding the stage, the description of the wound bed or measurements of the wound upon first identification were provided. On 7/19/18 at 8:30 a.m. an interview was conducted with the DON. The DON began working at the facility on 5/10/18. The DON stated that when she started at the facility she identified that the management of pressure ulcers needed immediate attention. From (MONTH) (YEAR) until (MONTH) (YEAR), the facility did not have a wound care nurse. The floor nurses assessed the resident's skin and completed wound treatments. During the interview, the DON stated that there was no wound measurements or staging completed for the abdominal wound. In summary, the three abdominal wounds were under the waist band of the adult brief. This is a highly visible area as this skin would be exposed with each brief change. While the facility did not stage the three abdominal wounds, when they were first identified they were necrotic. This would indicate that these wounds were first identified at a stage III, IV or unstageable.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to implement abuse policies on preventing neglect for one resident (Resident # 361) in a survey sample of 51 Residents resulting in harm. For Resident # 361, the facility staff failed to implement the policies on reporting abuse/neglect Findings: Resident #361 was admitted to the facility on [DATE] for skilled services in nursing and therapy related to altered mental status and [MEDICAL CONDITION]. [DIAGNOSES REDACTED]. Review of the Resident # 361's closed clinical record revealed the most recent MDS (Minimum Data Set) was an Admission Assessment with an ARD (Assessment Reference Date) of 8/9/2017. Resident # 361 was coded as having a BIMS (Brief Interview of Mental Status) of 13/15 indicating no cognitive impairment. The resident was coded as requiring extensive assistance of one staff member for ADLs (activities of daily living) including bathing except for eating, where he was coded as independent and requiring set up only. Resident # 361 was coded as always incontinent of bowel and bladder. Review of the closed clinical record was conducted on 7/18/2018 and 7/19/2018. An interview was conducted with the Administrator on 7/18/2018 regarding reporting the allegation of neglect for Resident # 361. The Administrator stated that he heard rumors about the allegation of neglect soon after he was employed at the facility in (MONTH) (YEAR). He stated he searched but could not find any documentation that the allegation of neglect had been reported to the State Agency by the previous administrator so he completed the FRI (Facility Reported Incident). The Administrator stated it was the right thing to do. Review of the FRI showed the incident happened on 9/18/2017 and was reported on 2/15/218 by the new administrator. Review of the FRI (Facility Reported Incident submitted to the state agency on 2/15/2018 reported an allegation of neglect that occurred on 9/18/17. The FRI stated a nurse LPN (Licensed Practical Nurse) H failed to provide wound care to Resident # 361 resulting in resident being sent to the emergency room for further evaluation. It was noted that maggots were in his wound located on his right heel. The hospital sent resident back to the facility on [DATE] and requested that the resident have a wound consult. Resident did return with orders for antibiotic treatment. Resident was sent back to hospital on [DATE] and did not return. LPN H was suspended and during the investigation, LPN H verbally admitted that she did not provide wound care as ordered by the physician during her assigned shift. She was terminated and she was reported to the Department of Health Professions-Enforcement Division. Review of the closed clinical record was conducted on 7/18/2018 and 7/19/2018. The DON stated that she would report to the state agency immediately but no later than 2 hours after the allegation is made. The facility abuse policy Abuse: Prohibition, Reporting, and Investigation of Resident Abuse, Neglect, And Mistreatment was reviewed. Page 3, bullet 5 read As soon as possible, but within no more than twenty-four (24) hours of the suspected abuse, neglect or mistreatment, the Administrator shall notify the Office of Health Care Quality and the local police department (as appropriate) of the suspected abuse, neglect or mistreatment. On 7/19/18 at 4:00 p.m., the Administrator and DON were asked to submit any information they would like to have reviewed regarding the issue. Both stated that no other information was able to be found. The Administrator and DON were not employed at the facility at the time of the allegation of Neglect. No further information was provided. COMPLAINT DEFICIENCY

Based on observations, resident and staff interview, facility documentation and clinical record review, the facility staff failed to ensure one resident (Resident #17) in a survey sample of 32 residents, with end stage [MEDICAL CONDITIONS], received the care and services to maintain the highest practicable wellbeing, consistent with the resident's assessment and plan of care, resulting in immediate jeopardy and substandard quality of care. After acceptance of the POC (plan of correction), the deficiency was lowered to a level three, isolated, to include Resident #1 who also, had a harm level deficiency. Resident #2 and Resident #14 were included in the citation but not at harm level. 1. Resident #17 was not assessed and monitored per standards of care for [MEDICAL CONDITION] and use of Dobutamine. Nurses were not trained to monitor for symptoms, use and side effects of the Dobutamine. Weights were not monitored or reported per standards of practice for Dobutamine use. There was no care plan for monitoring the blood pressures (B/P) for the use of the Dobutamine. 2. For Resident #1, the facility staff failed to administer medications per physician's orders [REDACTED]. 3. For Resident #2 the facility staff failed to include parameters for the administration of [MEDICATION NAME], a blood pressure medication that was ordered to be administered on an as needed basis. 4. For Resident #14, the facility staff failed to administer physician ordered [MEDICATION NAME], used for diabetic management. 5. For Resident # 26, the facility staff failed to remove staples from a laceration on the scalp for over 3 months. The staples were applied on 8/2/2016 but not removed until 11/20/16 when a Certified Nursing Assistant found the staples on her scalp. They should have been removed on 8/9/16. The findings included: 1. Resident #17 was a [AGE] year old who was originally admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #17's most recent MDS (Minimum Data Set Assessment) was a quarterly with an ARD (Assessment Reference Date) of 2/1/17. The MDS assessment coded Resident #17 as having no cognitive impairment in daily decision making. Resident #17 was coded as requiring standby assistance with transferring and all other activities of daily living such as eating and toileting, and walking on and off the unit. The resident was not coded as Hospice, but was a DNR (do not resuscitate). On 5/18/17, the clinical record revealed the following physician order [REDACTED]. Dobutamine is an inotropic (improves cardiac output) cardiac medication. The facility was asked for their drug handbook; the nurse could not find one in the nurses station or the drug cart, and never returned with any drug book. The Nursing Drug Handbook (Saunders) 2015, contained the following regarding nursing monitoring for Dobutamine Continuous monitoring on ECG (electrocardiogram), [MEDICAL CONDITION] artery wedge pressure (done in intensive care or telemetry in the hospital), blood pressure (BP), cardiac and urine output. Adverse effects include: marked increase in heart rate ( 30 beats per minute or higher,), marked increase in BP (50 mm (millimeters) or higher) [MEDICAL CONDITION] pain and premature ventricular contractions. Remedi Senior care 2013 (Gahart BL, Nazareno AR. 2013 Intravenous Medications. 29th ed. St Louis, MO; Mosby/Elsevier) discusses Dobutamine as though continuous cardiac monitoring is not required in set dosing, dose use in long term setting not recommended. Davis' Drug Guide lists IV Dobutamine as a High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error. Review of the discharge hospital notes dated 10/24/16 included: Weight daily . notify the Primary Care clinic if you gain more than 3 pounds in a day, or 5 pounds in a week. There was no order for weight monitoring on admission to the facility. Further clinical review revealed the following: Admission weight was 133 pounds. On 12/1/16, the physician note documented daily weights (weights were being done twice weekly). On 12/5/16, the facility weight tracking identified the weight on 11/21/16 as 135 pounds; two weeks later on 12/5/16, the weight had increased to 145, a 10 pound (7.4%) weight gain in two weeks. On 12/12/16, the NP (nurse practitioner) documented, Weights stable, continue twice weekly weights. On 12/20/16 , the NP documented, SOB (short of breath) related to [MEDICAL CONDITION], [MEDICATION NAME] (diuretic) increased to 40 mg daily. On 1/2/17, the weight was 151.1 pounds. On 1/29/17, the NP wrote the following orders: Get appointment at (name of hospital) resident's cardiologist to evaluate worsening [MEDICAL CONDITION] and [MEDICAL CONDITION]. On 1/30/17 the NP wrote, 1+ lower leg [MEDICAL CONDITION], positive pedal [MEDICAL CONDITION] .Get appointment with cardiology to assess increase in Dobutamine drip. The next cardiology appointment was done on 3/2/17 and read: Stable HF (heart failure) on inotrope (Dobutamine) . watch BP (if systolic blood pressure is less than 90 and symptomatic). No parameters for blood pressure frequency or weight monitoring was mentioned. The order was not clarified by the facility staff. On 5/18/17 at 9:00 AM, the nurse practitioner was questioned about monitoring of Dobutamine. She stated, Should be checking BP's every shift and weights have been stable. On 3/19/17, the dietary technician's notes documented the following: 13% weight gain in 60 days. Review of the dietary technician notes dated 4/13/17 showed a 12% (sixteen pounds) weight loss. The physician was not notified of the weight changes, the dosage was not adjusted, which would require hospitalization during the dose titration. The resident had not had any admissions to the hospital. No blood pressures were documented since 4/10/17. On 5/18/17 at 10:15 AM, an interview was conducted with LPN (licensed practical nurse) A, who stated, Yes, I change the cassette (bag). She added, We are supposed to monitor BP every shift. She went on to state that she had not documented these blood pressures on the clinical records, but in her own notes. Resident #17 was being treated for [REDACTED]. This device was in a carrying case that was on his belt or could be carried over his shoulder. The case was approximately 8 x 3 and contained a small infusion pump, a battery pack, and a 250 ml bag of dobutamine. The dobutamine infused to a PICC line on his right arm from the portable pump. When the batteries were low, a signal sound would alert the resident who would contact an LPN for new batteries. The drip was at 4.5 ml/hr and when the bag was low another alarm would sound for an LPN to change the medication. On 5/18/17 at approximately 10:30 AM, the care plan dated 2/21/17 was reviewed and did not include interventions for the PICC (peripherally inserted central catheter) line. Web MD describes a PICC line as a central venous catheter, also called a central line, is a long, thin, flexible tube used to give medicines, fluids, nutrients, or blood products over a long period of time, usually several weeks or more. A catheter is often inserted in the arm or chest through the skin into a large vein. The catheter is threaded through this vein until it reaches a large vein near the heart. The resident was not care planned for Dobutamine usage, monitoring including frequency of VS (vital signs), weights or symptoms to report to physician. Managing Heart Failure By Lacey Buckler, Lippincott Williams and Wilkins identify the standards of practice for managing [MEDICAL CONDITION]: Administer medications and monitor response Weigh the patient daily at the same time on the same scale, early in the day after urination; report a 2 to 3 pound gain in a day or 5 pounds in a week to the healthcare provider Auscultate lung sounds Monitor vital signs Identify and evaluate [MEDICAL CONDITION] severity Examine skin turgor On 5/18/17 at 12:55 PM, the admission coordinator was questioned about Resident #17's admission. She stated, Not all admissions are reviewed by nursing. We have a list of automatic admissions. This document called Commit to admit included: Infusion care including [MEDICATION NAME], Hydration, [MEDICATION NAME], Potassium, [MEDICATION NAME], Vitamins and minerals. On 5/18/17 at 1:30 PM, an interview of the Medical Director was conducted. He stated, I have sent people home with no monitoring. He went on to state that he had taken on the role of Medical Director in January of 2016. On 5/18/17 at 3:05 PM, an interview was conducted with LPN (B), who stated, Dobutamine is for his enzyme imbalance. He went on to state, I watch for IV site infection, infiltration, weekly vital signs and I have not been trained here, but have done it in other facilities. He added that he changed the PICC (peripheral inserted central catheter) dressing and the medication cassette. On 5/18/17 at 3:30 PM, the pharmacy consultant was questioned about monitoring the medication. He stated, Normal monitoring; I understand (name of hospital) is monitoring weights and drug monitoring. He did not know of frequency of weight monitoring. He went on to state that, Now that I think about it, it makes me nervous. He stated he would call the IV pharmacy consultant. On 5/18/17 at 4:05 PM, the IV pharmacy consultant called back. He stated, They are supposed to get daily weights, daily vital signs. He went on to state, The pharmacy consultant should have picked up the lack of monitoring. He then stated he would send me the Nurses' infusion manual for long term care. It documented, VS and lung sounds must be obtained: - Prior to initiation of inotropic medication - Every 15 minutes for one hour - Every hour for 2 hours - Every 4 hours Weigh every day. In addition, the orders must include: Vital sign frequency with reportable parameters. On 3/2/17, the resident had a consultation with the cardiac physician. The note included: Watch BP (if systolic blood pressure is less than 90 and symptomatic). No frequency of BP's were included and actions to take if this occurred. No clarification of this order was documented. On 5/18/17 at approximately 4:10 PM, the inservice educator was questioned about staff training on Dobutamine use and monitoring. She stated, We are doing it now. On 5/18/17 at 4:35 PM, the LTC supervisor notified the survey team of IJ (immediate jeopardy) and substandard quality of care. The sample was extended to include residents IV medications. No other residents were on Dobutamine or other cardiac medications. The only residents receiving IV medications were antibiotics. Additional tasks were added and performed. On 5/18/17 at about 4:40 PM, the Administrator and DNS (director of nursing services) were notified of IJ and substandard quality of care. 5/18/17 at 6:30 PM, Resident #17 was interviewed. He stated, When I first came here, they didn't know what to do with my machine. He went on to state that they did not run the machine all night. He further reported that a week before Valentine's day, staff did not place an extension tube on the IV line and it leaked, causing a burn, like a cigarette burn on his inner arm at the IV site. The area was examined and showed a small scar near the PICC line site. On 5/18/17 at 6:40 PM, the DON (director of nursing) stated, We are supposed to notify the physician of a three pound weight change. She went on to state that the pharmacy does dosage changes based on weights and that for a weight change and dosage change, the resident has to be admitted to the hospital for monitoring and titration. On 5/18/17 at 7:00 PM, the nurses note read, Resident was weighed 138.9 pounds, currently on 2.5 mcg, pharmacy was called and made aware stated resident have (sic) a slight weight gain since admission. 60 K (kilograms) to 63 since admission stated to call cardiologist to follow up for adjustment of medication. Spoke with (Name of NP) regarding weight and medication stated to place resident IV at 4.7 ml (milliliters) (from 4.5) per hour. Resident own RP (responsible party) made (this sentence was crossed out) Resident pump currently running at 4.5 ml/hour., NP stated to keep pump at current setting and follow up with cardiologist. On 5/18/17 at 5:53 PM, the facility presented the POC (plan of correction). The POC was reviewed by the survey team and not accepted. On 5/18/17 at 6:35 PM, the Administrator and DON were notified the second POC was not accepted. On 5/18/17 at 7:00 PM, the POC was accepted. The IJ was reduced to a level 2 isolated. It was later determined the team had identified harm level deficiencies in this citation. The IJ was then increased to a level three, isolated. The LTC supervisor was notified. The facility POC documented the following 5 points: 1. Resident receiving Dobutamine drip in the facility has had no adverse reaction, but the deficient practice has the potential for an adverse reaction as not all staff providing care for this resident are aware of this medications indications for usage, signs and symptoms of adverse effects, appropriate monitoring protocols, nor licensure qualifications for any of the above. The following to be implemented immediately to ensure appropriate care for affected resident . a. Provide 24 hour RN (registered nurse) coverage on the unit in which the resident resides b. Monitor resident weight daily c. Monitor resident intake and output every shift d. Monitor VS every 4 hours e. Obtain labs as indicated f. Transfer to an acute care setting should titration of medication become necessary 2. Residents that reside in the facility receiving IV medications have the potential by this deficient practice. There are no other residents in this facility receiving Dobutamine at this time. Every resident receiving IV medications have been assessed and no adverse reaction noted. 3. Licensed nursing staff in the facility will be educated on the usage of Dobutamine and the side effects. The licensed nurses will be educated on the management of PICC line access and the evaluation of the site and surrounding tissues. The following systemic changes are to be implemented to ensure deficient practice will not recur: a. Provide 24 hour RN coverage on the unit in which any resident with inotropic medication resides b. Monitor resident weight daily c. Monitor resident intake and output every shift d. Monitor VS every 4 hours e. Obtain labs as indicate 4. The DNS /ADSC will ensure 24 hour RN coverage to oversee protocols as stated above 5. Allegation of compliance: 7:00 pm 5/18/17. On 5/19/17 at 9:55 AM, the LPN (LPN H) responsible for the care plan for Resident #17 was interviewed as to why the [MEDICAL CONDITION] with Dobutamine use was not in the care plan. LPN (H) stated, At one time, I wasn't care planning medications. 2. For Resident #1, the facility staff failed to administer (22) medications for 5 days, including blood pressure medications, insulin, and bowel medications, resulting in harm as the Resident was re-hospitalized 3 times for pain, psychological distress, nausea, vomiting, elevated blood pressure, elevated blood sugar and constipation Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1's most recent (MDS) Minimum Data Set with an assessment reference date (ARD) of 4-16-17 was coded as a quarterly assessment. The Resident was coded as having no cognitive impairment. Resident #1 was also coded as needing only supervision of set up help from staff to perform activities of daily living, such as dressing, transferring, bed mobility and hygiene. Review of the Resident's facility clinical record, and hospital records for the month of November 2016, revealed that the facility had to repeatedly send Resident #1 to the hospital for complaints of headache, constipation, abdominal pain, nausea, vomiting, and weakness. A chronological record of those hospitalization s, are as follows: On 11-1-16 the Resident was admitted to the hospital with [REDACTED]. The Resident was discharged from the hospital on 11-22-16 to the skilled nursing facility with new medications ordered by the hospital doctor. The ordered medications were to correct the hypertension, UTI, and constipation the Resident had been hospitalized for [REDACTED]. On 11-24-16, (2 days after readmission to the nursing facility), the Resident was again sent to the hospital emergency room for complaints of altered mental status, weakness, and constipation. The Resident was found to have a very high blood pressure (193/92 mmHg) MillimeterMercury; normal below 120/80) ) and was ordered by the hospital doctor to be given [MEDICATION NAME] 10 mg (milligrams) three times per day, added to the Resident's current ongoing daily drug list to correct the high blood pressure. The Resident's total number of current daily medications now stood at 24 on 11-24-16, and the Resident returned to the nursing facility the same day. On 11-25-16, (1 day later), the Resident was again sent out to the hospital emergency room , and found to be suffering from high blood pressure (164/115), and stated to the hospital nurse I just want to kill myself and get it over with., and while moaning and groaning Oh god please help me I can't take it anymore. The Resident was again sent back to the nursing facility with a [DIAGNOSES REDACTED]. On 11-26-16, (1 day later), the facility again sent the Resident to the hospital emergency room for complaints of hypertension, stomach pain, and feeling awful, nausea, vomiting, and abdominal pain. The Resident told the hospital doctor that the nursing facility had not been giving him his daily medications, and the hospital doctor documented such in the consultation report. The hospital doctor called the nursing facility and spoke with the nurse caring for Resident #1 (LPN L) to review the Resident's medication list. LPN L stated that the nurse who readmitted Resident #1 to the nursing facility, on 11-22-16, and 11-24-16 had missed a whole page of medication orders from the hospital for Resident #1, and that was why the Resident was only receiving 5 of the medications which had been ordered on 11-22-16, and 11-24-16. LPN L stated she would correct the error on 11-26-16. The social worker at the hospital became involved in the situation, and contacted Adult Protective Services (APS) on 11-26-16 to report neglect. The hospital physician documented that she was concerned about the Resident's kidneys, blood pressure, and bowel problems, born of the fact that the nursing facility was not administering the Resident's physician ordered medications, and creating repeated hospital visits. The hospital doctor also documented the stool burden may be compromising kidneys. The hospital team decided to not return the Resident to the nursing facility. They decided instead, to admit him to the hospital again to begin searching for safe placement, as the facility was not administering his medications. The hospital physician's documentation went on to say that she would not discharge the Resident back to the nursing facility due to unsafe conditions at SNF (skilled nursing facility), as the Resident had not had a bowel movement since his discharge from the hospital on 11-22-16, (5 days). The hospital doctor also documented that while in the facility the Resident had not been given any of his anti-hypertensive medications, nor was he on a scheduled bowel regimen (and medications for chronic problems). The doctor's progress note read that only five medications were being administered to the Resident in the nursing facility from 11-22-16 through 11-26-16, (5 days) were routine [MEDICATION NAME], and PRN (as needed, not routine) [MEDICATION NAME], and senna. It is also notable to mention that the Resident was an insulin dependent diabetic, and was also not receiving any insulin during this 5 day period. The Resident's blood glucose level was 183 mg/dl (milligrams per deciliter) upon admission to the hospital. Normal blood glucose is 80-130 mg/dl according to the American Diabetic Association. Valid physician orders [REDACTED]. These medications were documented as not having been administered for 5 days, from 11-22-16 through 11-26-16. 1. Pantoprazole 40 mg daily for stomach pain 2. [MEDICATION NAME] 10 mg daily for high blood pressure 3. Aspirin 81 mg daily for blood pressure 4. [MEDICATION NAME] suppositories 10 mg rectally every 12 hours for constipation 5. carvedilol 25 mg every 12 hours high blood pressure 6. [MEDICATION NAME] 10 mg twice daily for muscle spasm 7. [MEDICATION NAME] 100 mg two tablets twice daily for constipation 8. duloxetine 60 mg daily for depression 9. [MEDICATION NAME] 5 mg daily for prostate 10. [MEDICATION NAME] 600 mg three times per day for [MEDICAL CONDITION] 11. [MEDICATION NAME] 10 mg three times per day for blood pressure 12. insulin [MEDICATION NAME] 100 units/ml (milliliter) 10 units inj subcutaneously daily for diabetes 13. [MEDICATION NAME] topical 5% patches on for 12 hours joint pain 14. [MEDICATION NAME] 50 mg daily at bedtime depression 15. polyethylene [MEDICATION NAME] 3350 17 grams twice daily for constipation 16. senna 8.6 mg daily at bedtime for constipation 17. [MEDICATION NAME] 18 mcg (micro grams ) inhaled 1 cap daily for [MEDICAL CONDITION] 18. [MEDICATION NAME] 50 mg three times per day PRN (as needed) for break through pain 19. [MEDICATION NAME] 10/325mg (milligrams) four times daily PRN (as needed) for pain 20. guifenesin 600 mg every 6 hours (prn) for cough 21. [MEDICATION NAME] 100 mg every 12 hours antibiotic 22. [MEDICATION NAME] 4 mg every 6 hours PRN (as needed) nausea/vomiting On 5-17-17 the Director of Nursing (DON), and administrator were asked to allow an interview with LPN L. They stated that the employee was terminated in January 2017, shortly after the incident. Her employee record was reviewed, and revealed a termination date of 1-12-17. On 5-17-17 copies of the physician's orders [REDACTED]. On 5-18-17 at the end of day, the DON and Administrator delivered the October, and December 2016 POS, and MAR records, however, stated that the November 2016 physician's orders [REDACTED]. The medical records staff, and nursing staff had searched the entire building for 2 days, and only this part of the clinical record was missing. The October 31, 2016 POS, revealed 16 medications ordered, including 2 kinds of injectable insulin for diabetes. The DON was asked why staff had not called the doctor to clarify orders when only 5 medications were ordered for November, and the insulin that the Resident had been taking was abruptly stopped. Her response was I don't know, they should have. The facility policy on medication administration stated Obtain, and verify physician's orders [REDACTED]. The Administrator and DON were made aware of these findings at a harm level, at the end of day debrief on 5-18-17, and 5-19-17. Harm occurred as the Resident was repeatedly hospitalized with symptoms related to the facility staff omission of the Residents needed, and ordered significant medications for 5 days. No further information was able to be provided by the facility. COMPLAINT DEFICIENCY 3. For Resident #2 the facility staff failed to include parameters for the administration of [MEDICATION NAME], a blood pressure medication that was ordered to be administered on an as needed basis. Resident #2, a [AGE] year old, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 3/16/17. Resident #2 was coded with a Brief Interview of Mental Status score of 13 indicating no cognitive impairment. He required assistance with his activities of daily living. Resident #2 had an order dated 12/6/16 for [MEDICATION NAME] 0.1 milligram, 1 tab by mouth twice daily as needed for hypertension (high blood pressure). According to the monthly Medication Administration Records (MAR), the [MEDICATION NAME] has never been administered. On 5/17/17 at 5:40 p.m., Licensed Practical Nurse J (LPN J) was asked to look at the [MEDICATION NAME] order. She was asked how she would know if Resident #2 needed the [MEDICATION NAME]. LPN J stated that the medication should have parameters, specifically for blood pressure. It was reviewed with LPN J that it did not appear that Resident #2's blood pressure was being monitored on a daily basis. LPN J stated that the blood pressure readings would be documented on the monthly MAR if it was measured with regard to medication administration. The [MEDICATION NAME] order was reviewed with the Administrator and Director of Nursing at the end of day meeting on 5/17/17. No issues related to elevated blood pressure were identified in the clinical record. 4. For Resident #14, the facility staff failed to administer physician ordered [MEDICATION NAME] used for diabetic management: [MEDICATION NAME] 100/ML Unit Sliding Scale. Missing doses: 3/29/17 (4:30 P.M., 9:00 P.M.), 4/19/17 (4:30 P.M.), 4/28/17 (7:30 A.M., 4:30 P.M.) And [MEDICATION NAME] 100 Unit/1 ML inject 10 units at bedtime. Missing doses: 4/4/17 (9:00 P.M.), 4/12/17 (9:00 P.M.) Resident #14 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #14's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 11/19/16 coded Resident #14 as having a Brief Interview of Mental Status score of 2, indicating severely impaired cognition. On 5/17/17 at 9:45 A.M. Resident #14 was observed eating his breakfast in the dining room on the locked unit. He had consumed about 90% of his meal. He was clean, and dressed appropriately. He wore socks and enclosed bedroom slippers on his feet. He did not exhibit any inappropriate behaviors toward the two other male residents at his table. On 5/18/17 at 1:00 P.M. Resident #14 was observed eating lunch, which consisted of spaghetti and chopped vegetables. He wore socks and enclosed bedroom slippers on his feet. He did not interact with other nearby residents. On 5/17/17 a review was conducted of Resident #14's clinical record. There were physician orders [REDACTED]. * [MEDICATION NAME] 100/ML Unit Sliding Scale. If 149-199=2 Units; 200-249= 3 Units; 250-299= 6 Units; 300-349= 9 Units; 350-399= 12 Units; If blood sugar is greater that 400 (mg/dL) give 15 Units then call MD with blood sugar report. Missing doses: 3/29/17 (4:30 P.M., 9:00 P.M.), 4/19/17 (4:30 P.M.), 4/28/17 (7:30 A.M., 4:30 P.M.) * [MEDICATION NAME] 100 Unit/1 ML inject 10 units at bedtime. Missing doses: 4/4/17 (9:00 P.M.), 4/12/17 (9:00 P.M.) In addition, there were no blood glucose monitoring done on the aforementioned dates and times. Resident #14's most recent Hemoglobin A1C test was reviewed. It read, 12/29/16. 10.0 (High). Recommendation: more stringent goals (i.e., a normal Hemoglobin A1C, (less than) <6% can be considered in individual diabetic patients. On 5/18/17 a review was conducted of facility documentation. the Blood Glucose Monitoring Policy dated 11/30/14 read, A resident's blood glucose level shall be monitored through blood glucose testing. Document result in nurse's notes and / or on Medication Administration Record with any insulin administered. Resident#14's Care plan was reviewed. It read, 9/8/16. The Resident is at risk for Metabolic Complications r/t (related to) DM 2 (Diabetes Mellitus, Type 2). Medications as ordered. Blood Glucose levels as ordered. On 5/17/17 at 6:10 P.M. the facility Administrator (Administration A), and Director of Nursing (DON-Administration B) were notified of the findings. The DON stated that the nurse should have tested the blood glucose level and administered the medication as ordered. No further information was received. 5. For Resident # 26, the facility staff failed to remove staples from a laceration on the scalp for over 3 months. The staples were applied on 8/2/2016 but not removed until 11/20/16 when a Certified Nursing Assistant found the staples on her scalp. They should have been removed on 8/9/16. Resident # 26, an [AGE] year old female, was admitted to the facility 3/2/2010 and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident # 26 resided on the 30 bed Secured Unit. Resident # 26 was discharged from the facility on 11/30/2016 and did not return to the facility. Resident #26's most recent MDS (minimum data set) with an ARD (assessment reference date) of 11/26/2016 was coded as a Significant Change Assessment. She was coded as having a BIMS score of 2 indicating severe cognitive impairment. Coded as having short and long term memory deficits and required total assistance with making daily life decisions. Resident # 26 was coded as needing limited to extensive assistance of one staff person with her activities of daily living except for bathing for which she required total assistance of one staff person. She required extensive assistance of one staff person for ambulation, toileting and transfers. She was coded as frequently incontinent of bowel and bladder. The previous MDS with an ARD of 9/30/16 was coded as a Quarterly Assessment. Resident # 26 was coded as having a BIMS score of 2 indicating severe cognitive impairment. She was coded as requiring supervision of one staff person for all Activities of Daily Living including ambulation, toileting and transfers except for bathing for which she required total assistance of one person. She was coded as occasionally incontinent of bowel and bladder. Review of the closed clinical record was conducted on 5/18/2017. Review of the Interdisciplinary notes (Nurse's Notes) revealed documentation on 11/20/2016 of new order to remove 4 staples from posterior head. Staples removed by Wound Nurse. RP(Responsible Party) made aware. Aid found staples while doing AM (morning) care. Review of Incident Reports revealed(TRUNCATED)

Based on resident and staff interview, facility documentation and clinical record review, the facility staff failed, for one Resident (Resident #17) in a survey sample of 32 residents, to provide standards for quality of care for the administration for IV (intravenous) Dobutamine, resulting in immediate jeopardy. After acceptance of the POC (plan of correction), the deficiency was lowered to a level 3 isolated because Resident #1 was harmed concerning the facility's failure to provide services that meet professional standards of quality. The following Residents were included in the deficiency although not at harm level for Resident #26, #12, #14 and #5. 1. For Resident #17, staff was unfamiliar with the necessary assessment and monitoring for the use of the IV Dobutamine. LPN's (licensed practical nurse) were unfamiliar with assessing and monitoring the resident's response to the Dobutamine. VS (vital signs, including BP-blood pressure) and significant weight changes were not monitored and reported to the physician for dosage change. 2. For Resident #1, the facility staff failed to administer medications per physician's order, resulting in harm as the Resident was rehospitalized 3 times for pain, psychological distress, nausea, vomiting, elevated blood pressure, and constipation. 3. The facility staff failed to remove the staples from Resident # 26's head as ordered by the emergency room physician on 8/2/2016. They should have been removed in 7 days on 8/9/2016. They were not removed until 11/20/2016. 4. Resident #12 had multiple areas where physician ordered medications were not documented as having been administered. 5. For Resident #14, the facility staff failed to follow the professional standards of quality by documenting why physician ordered wound care, diabetic management, and dietary management medications and treatments weren't administered. 6. For Resident #5, the facility staff administered [MEDICATION NAME] and folic acid without a dosage indicated by the prescriber. In addition, [MEDICATION NAME] and folic acid were discontinued without a physician order. The findings included: Resident #17 was a [AGE] year old who was originally admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #17's most recent MDS (Minimum Data Set Assessment) was a quarterly with an ARD (Assessment Reference Date) of 2/1/17. The MDS assessment coded Resident #17 as having no cognitive impairment in daily decision making. Resident #17 was coded as requiring standby assistance with transferring and all other activities of daily living such as eating and toileting, and walking on and off the unit. The resident was not coded as Hospice, but was a DNR (do not resuscitate). On 5/18/17, the clinical record revealed the following physician order dated on admission of 10/25/16 with continuous use until the present time as: Dobutamine in [MEDICATION NAME] 500 mg (milligrams) 250 ml (milliliters) infuse Dobutamine 2.5 mcg (micrograms) IV at 4.5 ml/hour. Dobutamine is an inotropic (improves cardiac output) cardiac medication. The facility was asked for their drug handbook; the nurse could not find one in the nurses station or the drug cart, and never returned with any drug book. The Nursing Drug Handbook (Saunders) 2015, page 462, contained the following regarding nursing monitoring for Dobutamine Continuous monitoring on ECG (electrocardiogram), [MEDICAL CONDITION] artery wedge pressure (done in intensive care or telemetry in the hospital), blood pressure (BP), cardiac and urine output. Adverse effects include: marked increase in heart rate (30 beats per minute or higher,), marked increase in BP (50 mm (millimeters) or higher) [MEDICAL CONDITION] pain and premature ventricular contractions. Remedi Senior care 2013 discusses Dobutamine as though continuous cardiac monitoring is not required in set dosing, dose use in long term setting not recommended. Davis' Drug Guide lists IV Dobutamine as a High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error. Review of the discharge hospital notes dated 10/24/16 included: Weight daily . notify the Primary Care clinic if you gain more than 3 pounds in a day, or 5 pounds in a week. There was no order for weight monitoring on admission to the facility. Further clinical review revealed the following: Admission weight was 133 pounds. On 12/1/16, the physician note documented daily weights (weights were being done twice weekly). On 12/5/16, the facility weight tracking identified the weight on 11/21/16 as 135 pounds; two weeks later on 12/5/16, the weight had increased to 145, a 10 pound (7.4%) weight gain in two weeks. On 12/12/16, the NP (nurse practitioner) documented, Weights stable, continue twice weekly weights. On 12/20/16, the NP documented, SOB (short of breath) related to [MEDICAL CONDITION], [MEDICATION NAME] (diuretic) increased to 40 mg daily. On 1/2/17, the weight was 151.1 pounds. On 1/29/17, the NP wrote the following orders: Get appointment at (name of hospital) resident's cardiologist to evaluate worsening [MEDICAL CONDITION] and [MEDICAL CONDITION]. On 1/30/17 the NP wrote: 1+ lower leg [MEDICAL CONDITION], positive pedal [MEDICAL CONDITION] .Get appointment with cardiology to assess increase in Dobutamine drip. The next cardiology appointment was done on 3/2/17 and read: Stable HF (heart failure) on inotrope (Dobutamine) . watches BP (if systolic blood pressure is less than 90 and symptomatic). No parameters for blood pressure frequency or weight monitoring was mentioned. The order was not clarified by the facility staff. On 5/18/17 at 9:00 AM, the nurse practitioner was questioned about monitoring of Dobutamine. She stated, Should be checking BP's every shift and weights have been stable. On 3/19/17, the dietary technician's notes documented the following: 13% weight gain in 60 days. Review of the dietary technician notes dated 4/13/17 showed a 12% (sixteen pounds) weight loss. The physician was not notified of the weight changes, the dosage was not adjusted, which would require hospitalization during the dose titration. The resident had not had any admissions to the hospital. No blood pressures were documented since 4/10/17. On 5/18/17 at 10:15 AM, an interview was conducted with LPN (licensed practical nurse) A, who stated, Yes, I change the cassette (bag). She added, We are supposed to monitor BP every shift. She went on to state that she had not documented these blood pressures on the clinical records, but in her own notes. Resident #17 was being treated for [REDACTED]. This device was in a carrying case that was on his belt or could be carried over his shoulder. The case was approximately 8 x 3 and contained a small infusion pump, a battery pack, and a 250 milliliter (ml) bag of dobutamine. The dobutamine infused to a PICC line on his right arm from the portable pump. When the batteries were low, a signal sound would alert the resident who would contact an LPN for new batteries. The drip was at 4.5 ml/hr (hour) and when the bag was low another alarm would sound for an LPN to change the medication. On 5/18/17 at approximately 10:30 AM, the care plan dated 2/21/17 was reviewed and did not include interventions for the PICC (peripherally inserted central catheter) line. Web MD describes a PICC line as a central venous catheter, also called a central line, is a long, thin, flexible tube used to give medicines, fluids, nutrients, or blood products over a long period of time, usually several weeks or more. A catheter is often inserted in the arm or chest through the skin into a large vein. The catheter is threaded through this vein until it reaches a large vein near the heart. The resident was not was care planned for Dobutamine usage, monitoring including frequency of VS, weights or symptoms to report to physician. Managing Heart Failure By Lacey Buckler, Lippincott Williams and Wilkins identify the standards of practice for managing [MEDICAL CONDITION]: Administer medications and monitor response Weigh the patient daily at the same time on the same scale, early in the day after urination; report a 2 to 3 lb gain in a day or 5 lbs in a week to the healthcare provider Auscultate lung sounds Monitor vital signs Identify and evaluate [MEDICAL CONDITION] severity Examine skin turgor On 5/18/17 at 1:30 PM, an interview of the Medical Director was conducted. He stated, I have sent people home with no monitoring. He went on to state that he had taken on the role of Medical Director in January of 2016. On 5/18/17 at 3:05 PM, an interview was conducted with LPN (B), who stated, Dobutamine is for his enzyme imbalance. He went on to state, I watch for IV site infection, infiltration, weekly vital signs and I have not been trained here, but have done it in other facilities. He added that he changed the PICC (peripheral inserted central catheter) dressing and the medication cassette. Virginia DHP (department of health professions) on LPN scope of practice includes: Selected nursing acts, requires knowledge, judgement and skill in nursing procedures gained through prescribed educations and under direction and supervision. There is a decision making model for determining RN (registered nurse)/LPN Scope of Practice which included: Do you personally possess current clinical skills to perform the activity/ task in a competent safe manner and Do you personally possess the depth and breadth of knowledge to perform the activity task, safely and effectively as required in a prelicensure program, post basic program, continuing education program, or structured self study program? If the answer is no, the LPN is not to perform those duties. There was no education provided to the nurses on IV Dobutamine use. On 5/18/17 at 3:30 PM, the pharmacy consultant was questioned about monitoring the medication. He stated, Normal monitoring; I understand (name of hospital) is monitoring weights and drug monitoring. He did not know of frequency of weight monitoring. He went on to state that, Now that I think about it, it makes me nervous. He stated he would call the IV pharmacy consultant. On 5/18/17 at 4:05 PM, the IV pharmacy consultant called back. He stated, They are supposed to get daily weights, daily vital signs. He went on to state, The pharmacy consultant should have picked up the lack of monitoring. He then stated he would send me the Nurses' infusion manual for long term care. It documented, VS and lung sounds must be obtained: - Prior to initiation of inotropic medication - Every 15 minutes for one hour - Every hour for 2 hours - Every 4 hours Weigh every day. In addition, the orders must include: Vital sign frequency with reportable parameters. On 3/2/17, the resident had a consultation with the cardiac physician. The note included: Watch BP (if systolic blood pressure is less than 90 and symptomatic). No frequency of BP's was included and actions to take if this occurred. No clarification of this order was documented. On 5/18/17 at approximately 4:10 PM, the inservice educator was questioned about staff training on Dobutamine use and monitoring. She stated, We are doing it now. 5/18/17 at 6:30 PM, Resident #17 was interviewed. He stated, When I first came here, they didn't know what to do with my machine. He went on to state that they did not run the machine all night. He further reported that a week before Valentine's day, staff did not place an extension tube on the IV line and it leaked, causing a burn, like a cigarette burn on his inner arm at the IV site. The area was examined and showed a small scar near the PICC line site. On 5/18/17 at 6:40 PM, the DON (director of nursing) stated, We are supposed to notify the physician of a three pound weight change. She went on to state that the pharmacy does dosage changes based on weights and that for a weight change and dosage change, the resident has to be admitted to the hospital for monitoring and titration. The DON stated the Facility uses Lippincott as their reference for policies and procedures. On 5/18/17 at 7:00 PM, the nurse's note read, Resident was weighed 138.9 pounds, currently on 2.5 mcg (micrograms), pharmacy was called and made aware stated resident have (sic) a slight weight gain since admission. 60 K (kilograms) to 63 since admission stated to call cardiologist to follow up for adjustment of medication. Spoke with (Name of NP) regarding weight and medication stated to place resident IV at 4.7 ml (milliliters) (from 4.5) per hour. Resident own RP (responsible party) made (this sentence was crossed out) Resident pump currently running at 4.5 ml/hour, NP stated to keep pump at current setting and follow up with cardiologist. On 5/18/17 at about 4:35 PM, the LTC supervisor notified the survey team of IJ (immediate jeopardy) and substandard quality of care. The sample was extended to include residents IV medications. No other residents were on Dobutamine or other cardiac medications. The only IV medications were antibiotics administered to residents. Additional tasks were added and performed. On 5/18/17 at about 4:40 PM, the Administrator and DNS (director of nursing services) were notified of IJ and substandard quality of care. On 5/18/17 at 5:53 PM, the facility presented the POC (plan of correction). The POC was reviewed by the survey team and not accepted. On 5/18/17 at 6:35 PM, the Administrator and DON were notified the second POC was not accepted. On 5/18/17 at 7:00 PM, the POC was accepted. The IJ was reduced to a level 2 isolated. It was later determined the team had identified harm level deficiencies in this citation. The IJ was then increased to a level three, isolated. The LTC supervisor was notified. The facility POC documented the following 5 points: 1. Resident receiving Dobutamine drip in the facility has had no adverse reaction, but the deficient practice has the potential for an adverse reaction as not all staff providing care for this resident are aware of this medications indications for usage, signs and symptoms of adverse effects, appropriate monitoring protocols, nor licensure qualifications for any of the above. The following to be implemented immediately to ensure appropriate care for affected resident . a. Provide 24 hour RN (registered nurse) coverage on the unit in which the resident resides b. Monitor resident weight daily c. Monitor resident intake and output every shift d. Monitor VS every 4 hours e. Obtain labs as indicated f. Transfer to an acute care setting should titration of medication become necessary 2. Residents that reside in the facility receiving IV medications have the potential by this deficient practice. There are no other residents in this facility receiving Dobutamine at this time. Every resident receiving IV medications have been assessed and no adverse reaction noted. 3. Licensed nursing staff in the facility will be educated on the usage of Dobutamine and the side effects. The licensed nurses will be educated on the management of PICC line access and the evaluation of the site and surrounding tissues. The following systemic changes are to be implemented to ensure deficient practice will not recur: a. Provide 24 hour RN coverage on the unit in which any resident with inotropic medication resides b. Monitor resident weight daily c. Monitor resident intake and output every shift d. Monitor VS every 4 hours e. Obtain labs as indicate 4. The DNS /ADSC will ensure 24 hour RN coverage to oversee protocols as stated above 5. Allegation of compliance: 7:00 pm 5/18/17. On 5/19/17 at 9:55 AM, the LPN (LPN H) responsible for the care plan for Resident #17 was interviewed as to why the [MEDICAL CONDITION] with Dobutamine use was not in the care plan. LPN (H) stated, At one time, I wasn't care planning medications. 2. For Resident #1, the facility staff failed to administer medications per physician's order, resulting in harm as the Resident was rehospitalized 3 times for pain, psychological distress, nausea, vomiting, elevated blood pressure, and constipation. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1's most recent MDS with an assessment reference date (ARD) of 4-16-17 was coded as a quarterly assessment. The Resident was coded as having no cognitive impairment. Resident #1 was also coded as needing only supervision of set up help from staff to perform activities of daily living, such as dressing, transferring, bed mobility and hygiene. Review of the Resident's facility clinical record, and hospital records for the month of November 2016, revealed that the facility had to repeatedly send Resident #1 to the hospital for complaints of headache, constipation, abdominal pain, and weakness. A chronological record of those hospitalization s follows; On 11-1-16 the Resident was admitted to the hospital with [REDACTED]. The Resident was discharged on [DATE] to the facility with new medications ordered by the hospital doctor to correct the hypertension, UTI, and constipation. The total number of current daily medications at hospital discharge for this Resident was 23. On 11-24-16, 2 days after readmission, the Resident was again sent to the hospital for complaints of altered mental status, weakness, and constipation. The Resident was found to have a very high blood pressure (193/92 mmHg) MillimeterMercury; normal below 120/80) and was ordered by the doctor to be given Hydralzine 10 mg (milligrams) three times per day, and added to the Resident's current ongoing daily drug list to correct the high blood pressure. The Resident's total number of current daily medications now stood at 24. On 11-25-16, 1 day later, the Resident was again sent out to the hospital, and found to be suffering from high blood pressure (164/115), and stated to the nurse I just want to kill myself and get it over with., and while moaning and groaning Oh god please help me i can't take it anymore. The Resident was sent back to the facility in narcotic with drawl as the facility stated that the facility doctor was weaning residents off of narcotics. On 11-26-16, 1 day later, the facility again sent the Resident to the hospital for complaints of hypertension, stomach pain, and feeling awful, nausea, vomiting, and abdominal pain. The Resident told the doctor at that time, that the facility had not been giving him his daily medications, and the doctor documented such in the consultation report. The hospial doctor called the facility and spoke with the nurse caring for Resident #1 (LPN L) to review the Resident's medication list. LPN L stated that the nurse who readmitted Resident #1, on 11-22-16, and 11-24-16 had missed a whole page of MEDICATION ORDERS FOR [REDACTED]. LPN L stated she would correct the error on 11-26-16. The social worker at the hospital became involved in the situation, and contacted Adult Protective Services (APS) on 11-26-16 to report neglect. The physician documented that she was concerned about the Resident's kidney, blood pressure, and bowel problems, born of the fact that the facility was not administering the Resident's physician ordered medications, and creating repeated hospital visits. The doctor also stated the stool burden may be compromising kidneys. The hospital team decided to not return the Resident to the facility, and to instead admit him to the hospital again to begin searching for safe placement, as the facility was not administering his medications. The physician's documentation went on to say that she would not discharge back to the facility due to unsafe conditions at SNF (skilled nursing facility), as the Resident had not had a bowel movement since his discharge from the hospital on 11-22-16, and that while in the facility he had not been given any of his antihypertensives, nor was he on a scheduled bowel regimen (and medications for chronic problems). The doctor's progress note goes on to state that the only five medications being administered to the Resident were; Routine [MEDICATION NAME], and PRN (as needed, not routine) [MEDICATION NAME], and senna. It is also notable to mention that the Resident was an insulin dependent diabetic, and was not receiving any insulin during this 4 day period from 11-22-16 through 11-26-16. The Resident's glucose level was 183 upon admission to the hospital. Valid physician orders were evident for the medications not documented as having been administered. The Resident's Medication list that was not followed, was as follows; 1. Pantoprazole 40 mg daily for stomach pain 2. [MEDICATION NAME] 10 mg daily for high blood pressure 3. Aspirin 81 mg daily for blood pressure 4. [MEDICATION NAME] suppositories 10 mg rectally every 12 hours for constipation 5. carvedilol 25 mg every 12 hours high blood pressure 6. [MEDICATION NAME] 10 mg twice daily for muscle spasm 7. [MEDICATION NAME] 100 mg two tablets twice daily for constipation 8. duloxetine 60 mg daily for depression 9. [MEDICATION NAME] 5 mg daily for prostate 10. [MEDICATION NAME] 600 mg three times per day for [MEDICAL CONDITION] 11. [MEDICATION NAME] 10 mg three times per day for blood pressure 12. insulin [MEDICATION NAME] 100 units/ml (milliliter) 10 units inj subcutaneously daily for diabetes 13. [MEDICATION NAME] topical 5% patches on for 12 hours joint pain 14. [MEDICATION NAME] 50 mg daily at bedtime depression 15. [MEDICATION NAME] 5 mg every 8 hours for urology 16. polyethylene [MEDICATION NAME] 3350 17 grams twice daily for constipation 17. senna 8.6 mg daily at bedtime for constipation 18. tamsulosin 0.4 mg daily after breakfast for urology 19. [MEDICATION NAME] 18 mcg inhaled 1 cap daily for [MEDICAL CONDITION] 20. [MEDICATION NAME] 50 mg three times per day PRN (as needed) for break through pain 21. [MEDICATION NAME] 10/325mg (milligrams) four times daily PRN (as needed) for pain 22. guifenesin 600 mg every 6 hours (prn) for cough 23. [MEDICATION NAME] 100 mg every 12 hours antibiotic 24. [MEDICATION NAME] 4 mg every 6 hours PRN (as needed) nausea/vomiting On 5-17-17 the Director of Nursing (DON), and administrator were asked to allow an interview with LPN L. They stated that the employee was terminated in January 2017, shortly after the incident. Her employee record was reviewed, and revealed a termination date of 1-12-17. On 5-17-17 copies of the physician's order (POS) sheets, and Medication administration (MAR) records for all of October, November, and through December of 2016 were requested from the Director of Nursing (DON), and administrator. On 5-18-17 at the end of day, the DON and Administrator delivered the October, and December 2016 POS, and MAR indicated [REDACTED]. The medical records staff, and nursing staff had searched the entire building for 2 days, and only this part of the clinical record was missing. The whereabouts of this Protected Health Information (PHI) was unknown. They stated that the previous DON had been contacted, and stated that the records had been in a folder in her office, but she did not know where the records were now. The current DON of 3 months stated no folder existed in her office with these records. The Administrator was made aware that PHI, and clinical records must be retained by law for 5 years after a Resident is discharged , and that federal Health Insurance Portability and Accountability Act (HIPAA) practices had been breached. The Administrator stated understanding. The October 31, 2016 POS, revealed 16 medications ordered, including 2 kinds of injectable insulin for diabetes. The DON was asked why staff had not called the doctor to clarify orders when only 5 medications were ordered for November, and the insulin, that the Resident had been taking was abruptly stopped. Her response was I don't know, they should have. The DON gave Lippincott as the facility nursing practice standard, the Lippincott reference is as follows; Document all medications administered in the patient's MAR indicated [REDACTED]. Lippincott Solutions Safe Medication Administration Practices, General 10/02/2015. The facility policy on protected health information (PHI) was the federal HIPAA standard. The facility policy on medication administration stated Obtain, and verify physician's orders. Prior to administering medications. The Administrator and DON were made aware of these deficient findings at a harm level, at the end of day debrief on 5-18-17, and 5-19-17. Harm ocurred as the Resident was repeatedly hospitalized with symptoms related to the facility staff omission of the Residents needed, and ordered medications for atleast 5 days. This being from 11-22-16 through 11-26-16. No further information was able to be provided by the facility. COMPLAINT DEFICIENCY 3. The facility staff failed to remove the staples from Resident # 26's head as ordered by the emergency room physician on 8/2/2016. They should have been removed in 7 days on 8/9/2016. They were not removed until 11/20/2016. Resident # 26, an [AGE] year old female, was admitted to the facility 3/2/2010 and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident # 26 resided on the 30 bed Secured Unit. Resident # 26 was discharged from the facility on 11/30/2016 and did not return to the facility. Resident #26's most recent MDS (minimum data set) with an ARD (assessment reference date) of 11/26/2016 was coded as a Significant Change Assessment. She was coded as having a BIMS score of 2 indicating severe cognitive impairment. Coded as having short and long term memory deficits and required total assistance with making daily life decisions. Resident # 26 was coded as needing limited to extensive assistance of one staff person with her activities of daily living except for bathing for which she required total assistance of one staff person. She required extensive assistance of one staff person for ambulation, toileting and transfers. She was coded as frequently incontinent of bowel and bladder. The previous MDS with an ARD of 9/30/16 was coded as a Quarterly Assessment. Resident # 26 was coded as having a BIMS score of 2 indicating severe cognitive impairment. She was coded as requiring supervision of one staff person for all Activities of Daily Living including ambulation, toileting and transfers except for bathing for which she required total assistance of one person. She was coded as occasionally incontinent of bowel and bladder. Review of Resident #26's closed clinical record revealed she had fallen on 8/2/2016 and sustained a laceration on the posterior head. Review of Incident Reports revealed documentation of an incident where Resident # 26 fell , sustained a laceration to the posterior head and was sent to the emergency room . 8/2/16 at 5:40 AM Resident found on floor on right side of bed in sitting position by (CNA) Certified Nursing Assistant. Laceration to posterior head. Staff attempted ice and pressure but refused Sent to ER . Resident returned from hospital 8/2/16 at 1:05 PM, Resident left in bed with call bell in reach Hospital Discharge Summary: 8/2/16 11:17 AM, Wound care, scalp laceration. You should follow up with your primary care physician in 7 days. Additional notes: STAPLES SHOULD BE REMOVED IN 7 DAYS. Further review of the clinical record revealed no documentation that the staples were removed until 11/20/2016. There was no documentation that the Facility updated the care plan with the intervention to remove the staples. Review of the Physicians Progress Notes revealed the physician visit on 8/16/16 for follow up on fall, there was no mention about the staples. Review of the subsequent progress notes dated 9/1/16, 9/14/16, 10/3/16, 10/17/16, 11/12/16, 11/14/16 also did not mention removal of the staples from Resident # 26's head. Fundamentals of Nursing, 6th Edition, Potter-Perry, p. 419, provides the following guidance regarding physicians' orders, The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. Therefore all orders must be assessed, and if one is found to be erroneous or harmful, further clarification from the physician is necessary. The facility staff used Lippincott as their nursing standard. The facility staff failed to remove the staples from Resident # 26's head as ordered by the emergency room physician on 8/2/2016. They should have been removed in 7 days on 8/9/2016. They were not removed until 11/20/2016. 4. Resident #12 had multiple areas where physician ordered medications were not documented as having been administered. Resident #12, a [AGE] year old male, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #12's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/18/2017 was coded as a quarterly assessment. Resident #12 was coded a BIMS (Brief Interview of Mental Status) score of 15/15 indicating no cognitive impairment. Resident #12 was also coded as needing the assistance of 2 persons for his activities of daily living, and was coded as being always incontinent of bowel and bladder. On 5/17/2017 at10:30 AM a review of the clinical record was conducted and revealed a MAR (Medication Administration Record) for January and April 2017 showing no documentation for the following medications per physician orders for the dates and times indicated: Aripiprazole 1mg (milligram)/1 ml (milliliter)-0.5 ml by mouth every morning: 1/30 9:00 AM [MEDICATION NAME] 10 mg by mouth every day: 1/30, 4/26 9:00 AM [MEDICATION NAME] Inject 1 ml (40 mg) subcutaneously Monday, Wednesday, Friday: 1/30, 4/19 7-3 shift [MEDICATION NAME] 20 mg by mouth 30 minutes before a meal: 1/30 7:30 AM [MEDICATION NAME] 5 mg by mouth 3 times daily: 1/30 9 AM, 1 PM. [MEDICATION NAME] 1 mg by mouth daily: 4/19 9:00 AM [MEDICATION NAME] 100 mg by mouth every morning: 4/19 9:00 AM A review of the clinical record did not reveal any documentation regarding the administration of the mentioned medication. A review of the physician order sheet revealed current and valid orders for these medications. An interview was conducted on 5/17/2017 at 6:00 PM with Administration B, Director of Nursing. She was not able to explain the omissions. A review of the facility policy on medication administration stated It is the policy that the resident can expect safe and accurate administration of medications. The facility cited Lippincott as their resource for professional nursing standards. Guidance is given from Lippincott Solutions, Safe Medication Administration Practices, General 10/02/2015. Document all medications administered in the patient's MAR indicated [REDACTED]. If a medication wasn't administered, document the reason why, any interventions taken, practitioner notification, and the patient's response to interventions. Administration was notified on 5/19/2017 at 5:30 PM. 5. For Resident #14, (TRUNCATED)

Based on observation, resident and staff interview, facility documentation review and clinical record review, the facility failed to ensure one Resident, Resident #17 in a survey sample of 32 residents, to ensure the resident was free from un-necessary drugs, resulting in immediate jeopardy and substandard quality of care. After acceptance of the POC (plan of correction), the deficiency was lowered to a level 2 isolated. Resident #17 was not monitored adequately for the use of IV (intravenous) Dobutamine. Weights were not monitored as required by standards of care, the dose was not adjusted as required. Staff was untrained to monitor for adverse effects of the Dobutamine and when to contact the physician. The findings included: Resident #17 was a [AGE] year old who was originally admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #17's most recent MDS (Minimum Data Set Assessment) was a quarterly with an ARD (Assessment Reference Date) of 2/1/17. The MDS assessment coded Resident #17 as having no cognitive impairment in daily decision making. Resident #17 was coded as requiring standby assistance with transferring and all other activities of daily living such as eating and toileting, and walking on and off the unit. The resident was not coded as Hospice, but was a DNR (do not resuscitate). On 5/18/17, the clinical record revealed the following physician order [REDACTED]. Dobutamine is an inotropic (improves cardiac output) cardiac medication. The facility was asked for their drug handbook; the nurse could not find one in the nurses station or the drug cart, and never returned with any drug book. The Nursing Drug Handbook (Saunders) 2015 page 462, contained the following regarding nursing monitoring for Dobutamine Continuous monitoring on ECG (electrocardiogram), [MEDICAL CONDITION] artery wedge pressure (done in intensive care or telemetry in the hospital), blood pressure (BP), cardiac and urine output. Adverse effects include: marked increase in heart rate ( 30 beats per minute or higher,), marked increase in BP (50 mm (millimeters) or higher) [MEDICAL CONDITION] pain and premature ventricular contractions. Remedi Senior care 2013 (Gahart BL, Nazareno AR. 2013 Intravenous Medications. 29th ed. St Louis, MO; Mosby/Elsevier) discusses Dobutamine as though continuous cardiac monitoring is not required in set dosing, dose use in long term setting not recommended. Davis' Drug Guide lists IV Dobutamine as a High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error. Review of the discharge hospital notes dated 10/24/16 included: Weight daily . notify the Primary Care clinic if you gain more than 3 pounds in a day, or 5 pounds in a week. There was no order for weight monitoring on admission to the facility. Further clinical review revealed the following: Admission weight was 133 pounds. On 12/1/16, the physician note documented daily weights (weights were being done twice weekly). On 12/5/16, the facility weight tracking identified the weight on 11/21/16 as 135 pounds; two weeks later on 12/5/16, the weight had increased to 145, a 10 pound (7.4%) weight gain in two weeks. On 12/12/16, the NP (nurse practitioner) documented, Weights stable, continue twice weekly weights. On 12/20/16 , the NP documented, SOB (short of breath) related to [MEDICAL CONDITION], [MEDICATION NAME] (diuretic) increased to 40 mg daily. On 1/2/17, the weight was 151.1. On 1/29/17, the NP wrote the following orders: Get appointment at (name of hospital) resident's cardiologist to evaluate worsening [MEDICAL CONDITION] and [MEDICAL CONDITION]. On 1/30/17 the NP wrote, 1+ lower leg [MEDICAL CONDITION], positive pedal [MEDICAL CONDITION] .Get appointment with cardiology to assess increase in Dobutamine drip. The next cardiology appointment was done on 3/2/17 and read: Stable HF (heart failure) on inotrope (Dobutamine) . watch BP (if systolic blood pressure is less than 90 and symptomatic). No parameters for blood pressure frequency or weight monitoring was mentioned. The order was not clarified by the facility staff. On 5/18/17 at 9:00 AM, the nurse practitioner was questioned about monitoring of Dobutamine. She stated, Should be checking BP's every shift and weights have been stable. On 3/19/17, the dietary technician's notes documented the following: 13% weight gain in 60 days. Review of the dietary technician notes dated 4/13/17 showed a 12% (sixteen pounds) weight loss. The physician was not notified of the weight changes, the dosage was not adjusted, which would require hospitalization during the dose titration. The resident had not had any admissions to the hospital. No blood pressures were documented since 4/10/17. On 5/18/17 at 10:15 AM, an interview was conducted with LPN (licensed practical nurse) A, who stated, Yes, I change the cassette. She added, We are supposed to monitor BP every shift. She went on to state that she had not documented these blood pressures on the clinical records, but in her own notes. On 5/18/17 at approximately 10:30 AM, the care plan dated 2/21/17 was reviewed and did not include interventions for the PICC (peripherally inserted central catheter) line. Web MD describes a PICC line as a central venous catheter, also called a central line, is a long, thin, flexible tube used to give medicines, fluids, nutrients, or blood products over a long period of time, usually several weeks or more. A catheter is often inserted in the arm or chest through the skin into a large vein. The catheter is threaded through this vein until it reaches a large vein near the heart. The resident was not care planned for Dobutamine usage, monitoring including frequency of VS (vital signs), weights or symptoms to report to physician. Managing Heart Failure by Lacey Buckler, Lippincott Williams and Wilkins identify the standards of practice for managing [MEDICAL CONDITION]: Administer medications and monitor response Weigh the patient daily at the same time on the same scale, early in the day after urination; report a 2 to 3 pound gain in a day or 5 pounds in a week to the healthcare provider Auscultate lung sounds Monitor vital signs Identify and evaluate [MEDICAL CONDITION] severity Examine skin turgor On 5/18/17 at 12:55 PM, the admission coordinator was questioned about Resident #17's admission. She stated, Not all admissions are reviewed by nursing. We have a list of automatic admissions. This document called Commit to admit included: Infusion care including [MEDICATION NAME], Hydration, [MEDICATION NAME], Potassium, [MEDICATION NAME], Vitamins and minerals. On 5/18/17 at 1:30 PM, an interview of the Medical Director was conducted. He stated, I have sent people home with no monitoring. He went on to state that he had taken on the role of Medical Director in January of 2016. On 5/18/17 at 3:05 PM, an interview was conducted with LPN (B), who stated, Dobutamine is for his enzyme imbalance. He went on to state, I watch for IV site infection, infiltration, weekly vital signs and I have not been trained here, but have done it in other facilities. He added that he changed the PICC (peripheral inserted central catheter) dressing and the medication cassette (bag). Resident #17 was being treated for [REDACTED]. This device was in a carrying case that was on his belt or could be carried over his shoulder. The case was approximately 8 x 3 and contained a small infusion pump, a battery pack, and a 250 ml bag of dobutamine. The dobutamine infused to a PICC line on his right arm from the portable pump. When the batteries were low, a signal sound would alert the resident who would contact an LPN for new batteries. The drip was at 4.5 ml/hr and when the bag was low another alarm would sound for an LPN to change the medication. On 5/18/17 at 3:30 PM, the pharmacy consultant was questioned about monitoring the medication. He stated, Normal monitoring; I understand (name of hospital) is monitoring weights and drug monitoring. He did not know of frequency of weight monitoring. He went on to state that, Now that I think about it, it makes me nervous. He stated he would call the IV pharmacy consultant. On 5/18/17 at 4:05 PM, the IV pharmacy consultant called back. He stated, They are supposed to get daily weights, daily vital signs. He went on to state, The pharmacy consultant should have picked up the lack of monitoring. He then stated he would send me the Nurses' infusion manual for long term care. It documented, VS and lung sounds must be obtained: - Prior to initiation of inotropic medication - Every 15 minutes for one hour - Every hour for 2 hours - Every 4 hours Weigh every day. In addition, the orders must include: Vital sign frequency with reportable parameters. On 3/2/17, the resident had a consultation with the cardiac physician. The note included: Watch BP (if systolic blood pressure is less than 90 and symptomatic). No frequency of BP's were included and actions to take if this occurred. No clarification of this order was documented. On 5/18/17 at approximately 4:10 PM, the inservice educator was questioned about staff training on Dobutamine use and monitoring. She stated, We are doing it now. On 5/18/17 at about 4:35 PM, the LTC supervisor notified the survey team of IJ (immediate jeopardy) and substandard quality of care. The sample was extended to include residents IV medications. No other residents were on Dobutamine or other cardiac medications. The only residents receiving IV medications were those on antibiotics. Additional tasks were added and performed. On 5/18/17 at about 4:40 PM, the Administrator and DNS (director of nursing services) were notified of IJ and substandard quality of care. 5/18/17 at 6:30 PM, Resident #17 was interviewed. He stated, When I first came here, they didn't know what to do with my machine. He went on to state that they did not run the machine all night. He further reported that a week before Valentine's day, staff did not place an extension tube on the IV line and it leaked, causing a burn, like a cigarette burn on his inner arm at the IV site. The area was examined and showed a small scar near the PICC line site. On 5/18/17 at 6:40 PM, the DON (director of nursing) stated, We are supposed to notify the physician of a three pound weight change. She went on to state that the pharmacy does dosage changes based on weights and that for a weight change and dosage change, the resident has to be admitted to the hospital for monitoring and titration. On 5/18/17 at 7:00 PM, the nurses note read, Resident was weighed 138.9 pounds, currently on 2.5 mcg, pharmacy was called and made aware stated resident have (sic) a slight weight gain since admission. 60 K (kilograms) to 63 since admission stated to call cardiologist to follow up for adjustment of medication. Spoke with (Name of NP) regarding weight and medication stated to place resident IV at 4.7 ml (milliliters) (from 4.5) per hour. Resident own RP (responsible party) made (this sentence was crossed out) Resident pump currently running at 4.5 ml/hour., NP stated to keep pump at current setting and follow up with cardiologist. On 5/18/17 at 5:53 PM, the facility presented the POC (plan of correction). The POC was reviewed by the survey team and not accepted. On 5/18/17 at 6:35 PM, the Administrator and DON were notified the second POC was not accepted. On 5/18/17 at 7:00 PM, the POC was accepted. The IJ was reduced to a level 2 isolated. It was later determined the team had identified harm level deficiencies in this citation. The IJ was then increased to a level three, isolated. The LTC supervisor was notified. The facility POC documented the following 5 points: 1. Resident receiving Dobutamine drip in the facility has had no adverse reaction, but the deficient practice has the potential for an adverse reaction as not all staff providing care for this resident are aware of this medications indications for usage, signs and symptoms of adverse effects, appropriate monitoring protocols, nor licensure qualifications for any of the above. The following to be implemented immediately to ensure appropriate care for affected resident . a. Provide 24 hour RN (registered nurse) coverage on the unit in which the resident resides b. Monitor resident weight daily c. Monitor resident intake and output every shift d. Monitor VS every 4 hours e. Obtain labs as indicated f. Transfer to an acute care setting should titration of medication become necessary 2. Residents that reside in the facility receiving IV medications have the potential by this deficient practice. There are no other residents in this facility receiving Dobutamine at this time. Every resident receiving IV medications have been assessed and no adverse reaction noted. 3. Licensed nursing staff in the facility will be educated on the usage of Dobutamine and the side effects. The licensed nurses will be educated on the management of PICC line access and the evaluation of the site and surrounding tissues. The following systemic changes are to be implemented to ensure deficient practice will not recur: a. Provide 24 hour RN coverage on the unit in which any resident with inotropic medication resides b. Monitor resident weight daily c. Monitor resident intake and output every shift d. Monitor VS every 4 hours e. Obtain labs as indicate 4. The DNS /ADSC will ensure 24 hour RN coverage to oversee protocols as stated above 5. Allegation of compliance: 7:00 pm 5/18/17. On 5/19/17 at 9:55 AM, the LPN (LPN H) responsible for the care plan for Resident #17 was interviewed as to why the [MEDICAL CONDITION] with Dobutamine use was not in the care plan. LPN (H) stated, At one time, I wasn't care planning medications.

Based on observation, staff interview, facility documentation review and clinical record review, the facility staff failed to prevent, identify, assess, and intervene, and treat residents with pressure wounds for 4 Residents (Residents #23, #4, #13 and #14 in a survey sample of 32 residents, resulting in harm for Resident #23. 1. For Resident #23, the facility staff allowed an ankle wound to progress to an unstageable wound prior to discovery, resulting in harm. 2. For Resident #4, the facility staff failed to assess (describe and measure) pressure wounds. 3. Resident #13 did not have his heels floated, and was repositioned in a manner to cause shearing of the skin. 4. For Resident #14, the facility staff failed to apply physician ordered Skin Prep to bilateral heels. The findings included: 1. For Resident #23, the facility staff allowed an ankle wound to progress to an unstageable wound prior to discovery, resulting in harm. Resident #23, a [AGE] year old male, was admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Resident #23's most recent MDS (Minimum Data Set) with an ARD (assessment reference date) of 4/27/2017 was coded as a significant change assessment. Resident #23 was coded a BIMS (Brief Interview of Mental Status) score of 02/15, indicating severe cognitive impairment. Resident #23 was coded as needing extensive assistance of one person for his activities of daily living and as being always incontinent of bowel. Resident #23 used a Foley catheter for urine elimination. A clinical record review was conducted on 5/18/2017 at 9:00 AM. This review revealed the above MDS report with an ARD of 4/27/2017. Section M on that report revealed that, as of 4/27/2017, Resident #23 had 3 unstageable pressure wounds that were not present on admission to the facility. A wound to the left elbow was found on 3/27/2017 as a blister. A wound on the right ischium was found on 3/11/2017 as a Stage 1. The final wound, a wound on the right lateral ankle, was found at an unstagable condition on 4/6/2017 by a wound care physician. At the time of the survey, all wounds were unstageable. Wounds were seen on 5/18/2017 at 12:50 PM with Administration B, Director of Nursing and LPN I, Staff Nurse. The wound on the right lateral (outside) ankle was visualized after the bandage was removed. The wound was unstageable according to the wound care physician on 4/6/17 now measured at 3.1 cm (centimeters) x 2.2 cm. The wound bed could not be seen as it was covered with thick slough. Slough is defined as yellow stringy substance attached to the wound bed, which must be removed for the wound to heal-Fundamentals of Nursing sixth edition, Potter and Perry, page 1487. Because of this slough, the wound was classified as unstageable. The left elbow was visualized after removal of the bandage. It measured 3 cm x 3cm and was covered in slough. The right ischium was seen to be 3 cm x 4 cm and was covered with slough. The wound care physician ordered treatment for [REDACTED]. The facility had no organized wound care records, however a nursing note was found dated 5/1/2017 at 4:00 PM which stated .right lateral ankle presents with slough and scant purulent drainage. Wound edges are defined. 2 x 2. This was the first note made in the clinical record. There was a Wound Care Specialist Initial Evaluation report from a physician's service dedicated to wound care. This report was dated 4/6/2017, approximately one month prior to the nursing note of 5/1/2017. This report describes the wound to the left lateral ankle as a pressure wound with unstageable necrosis. Wound size was 3 cm x 2.1 cm. The wound needed debridement (surgical removal of necrotic tissue to visualize the wound bed-a bedside procedure.). Debridement was necessary for healing. The wound care physician stated Reason for no debridement-Unable to obtain consent from patient or surrogate and unable to contact primary physician at this time. The wound still had not been debrided as of 5/18/2017. A review was conducted with Resident #23's care plan. The care plan was dated 4/2/2017 and the focus regarding pressure ulcers was as follows: (Resident #23) has impaired skin integrity r/t (related to) pressure ulcer. Goals were as follows: Interventions will remain in place to prevent further impaired skin integrity through the next review (Resident #23's) wound will show signs of healing and remain free from infection through the next review There were 23 skin/pressure wound prevention interventions listed. A meeting was held with Administration B, Director of Nursing, on 5/18/2017 at 5:00 PM. She stated that she did not know why there were no notes on Resident #23's ankle wound prior to its being discovered as an unstageable wound. She also did not know if there was any follow up with Resident#23's responsible party to obtain permission for a debridement procedure. She understood that without debridement the wound will not heal. Since there were no notes prior to 5/1/2017 regarding the ankle wound, she did not know how the wound care physician knew to address this wound. She stated that she would research the record to see if she could find answers to these issues. On 5/19/2017 at 2:00 PM Administration B, Director of Nursing stated that she was unsuccessful in researching the wound on Resident #23's ankle, and that she had nowhere else to look. Administration was informed of the finding of harm for Resident #23 on 5/19/2017 at 5:30 PM. 2. For Resident # 4, the facility staff failed to assess pressure areas (measurements and descriptions) on the buttocks and scrotum upon discovery and prior to admission to the hospital on [DATE], and failed to provide physician ordered Prevalon Boots for the prevention of pressure ulcers. Resident # 4, a [AGE] year old male, was originally admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Resident #4's most recent Minimum Data Set assessment was an annual assessment with an assessment reference date of 4/1/2017. Resident # 4 had a Brief Interview of Mental Status score of 00 indicating severe cognitive impairment. He required extensive to total assistance of one staff person with Activities of Daily Living except required total assistance of two staff persons for transfers. He was coded as always incontinent of bowel and bladder. The M Section was coded as high risk for pressure ulcers and coded as no open areas. There was no MDS done on readmission to the facility on [DATE]. On 5/16/2017 at 12:30 PM, an initial tour of the facility was conducted. A woman told the surveyor that she was there to visit her husband. The woman consented to an interview. During the family interview, she stated her husband had just returned to the facility the previous week after being hospitalized for [REDACTED]. The wife stated she knew he had two pressure areas but found out from the hospital staff that there were more. On 5/16/2017 at 3 PM, review of the clinical record was conducted. On 5/17/17 at 10:00 AM, Resident # 4's wound tracking was reviewed with the Unit Manager RN A (Registered Nurse A) who stated Resident # 4's wounds were looking better. RN A stated the area on the right shin had healed and the other areas looked better. On 5/17/2017 at 10:40 PM, observed Resident # 4 lying in bed, heels were not floated and resting on pillows. The DCS (Director of Clinical Services) and Unit Manager were informed that the surveyor wanted to observe the skin of Resident # 4. CNA (Certified Nursing Assistant) M was observed in Resident # 4's room, straightening his bed linens. On 5/17/17 at 11:10 AM., Resident # 4 was observed lying in bed, turned on right side. Resident # 4 allowed two surveyors along with the Wound Care Nurse (LPN B), Director of Clinical Services and Unit Manager (RN A) to observe the wounds. Resident # 4's heels were not floated, rested on pillows. His toe nails were observed to be long and uncut. Observation of the skin and documented wounds revealed: The area on the right shin was healed. The Unit Manager measured the wounds during the observation: The Left ankle measured 1.8 cm x 1.8 cm -100 % Dark Eschar surrounded by reddened peri-wound. Inside Left Heel (right lateral area) -1.0 cm x 1.8 cm, darkened in color Left Posterior heel -Fluid Filled Blood Blister- measured 4.0 cm x 3.2 cm fluid filled blister Sacrum-8 cm x 6.6 cm -with dark Eschar, had some bleeding, raw area from dressing adhesive On 5/17/2017 at 12:30 PM, DCS stated her expectation was that the staff would notify the doctor, get treatment orders, notify the responsible party, and the MDS (Minimum Data Set) Coordinator would update the care plan. DCS stated the treatment nurse was new and being trained but eventually would be able to update the care plan regarding episodic changes. 12:40 PM-DCS stated Resident # 4's heels were not floated during the wound observation but were on pillows. DCS stated she did show the CNA (CNA M) how to float heels appropriately. DCS stated she believed it was effective to inservice staff was on the spot when care issues were noted. On 5/17/17 at 1:35 PM, an interview was conducted with the wound care nurse, Licensed Practical Nurse B (LPN B). LPN B explained that she was still in training and had only worked at the facility for 2 weeks. LPN B stated that Resident #4 was receiving treatments for open areas. LPN B was asked how she staged the wounds. LPN B stated she attended Weekly Wound rounds with the Wound Care doctor and Director of Clinical Services and was learning how to stage wounds and document properly about wounds. On 5/17/2017 at 3 PM, Resident #4, was observed lying in bed on his right side. No boots or protective foot coverings were present, other than the dressing that was in place. On 5/17/2017 at 3:25 PM, the DCS stated Resident # 4 did not have a special mattress. DCS stated all of the mattresses in the facility are pressure reducing mattresses. She further stated she was going to get an order to get a specialty mattress for Resident # 4. On 5/18/17 at 8:50 AM, Resident # 4 was observed lying in bed, no boots observed, heels were not floated. The Certified Nursing Assistant (CNA) M had just finished feeding breakfast to Resident # 4. The Weekly Skin Integrity Review sheets were reviewed. Documentation revealed a skin check was performed on 4/26/2017. Areas to the left buttock and left ankle were indicated. The left buttock was documented as skin tear and open area. An area on the left ankle was documented as a skin tear. No measurements were documented. The next Weekly Skin Integrity Review sheet was dated 5/8/2017 with open area and five sites marked on the anatomical drawings indicated the left heel, sacrum, two areas near the left ankle and right shin. The Weekly Skin Integrity Review sheet dated 5/15/2017 showed the skin condition as open area and the same five sites were indicated. There was no staging or measurements. Review of the Admission/Readmission Data Collection sheet dated 5/8/3017 at 3:30 PM revealed documentation of skin condition on Section M SKIN as five areas: # 1- heel-deep tissue injury # 2-abrasion to right shin, # 3-plantar left foot (no description) # 4-left posterior leg below buttocks-pressure area # 5-sacral wound-pressure area Under Admission Nurse's Notes on 5/8/2017 was documented that Resident # 4 had skin areas to (L) (left) plantar foot, (L) (left) ankle, (R) (right) shin, sacrum wound and (L) (left) posterior leg just under buttocks. The note also stated dressings were in tact for further observation by wound nurse. Nursing notes from 4/19/2017 to 5/16/2017 were reviewed. Nurse's note dated 4/26/2017 7-3 documented that the 11-7 shift Certified Nursing Assistant observed open skin on Resident # 4's buttocks. Nurse wrote was told to use [MEDICATION NAME] cream to Resident buttocks for Incontinent episodes. There was no description of the open area on the buttocks. 4/27/2017 8:45 AM- RP (Responsible Party) and MD (Medical Doctor) aware of left ankle skin tear. TX (treatment) put in place. [MEDICATION NAME] to Left ankle-cleanse with Normal Saline, pat dry, apply [MEDICATION NAME], cover with dry sterile dressing till healed. 4/28/2017 # PM-Responsible Party called to check on resident. She was notified treatment in place and completed on this shift. Resident turned and repositioned will (sic) in bed. 4/29/2017 7-3-Resident has open area on right shin of leg from blister popping and open area on scrotum. TX in process, RP and MD aware. 4/30/2017 3-11- Resident continues to have open area to right shin TX noted to open area on scrotum . There was no description of the open area on the scrotum. Review of documentation in the Nurse's notes revealed no documentation of the stages or measurements of the skin conditions indicated. An SBAR (Situation, Background, Appearance, Review and Notify) Communication Form dated 4/26/2017 revealed documentation of a skin tear, red open area r/t (related to) the wanderguard on the left ankle. Orders were obtained to remove the Wanderguard and apply [MEDICATION NAME] Ointment every day until healed. SBAR dated 4/29/2017 documented an open area on the right shin of left and open area on the scrotum. Treatment in progress. SBAR dated 5/1/2017 at 1:50 PM documented Resident # 4 was lethargic and unresponsive. He was admitted to the hospital on [DATE]. Review of the Physician's Orders revealed orders: 4/26/2017 at 1503 (3:03 PM) Cleanse with Normal Saline, pat dry and apply [MEDICATION NAME] ointment. 4/26/2017 at 2100 (9:00 PM) [MEDICATION NAME] to left ankle-Cleanse with normal saline/pat dry. Apply [MEDICATION NAME] cover with dry sterile dressing til healed. 4/29/2017 at 1400 (2:00 PM) TX-Cleanse right leg shin with Normal Saline, pat dry and apply [MEDICATION NAME] TX-Wash scrotum with warm soapy water, pat dry and apply zinc and dry dressing. The next order was written on 5/1/2017 at 1:45 PM to send to hospital for further evaluation. On another page of Physician's Telephone Orders was documented two orders: 4/30/2017 at 8 AM: 1) Cleanse sacrum wound with NS (Normal Saline), pat dry, apply Alginate and cover with 4 x 4 , tape or border gauze QD (every day) 2) Right and Left Ischium- Cleanse with NS, pat dry, apply alginate and cover with 2 x 2, tape or border gauze QD. 3) Scrotum cleanse with warm soap and water, pat dry, apply alginate, 2 x 2, cover with tape at border gauze QD and PRN (as needed) There was no documentation of open areas on the right and left Ischium on Resident # 4. 5/1/2017 at 1425 (2:25 PM) Order Clarification- TX-Cleanse right leg shin with NS, pat dry and apply [MEDICATION NAME], cover with dry dressing and xeroform dressing QD TX-Wash scrotum with warm soapy water, pat dry and apply zinc and dry dressing QD There was no documentation in the Nurse's notes of the above two orders. Also, the clarification order written on 5/1/2017 at 2:25 PM was written after Resident # 4 was transferred to the hospital on [DATE] at 2:00 PM for evaluation of being lethargic and unresponsive. There was no documentation of skin assessment prior to discharge to the hospital. On 5/17/2017 at 4:20 PM, an interview was conducted with the Director of Clinical Services (DCS) who stated she made rounds with the wound care doctor weekly along with the wound care nurse. The DCS stated the Wound Care Nurse was a Licensed Practical Nurse who had been employed at the facility approximately two weeks at the time of survey. The Director of Clinical Services (DCS) stated she had been employed at the facility for about 3 months and had identified a concern about pressure ulcers. The DCS stated she developed a POC (Plan of Correction) on 4/24/2017. The DCS presented a copy of the POC written on 4/24/2017 which revealed: To Prevent and Heal Pressure Ulcers 1. Facility staff failed to perform weekly documentation and measurements on residents with pressure ulcers. 2. 100% skin sweep to be conducted to identify residents with pressure ulcers/skin break down if observed Braden scales will be updated, residents will be assessed for appropriate mattress, wheel chair cushion and nutritional intervention. 3. Treatment nurse will be educated on weekly documentation 4. DCS /designee will conduct rounds weekly with treatment nurse and wound physician. 5. Findings will be reviews at monthly QAPI (Quality Assurance Performance Improvement) After reviewing the 4/24/2017 POC, the surveyor asked on what date was considered the Allegation of Compliance. The DCS stated the date was on going. The DCS was informed that the POC did not follow the 5 requirements of a POC and that pressure ulcers were discovered on Resident # 4 after the date of the clean sweep of all residents, which should have been identified. The DCS stated the nurses did observe pressure ulcers on Resident # 4 prior to his hospitalization but did not document observation of 5 areas. Review of the Care Plan was revised by facility MDS staff on 5/15/2017 and 5/17/2017. The Skin/wound care plan read The resident has impaired skin integrity. The following skin issues were documented: Pressure Ulcer to Sacrum, right shin and scrotum-non pressure. Date initiated 7/13/2016 and revision 5/17/2017. Approaches & Interventions included 4/29/17-Treatment to right shin and scrotum. 4/28/17-TX as ordered to sacral area 4/30/17-TX as ordered to sacral wound, right and left Ischium, scrotum 5/1/17-4/28/17-TX as ordered to scrotum & right shin Date initiated: 9/2/2016 Revision 5/15/2017 Administer treatments as ordered and monitor for effectiveness. Date initiated 7/13/2016 Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Placement of adaptive devices (specify-pressure relieving/reducing mattress, w/c (wheelchair) cushion, back leg rest to w/c (wheelchair) Date initiated 7/13/2016 Notify nurse of any new areas of skin breakdown: Redness, Blisters, and Bruises, discoloration noted during bath or daily care Date initiated 7/13/2016 Approaches documented as revised on 5/17/2017 (during survey) included: Weekly Skin Checks Therapy screens PRN (as needed) RD (Registered Dietitian) consult PRN Float Heels Administer supplements as ordered Monitor for pain during treatment. Treat pain as per orders prior to treatment to ensure the resident's comfort Moisturize skin Monitor changes in skin status; appearance, color, wound healing, signs and symptoms of infection, wound size and or stage Monitor dressing (FREQ) (frequency) to ensure it is intact and adhering. Report loose dressing to nurse. Monitor for and report any new skin impairment noted during care Notify Physician for change in condition Review of timeline presented by DCS stated: 4/26/2017-11-7 night nurse observed open area on resident buttocks, RP/MD aware calamazine cream applied 4/26/17-Unit Manager assessed area noted on sacrum not buttocks, RP/MD made aware new orders obtained cleanse open area on sacral with normal saline (clarification order) 4/27/17-Skin tear on left ankle observed from wanderguard, RP/MD notified new orders obtained to cleanse with normal saline, pat dry apply [MEDICATION NAME] cover with dry dsg (dressing) until healed (RP requested wanderguard be removed) 4/29/17-Resident noted with open area on right shin from blister popping and open area on scrotum RP/MD notified new treatment orders obtained 5/1/17-1400 resident transferred to ______(hospital) for evaluation 5/8/17-resident returned to facility with new 1/ Unstageable area to his left ankle (prior to discharge noted to be a skin tear from wonder guard by staff) 2. Unstageable pressure ulcer to sacrum (prior to discharge superficial using [MEDICATION NAME] and calamazine for incontinence), 3. Left heel DTI (new on admission), 4. 2 scabbed areas on his right shin (prior to discharge one area noted blister popped), The surveyor asked the DCS to provide documentation of the staging of the wounds prior to Resident # 4 being admitted into the hospital on [DATE]. The DCS stated the wounds to the right shin and scrotum were observed on 4/29/2017 which was a Saturday and that the DCS and Wound Care nurse did not get a chance to inspect the wounds prior to his being discharged from the facility on Monday, 5/1/2017. The DCS stated that normally she would inspect any new wounds along with the wound care nurse upon her return to the facility on the Monday after the weekend. She stated then the resident would be added to the list for the wound care doctor to see on his routine visits on Thursdays. DCS also stated there was no description of the open area on the shin or scrotum and that the nurses did not document the stage or description of the open area on the sacrum or left ankle. The DCS stated there were no measurements or staging of any of the open areas. Clinical record review revealed re-admission physician's orders dated 5/8/2017 which included: Prevalon Boots while in bed: remove for hygiene and skin checks. turn and reposition frequently each shift, pressure reducing mattress to bed, moisture barrier apply every shift and as needed, pressure reducing cushion to wheel chair and check placement every shift, and a multivitamin for supplement. Resident # 4 was not observed to be wearing Prevalon boots during any of the observations throughout the 4 days of survey. There was no mention in the care plan of protective measures for the heels, such as Prevalon heel boots. The last revision to the care plan was made on 5/17/2017 (during survey). Facility policies and procedures were reviewed. Review of the Policies and Procedures Subject: Pressure Injury Record: Effective Date: 11/30/2016, Revision Date 4/1/2017 Policy: To document the presence of skin impairment/new skin impairment related to pressure when first observed and weekly thereafter until the site is resolved. One site will be recorded per page. Under Procedure was written: Residents will have a Pressure Injury Record completed for each skin impairment that is related to pressure. 2. Mark the pressure area on the body description identifying the site. 3. Enter the date. 4. Enter the stage of the pressure injury 5. Enter the size of the pressure injury-length x width x depth in centimeters 6. Enter the tissue type and color 7. Enter the wound edges and drainage 8. Enter the peri-wound information. 9. Licensed nurse to sign the appropriate area Review of the Facility policy Clinical Guideline-Skin & Wound Dated 4/1/2017 stated under Process: Licensed Nurse to complete skin evaluation weekly and prior to transfer/discharge and document in the medical record. and Document individualized goals and interventions and document on the care plan . The DCS stated the facility staff did not follow the facility policy and procedure and document all of the information about wounds to include the stage of the pressure wounds, size of the pressure injury, tissue type or color. She stated she identified problems with documentation of pressure wounds and had addressed the problems. She stated the process was on going. She further stated that the facility's newly hired Wound Care nurse had submitted her resignation, so the facility was looking for another Wound Care nurse. During the end of day debriefing on 5/18/2017, the Administrator and DCS were informed of the failure of the staff to assess pressure areas. The facility staff documented observation of an open area on the buttocks on 4/26/2017. There was no description of the open area, no staging and no measurements. The facility staff documented an open area on shin of right leg from blister popping and open area on scrotum on 4/29/2017. There were no measurements of the areas noted. Resident # 4 and did not provide the Prevalon boots as ordered by the physician. No further information was provided. 3. Resident #13 did not have his heels floated and was repositioned in a manner to cause shearing of the skin. Resident #13 was originally admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #13's most recent MDS (Minimum Data Set Assessment) was a quarterly with an ARD (Assessment Reference Date) of 5/1/17. The MDS assessment coded Resident #13 as having severe cognitive impairment in daily decision making. Resident #13 was coded as requiring extensive to total assistance with bed mobility and all other activities of daily living such as eating and toileting. The resident was coded with a stage 4 pressure wound, measuring 8.7 cm (centimeters) by 2.8 cm with slough. Guidance provided at www.NPUAP.com defined a stage 4 as Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. On 5/16/17 at 3:10 PM, Resident #13 was observed in bed, both heels were on the pillow, not floated, flat on pillow. 5/17/17 at 9:25 AM, Resident #13 was in bed, responded to questions. Oxygen at 2 liters per minute via nasal cannula. Heels flat against the pillow, not floated. He was on a low air loss mattress. On 5/17/17 at 9:35 AM, wound care was observed. Heels remained flat on the pillow. The DON (director of nursing) who was performing wound care stated, Heels need to be positioned better. Wound care was not completed as the resident began to show signs of pain. On 5/17/17 at 12:55 PM, CNA (certified nursing assistant) A was observed using the draw sheet (incontinence pad) to reposition the resident by herself. She jerked on the draw sheet, dragging the resident across the bed. On 5/17/17 at 1:35 PM, the DON stated, Anyone who does not ambulate should have their heels floated. On 5/18/17 at 10:45 AM, prior to wound care being performed, CNA (A) attempted to reposition the resident by grasping the incontinent pad (used as a turn sheet). The DON stopped the CNA and stated, Let me help you. The abrasion on the left hip was healed. The sacrum was a full thickness wound with bone visible. There was scattered areas of slough. The wound care was done according to the order. On 5/11/17, the wound care clinic documented a shear wound on the left buttock, measuring 1 cm by 1 cm. The sacrum was described as an unable to stage, measuring 6 centimeters (cm) by 6.7 cm with a depth of 2.5 cm. Review of the current physician order sheet dated 5/16/16 included the following: Keep bilateral heels float (sic) at all times. Review of the clinical record revealed the resident acquired a stage 2 blister to the left heel. Review of the care plan dated 5/1/17 contained the following interventions for impaired skin integrity impairment included: air mattress, treatment as ordered to bilateral heels, weekly skin checks. No mention was made of floating heels. On 5/19/17 at approximately 3:00 PM, the Administrator and DON were notified of above findings. No further information was provided. 4. For Resident #14, the facility staff failed to apply physician ordered Skin Prep to bilateral heel wounds. Resident #14 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #14's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 11/19/16 coded Resident #14 as having a Brief Interview of Mental Status score of 2, indicating severely impaired cognition. On 5/17/17 at 9:45 A.M. Resident #14 was observed eating his breakfast in the dining room on the locked unit. He had consumed about 90% of his meal. He was clean, and dressed appropriately. He wore socks and enclosed bedroom slippers on his feet. He did not exhibit any inappropriate behaviors toward the two other male residents at his table. On 5/18/17 at 1:00 P.M. Resident #14 was observed eating lunch, which consisted of spaghetti and chopped vegetables. He wore socks and enclosed bedroom slippers on his feet. He did not interact with other nearby residents. On 5/17/17 a review was conducted of Resident #14's clinical record. There were physician orders for the following treatments that were not documented on the Medication Administration Record (MAR), or in the Nursing Progress Notes as having been administered: * Apply Skin Prep to bilateral heels each shift. Missing treatment: 4/18/17 (7 - 3 shift); 4/21/17 (7 - 3 shift, and 3 - 11 shift) Resident #14's clinical record contained a nursing assessment that read, bilat (bilateral - both) deep tissue injury to heels, signed by LPN K. She also wrote a Nursing Progress Note that read, Resident observed to have bilat heel deep tissue injuries, zero pain or discomfort noted, proper footwear in use, skin intact. N.O. (new order) apply Skin Prep to bilateral heels q (every) shift. Left message for R.P. (responsible party) to return call. MD (medical doctor) notified. On 5/17/17 at approximately 6:00 P.M. an interview was conducted with the Assistant Director of Nursing (ADON-Administration C) in the conference room. When asked about the importance of correct wound staging and identification, the ADON stated, She should have described it. She's supposed to say what she saw because she is not supposed to stage it. The color and size are missing, bleeding, drainage are all missing. The importance of using Skin Prep is so that the wound won't open and get worse. On 5/17/17 a review of facility documentation was conducted, revealing a Skin and Wound Policy dated 4/1/17. It read, To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of / prevention of pressure injury. Monitor residents' response to treatment and modify treatment as indicated. Evaluated the effectiveness of interventions, and progress towards goals during the care management meeting and as needed. On 5/17/17 at 6:10 P.M. the facility Administrator (Administration A), and Director of Nursing (DON-Administration B) were notified of the findings. The DON stated that she didn't know why the wound care had not been done. No further information was received.

Based on staff interview, facility documentation review, clinical record review and in the course of a complaint investigation, the facility staff failed to provide a safe environment for two residents (Resident # 26 and #5) resulting in harm for Resident # 26 in a survey sample of 32 residents. 1. For Resident # 26, the facility staff failed to provide adequate supervision to prevent falls with injuries resulting in harm. On 6/12/2016, Resident # 26 had an injury of unknown origin, fractured right clavicle. On 6/13/2016, she fell , was sent to the emergency room for evaluation, diagnosed with [REDACTED].# 26 sustained two falls, at 5:40 AM, she sustained a laceration to the head which required staples and 8/2/2016 at 6:50 PM, she sustained a laceration to the nose and hematoma to the forehead. On 11/26/2016, she had a fractured right ankle, injury of unknown origin and on 11/30/2016 she had a fractured left ankle, injury of unknown origin. 2. Resident #5 had a history of [REDACTED]. Findings included: Resident # 26, an [AGE] year old female, was admitted to the facility 3/2/2010 and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident # 26 resided on the 30 bed Secured Unit. Resident # 26 was discharged from the facility on 11/30/2016 and did not return to the facility. Resident #26's most recent MDS (minimum data set) with an ARD (assessment reference date) of 11/26/2016 was coded as a Significant Change Assessment. She was coded as having a Brief Interview of Mental Status (BIMS) score of 2 indicating severe cognitive impairment. Coded as having short and long term memory deficits and required total assistance with making daily life decisions. Resident # 26 was coded as needing limited to extensive assistance of one staff person with her activities of daily living except for bathing for which she required total assistance of one staff person. She required extensive assistance of one staff person for ambulation, toileting and transfers. She was coded as frequently incontinent of bowel and bladder. The previous MDS with an ARD of 9/30/16 was coded as a Quarterly Assessment. Resident # 26 was coded as having a BIMS score of 2 indicating severe cognitive impairment. She was coded as requiring supervision of one staff person for all Activities of Daily Living including ambulation, toileting and transfers except for bathing for which she required total assistance of one person. She was coded as occasionally incontinent of bowel and bladder. Review of Resident #26's closed clinical record revealed she had fallen on the following dates from May 2016 until November 2016: 5/24/16 found on floor, no injury, Had on big shoes, found on floor in front of closet with drawer open. SBAR (Situation, Background, Appearance, Review and Notify) Communication form unwitnessed fall Care plan intervention added:5/24/16 Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair,5/24/16 Velcro shoes and Neuro checks Incident Report: 6/4/16 at 6:34 AM found sitting on floor no injuries, urine observed next to her on floor SBAR- Unwitnessed fall-Keep environment clean and clear Care Plan- Maintain a clutter free/spill free environment, rehab referral 6/4/16 at 4:00 PM Resident got out of chair, leaned against the table, the table moved and resident fell on the floor on her buttocks, SBAR- Witnessed fall- Maintenance to evaluate furniture (table) Care Plan- Maintenance department referral for equipment, furniture evaluation 6/12/16 10 AM Bruise noted on right Shoulder, Resident would not lift right arm PRN (as needed) Tylenol 325 milligrams two tablets given by mouth at 11 AM and again at 4:15 PM - X-ray obtained at 11:30 AM, X Ray revealed right acute clavicle fracture, Sent to hospital. Returned on 6/13/16 at 1:15 AM. MD (Medical Doctor) and RP (Responsible Party) notified Bruise Checklist completed, SBAR- Unwitnessed Incident, no changes in condition, Environment continues to be kept clean and clear Incident Report and Witness Statements. Hospital Discharge Summary: 6/12/2016 11:43 PM, clavicle fracture right, You should follow up with Primary Care physician in 2 days, Additional Notes:Discharge Plan: distal right clavicle fracture noted. Shoulder immobilizer placed. No other imaging studies was done. The clavicle fracture does not warrant surgical repair. It will heal by itself. Keep shoulder immobilizer on for comfort . FRI Injury of unknown origin was submitted to the State Agency. Completed timely 6/13/16, final report 6/15/16. Care Plan-no new interventions listed 6/13/16 at 11:30 AM Pt stood up out of her seat and fell . Nurse noticed bruise on forehead prior to fall. Resident displayed being fatigued after fall and was sent to the hospital. Discharge summary diagnosed minor head injury. SBAR-Unsteady Gait Skin evaluation: Bruise on right clavicle area, bruise forehead. Appearance: Resident observed/appearing lethargic, unsteady gait. Review and Notify: Resident sent to hospital with necessary paperwork, Bed hold policy sent, RP/MD notified, 24 hour report in place. Incident Report:6/13/2016 3:54 PM, you should follow up with Primary Care Physician tomorrow. Care Plan: Revision on 6/14/2016-Sent to ER, medication reviews and labs 6/22/16 at 6:45 PM Reached for handrail during ambulation and lost balance, lowered to floor by staff, no injuries No documentation of an incident report. No fall assessment completed. 6/22/16 at 11:45 PM Resident found sitting on floor in her room in front of her bed. Found during routine room checks at change of shift by care nurses at 11 PM No documentation of an incident report, no fall assessment completed Physician orders [REDACTED]. Care Plan: vision consult, 6/29/16 Ortho (Orthopedics) consult, Revision on 6/30/2016 8/2/16 at 5:40 AM Resident found on floor on right side of bed in sitting position by (CNA) Certified Nursing Assistant. Laceration to posterior head. Staff attempted ice and pressure but refused Sent to ER . Resident returned from hospital 8/2/16 at 1:05 PM, Resident left in bed with call bell in reach Hospital Discharge Summary: 8/2/16 11:17 AM, Wound care, scalp laceration. You should follow up with your primary care physician in 7 days. Additional notes: STAPLES SHOULD BE REMOVED IN 7 DAYS Care Plan: 8/2/16 Treatment as ordered, keep insight of staff at all times. ER (emergency room ) Eval (Evaluation), Neuro checks, rehab referral, offer toileting Incident Report:completed. Recommendation-non skid socks when out of bed. The Fall Risk Evaluation dated 8/2/2016 was scored as 18, a total score of 10 or above deemed the resident at risk. 8/2/16 at 6:50 PM- Nurse observed resident lying on the floor on left side of sink with a wet washcloth in hand and wet floor. Laceration to bridge of nose and hematoma to front of forehead. Sent to ER for evaluation. Every 15 minute Neuro checks in place, Fall prevention in place. Resident returned from hospital 8/2/16 at 10:45 PM, Refused vs (vital signs) remain in bed with call light in place. 15 min Neuro check in place, fall prevention in place. Denies pain at this time. Hospital Discharge Summary:8/2/106 9:43 PM-Clavicle fracture, head injury, facial and scalp contusions, wound care -laceration, You should follow up with physician in 2 days. Follow up notes: on 8/2/2016, this patient was treated at ___hospital. for Refer to Discharge Instruction List, Additional notes: return to ER for worsening or changes. Clavicle fracture on right likely subacute. Care Plan: 8/2/16 Treatment as ordered, keep insight of staff at all times. ER (emergency room ) Eval (Evaluation), Neuro checks, rehab referral, offer toileting Incident Report: completed Review of the Incident Report dated 8/2/2016 revealed A Possible Fall Interventions form that listed interventions numbered a through LL from which staff could circle those which applied to the Resident. 8/2/16 6:50 PM- interventions circled were: (y) Location of resident's room, (bb) Activity department to set up routine activity programs at times of greatest needs and (hh) Keep resident in area where staff can monitor. There was no documentation to show Resident # 26 was kept in sight of staff at all times as written on 8/2/2016. 11/26/16 right ankle swollen, sent to hospital, X-ray revealed Right fractured ankle, cast applied and pain medication ordered, SBAR-Skin evaluation: swollen right ankle warm to touch purplish bruise, Review and notify: MD notified, X-ray, transfer to hospital, emergency medical transport Hospital Discharge Summary:11/26/2016 8:47 PM, Fractured ankle, you should follow up with Orthopedic Surgery Physician in 2 days. Care Plan: 11/26/16 ER Eval and 15 min safety checks 11/30/16 two blisters noted on left lower left extremity, Q 15 min checks, SBAR 11/30/16 2:11 PM -Skin evaluation: two blisters red in color on left lower extremity, Review and notify: MD notified, X-ray ordered SBAR 11/30/16 8:45 PM-Situation: Left Ankle Fracture, Skin evaluation: blister, Pain evaluation:new pain located on left and right ankle, Resident showing non verbal signs of pain: grimacing, tearful, Review and notify: MD notified, recommendations sent to hospital. Nursing notes: left ankle remains bruised/swollen, 2 blisters noted to anterior lower left extremity, signs and symptoms of pain, medicated at 8:30 Norco 5/325 milligrams accepted Care plan: No changes were made. Resident # 26 was admitted to the hospital and did not return to the facility. FRI submitted on 12/1/2016, Final report 12/2/16 physician's orders [REDACTED].>11/29/16 at 5 PM Physicians Order to (1) Monitor soft cast to right lower leg (2) Monitor capillary refill q shift (every shift) 11/30/16 at 8:45 AM-Physicians Order-X-ray to left lower leg and ankle. Review of the care plan revealed a Focus Problem initiated on 4/6/16 and revised on 6/23/16: The resident has the potential for injury related to AEB (As evidenced by), poor safety awareness, wandering , history of falls, epilepsy, osteoporosis, arthritis, cataract, Mental Retardation, cancer The Goal: The resident will not injure themselves in a fall through next review. Resident will not exit building unattended. Date initiated 4/6/2016, revision 12/8/2016 The interventions developed to prevent Resident #26 from falling or having an injury when she did fall included: 4/6/16-The resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night, handrails on walls, personal items within reach Follow facility fall protocol Keep needed items, water, etcetera in reach Medication as ordered Medication review Safety checks per facility protocol 5/24/16 Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair 5/24/16 Velcro shoes and Neuro checks 6/22/16 Toileting program 6/29/16 Vision consult 8/2/16 Treatment as ordered, keep insight of staff at all times. ER (emergency room ) Eval (Evaluation), Neuro checks, rehab referral, offer toileting 9/16/16 Room change 11/26/16 ER Eval and 15 min safety 11/30/16 Redirect behaviors. Ensure resident wears Velcro shoes Review of the care plan revealed no documentation of review and revision of the care plan after each fall. Review of the facility's policy entitled Falls Management Program included: 1. A Fall Risk Assessment will be completed upon admission, readmission, quarterly, and significant change of condition. 2. Incorporate identified intervention into the Comprehensive Care Plan as applicable. 3. Discuss fall risks and interventions with patient/RP with supporting documentation. 4. Review and re-evaluate initial fall risk assessment and Device Assessment during initial weekly fall meeting and the initial care plan meeting after admission. 5. Refer the patient to PT/OT for screening, evaluation, and treatment as indicated. 6. Consult Maintenance personnel for any necessary adaptation (i.e. wheelchair height adjustment, handrail placement, lighting, etc.) Further review of the policy included the following guidance after Resident #26 experienced a fall: 1. Complete the Post Fall Assessment to determine, to the extent possible the cause of a patient fall. 2. A licensed nurse, using the Incident Report and the Post Fall Assessment will: Investigate the fall, and Record findings surrounding the fall. 3. A licensed nurse will review, revise, and implement interventions to the care plan based on Post Fall Assessment findings Review of Device Assessment Review of Fall Risk Assessment. Post fall assessments were not completed for the falls on 6/22/16 at 11 PM or 6/22/16 at 6:45 PM. There were no fall assessments regarding the injuries noted on 11/26/2016 (right fractured ankle) and 11/30/2016 (left fractured ankle). They were injuries of unknown origin. Falls Committee Effective Date: 11/30/2014 was not revised since 2014. 1. The Falls Committee Meeting will meet weekly. 2. The Director of Clinical Services is the chairperson. 3. Subject: a. Residents who have had a fall in last 60 days. b. New residents who have fallen since last meeting. c. Appropriateness of intervention and care plan. d. Reduction of Psychotropic medications e. Least restrictive restraints. Plan of Care: Utilize fall prevention POC (Plan of Care) Individualize interventions Review and revise interventions Fall: Assess for injury and treat Notify Dr. and family Complete Incident Report Chart- 24 hour report and Medical Record Investigate to determine cause Staff meeting to determine cause Complete Fall Response Action Plan Establish Interventions on POC after each fall Implement interventions on POC after each fall Daily Falls meeting Weekly falls meeting Supervisor to review investigation and verify all steps followed . The facility did not have individualized prevention interventions added to the plan of care for Resident # 26 after each fall. Facility Fall Risk Policy dated 11/30/2014 (had not been revised since 2014) stated the policy : to identify risk factors which place the resident at risk for falls and to facilitate the development of interventions to minimize or prevents falls to the extent possible, resident will have a fall risk evaluation completed on admission/readmission and quarterly. Under Procedure was listed Residents identified at risk for falls will have individualized prevention interventions added to the resident's plan of care. Initiate appropriate intervention to reduce risk. Document identified risk and intervention (s) in the resident's plan of care. The facility did not have individualized prevention interventions added to the plan of care for Resident # 26 after each fall. Facility Policy on Resident Safety Checks dated 11/30/2014 was not revised since 2014, stated Procedure: Initiate Resident Safety Check form with intervals designated by physician or Clinical Nurse noting reason for form Check resident at required intervals Initial from indicating check was completed Form is filed in Medical Record. Review of the clinical record revealed the only Safety Check form filed in the medical record was dated 11/29/2016 through 11/30/2016. Review of the Change of Condition Medication Regimen Review Reports revealed two reports which addressed falls: 6/15/16-Comment: Resident # 26 noted to be experiencing new onset or worsening of falls, dizziness or impaired coordination as indicated on a change of condition medication regimen review request completed by the facility. Also stated Resident # 26 was also reported to be experiencing bruising whether related to falls , however is not known to me at this time. The Phenytoin and Valproic Acid (both for seizures) serum levels were noted to be below what is considered therapeutic levels. Oxycodone was being used only as needed and was started after falls were reported. Under Recommendation: At this time, falls and bruising do not appear to be medication related. 8/4/16-Phenytoin level was therapeutic at 16 on 8/1/16 and last VPA (Valproic Acid) level was low at 33 as indicated for seizures. Recommendation: The resident's medication regimen contained no new irregularities that could reasonable be expected to have contributed to the change in the resident's condition. A consult with the Orthopedic Specialist on 7/5/16 reported: Diagnosis: [REDACTED]. Recommendations: Advance Activity as tolerated. follow up as needed. On 5/18/2017 at 11:05 AM, an interview was conducted the Administrator -Executive Director (Admin A) who stated that he would provide copies of the fall investigations and incident reports regarding Resident # 26's falls from June 2016 - November 2016. On 5/18/2017 at 3 PM, an interview was conducted with the Director of Clinical Services (Admin B) who stated she was would review the clinical record for Resident # 26. Admin B stated she was not employed at the facility when Resident # 26 resided at the facility. Admin C stated she had been employed for 3 months at the time of the survey. Admin B stated she would have the Assistant Director of Clinical Services (Admin C) develop a timeline and synopsis of the falls from June 2016 through November 2016 for Resident # 26. Admin C was also not employed at the facility when Resident # 26 resided at the facility. Admin C had been employed two weeks at the time of survey. Admin B stated all falls that occur in the facility were reviewed weekly at the weekly falls committee meeting. Admin B stated interventions are developed within the committee meeting and implemented by the Unit Managers, including education of the direct care staff. The surveyor informed Admin C that the clinical record needed to be reviewed for all information regarding falls from June 2016-November 2016. On 5/19/17 at 11:45 AM., an interview was conducted with the Assistant Director of Clinical Services (Admin C) stated a post fall assessment should be completed after every fall Resident # 26 experienced. Admin C presented Resident # 26's fall risk assessment. The assessment was a compilation of fall risk factors and was utilized to care plan needed interventions. Admin C stated Resident #26 had been identified as being at risk for falls. The Fall Risk Evaluation dated 8/2/2017 was scored as 18, a total score of 10 or above deemed the resident at risk. Admin C presented a list of all the falls documented in the clinical record. Admin C was unable to determine why a post fall assessment was not completed after each fall. Admin C stated the care plan had not been reviewed and revised after each fall and there was no documentation that staff followed all of the interventions written on the care plan. Admin C stated Resident # 26 experienced six falls in June 2016 (fractured clavicle on 6/12/16), twice on August 2, 2016 (laceration to head and laceration to nose and forehead; received staples in scalp) and had two injuries of unknown origin in November 2016 (fracture of right ankle discovered on 11/26/16 and fracture of left ankle discovered on 11/30/16.) Admin C stated the facility staff did not provide a safe environment for Resident # 26. On 5/19/2017 at approximately 4:15 PM, the administrator, Admin B, Admin C and corporate consultant were advised of the failure of the staff to provide adequate supervision to prevent falls with injuries resulting in harm for Resident # 26. No further information was provided. 2. Resident #5 had a history of [REDACTED]. Resident #5, a [AGE] year old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The most recent Minimum Data Set assessment was an initial assessment with an assessment reference date of 3/16/17. Resident #5 was coded with a Brief Interview of Mental Status score of 0 indicating severe cognitive impairment. She required extensive assistance with activities of daily living. The following nursing note dated 4/21/17, 1:15 p.m. was documented in the clinical record Resident was seen coming from another resident's room (319) drinking full bottle of sparkle fresh mouth wash, NP (nurse practitioner) for (doctor name) notified and was instructed to call the company hotline (phone number). 1:25 P- Call placed to (company name), spoke with (name)- representative instructed to give resident water. NP notified will write specific orders for water take. RP (responsible party)- (name) made aware N.O. (new order) to hold giving 8 oz (ounce) water QID (4 times per day) thru Monday & give H2O (water) 8 oz Fri, Sat & Sun re mouthwash ingestion. Call poison control if any adverse reaction. Resident changed for afternoon care, NO adverse reactions noted, taking po (by mouth) fluids, continue to monitor. Resident #5 had a history of [REDACTED]. On 3/25/17, the day after admittance to the facility, it was first documented in the the clinical record that Resident #5 attempted to eat non food items. The nursing note read 3/25/17, 3:20 p.m. Resident confused, made several attempts to eat non-food items. The following nursing notes were also included in the record: 3/27/17- Resident continues to wander in unit, eating off the floor 3/31/17- continues to wander on the unit and pick up items on the floor to eat them 4/14/17- continues to wander in unit, picking up items to put in mouth requiring constant redirection 4/17/17- continues to wander in unit picking up items from the floor to put in mouth 4/18/17- resident observed picking up paper trying to place in mouth easily redirected but will chew on clothes 4/18/17- continues to wander in unit picking up objects to put in mouth 4/20/17- continues to grab at others food and drinks and eat/drink others food 4/20/17- cont to wander in unit picking up objects to put in mouth A copy of the care plan was requested and provided on 5/16/17. This care plan did not include the [DIAGNOSES REDACTED]. The care plan did include the focus Potential for impaired or inappropriate behaviors to include resident eats stool at times. As documented in the above nursing notes, Resident #5 attempted to eat many different types of non-food items. She did not experience an adverse outcome from drinking the mouthwash. On 5/17/17 at 1:30 p.m., an interview was held with the Director of Nursing (DON). The incident with the mouthwash was reviewed. When asked if Resident #5 should have had access to mouthwash, the DON stated no. When asked if the facility staff knew how much mouth wash was ingested, the DON stated about 10 cubic centimeters. The DON was asked to provide any investigation or any follow up information regarding the incident. No further information was provided. The issue was reviewed with the Administrator and DON at the end of day meeting on 5/17/17.

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, the facility staff failed for 2 Residents (Residents #1, & #2) to ensure residents were free from significant medication errors, for the 32 residents in the survey sample, resulting in harm for Resident #1. 1. For Resident #1, the facility staff failed to administer (22) medications for 5 days, including blood pressure medications, insulin, and bowel medications, resulting in harm as the Resident was re-hospitalized 3 times for pain, psychological distress, nausea, vomiting, elevated blood pressure, elevated blood sugar and constipation. 2. For Resident #2, [MEDICATION NAME] was not administered per physician order. The findings included: 1. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1's most recent (MDS) Minimum Data Set with an assessment reference date (ARD) of 4-16-17 was coded as a quarterly assessment. The Resident was coded as having no cognitive impairment. Resident #1 was also coded as needing only supervision of set up help from staff to perform activities of daily living, such as dressing, transferring, bed mobility and hygiene. Review of the Resident's facility clinical record, and hospital records for the month of November 2016, revealed that the facility had to repeatedly send Resident #1 to the hospital for complaints of headache, constipation, abdominal pain, nausea, vomiting, and weakness. A chronological record of those hospitalization s, are as follows: On 11-1-16 the Resident was admitted to the hospital with [REDACTED]. The Resident was discharged from the hospital on 11-22-16 to the skilled nursing facility with new medications ordered by the hospital doctor. The ordered medications were to correct the hypertension, UTI, and constipation the Resident had been hospitalized for [REDACTED]. On 11-24-16, (2 days after readmission to the nursing facility), the Resident was again sent to the hospital emergency room for complaints of altered mental status, weakness, and constipation. The Resident was found to have a very high blood pressure (193/92 mmHg) MillimeterMercury; normal below 120/80) and was ordered by the hospital doctor to be given [MEDICATION NAME] 10 mg (milligrams) three times per day, added to the Resident's current ongoing daily drug list to correct the high blood pressure. The Resident's total number of current daily medications now stood at 24 on 11-24-16, and the Resident returned to the nursing facility the same day. On 11-25-16, (1 day later), the Resident was again sent out to the hospital emergency room , and found to be suffering from high blood pressure (164/115), and stated to the hospital nurse I just want to kill myself and get it over with., and while moaning and groaning Oh god please help me I can't take it anymore. The Resident was again sent back to the nursing facility with a [DIAGNOSES REDACTED]. On 11-26-16, (1 day later), the facility again sent the Resident to the hospital emergency room for complaints of hypertension, stomach pain, and feeling awful, nausea, vomiting, and abdominal pain. The Resident told the hospital doctor that the nursing facility had not been giving him his daily medications, and the hospital doctor documented such in the consultation report. The hospital doctor called the nursing facility and spoke with the nurse caring for Resident #1 (LPN L) to review the Resident's medication list. LPN L stated that the nurse who readmitted Resident #1 to the nursing facility, on 11-22-16, and 11-24-16 had missed a whole page of medication orders from the hospital for Resident #1, and that was why the Resident was only receiving 5 of the medications which had been ordered on 11-22-16, and 11-24-16. LPN L stated she would correct the error on 11-26-16. The social worker at the hospital became involved in the situation, and contacted Adult Protective Services (APS) on 11-26-16 to report neglect. The hospital physician documented that she was concerned about the Resident's kidneys, blood pressure, and bowel problems, born of the fact that the nursing facility was not administering the Resident's physician ordered medications, and creating repeated hospital visits. The hospital doctor also documented the stool burden may be compromising kidneys. The hospital team decided to not return the Resident to the nursing facility. They decided instead, to admit him to the hospital again to begin searching for safe placement, as the facility was not administering his medications. The hospital physician's documentation went on to say that she would not discharge the Resident back to the nursing facility due to unsafe conditions at SNF (skilled nursing facility), as the Resident had not had a bowel movement since his discharge from the hospital on 11-22-16, (5 days). The hospital doctor also documented that while in the facility the Resident had not been given any of his anti-hypertensive medications, nor was he on a scheduled bowel regimen (and medications for chronic problems). The doctor's progress note read that only five medications were being administered to the Resident in the nursing facility from 11-22-16 through 11-26-16, (5 days) were routine [MEDICATION NAME], and PRN (as needed, not routine) [MEDICATION NAME], and senna. It is also notable to mention that the Resident was an insulin dependent diabetic, and was also not receiving any insulin during this 5 day period. The Resident's blood glucose level was 183 mg/dl (milligrams per deciliter) upon admission to the hospital. Normal blood glucose is 80-130 mg/dl according to the American Diabetic Association. Valid physician orders [REDACTED]. These medications were documented as not having been administered for 5 days, from 11-22-16 through 11-26-16. 1. Pantoprazole 40 mg daily for stomach pain 2. [MEDICATION NAME] 10 mg daily for high blood pressure 3. Aspirin 81 mg daily for blood pressure 4. [MEDICATION NAME] suppositories 10 mg rectally every 12 hours for constipation 5. carvedilol 25 mg every 12 hours high blood pressure 6. [MEDICATION NAME] 10 mg twice daily for muscle spasm 7. [MEDICATION NAME] 100 mg two tablets twice daily for constipation 8. duloxetine 60 mg daily for depression 9. [MEDICATION NAME] 5 mg daily for prostate 10. [MEDICATION NAME] 600 mg three times per day for [MEDICAL CONDITION] 11. [MEDICATION NAME] 10 mg three times per day for blood pressure 12. insulin [MEDICATION NAME] 100 units/ml (milliliter) 10 units inj subcutaneously daily for diabetes 13. [MEDICATION NAME] topical 5% patches on for 12 hours joint pain 14. [MEDICATION NAME] 50 mg daily at bedtime depression 15. polyethylene [MEDICATION NAME] 3350 17 grams twice daily for constipation 16. senna 8.6 mg daily at bedtime for constipation 17. [MEDICATION NAME] 18 mcg (micro grams ) inhaled 1 cap daily for [MEDICAL CONDITION] 18. [MEDICATION NAME] 50 mg three times per day PRN (as needed) for break through pain 19. [MEDICATION NAME] 10/325mg (milligrams) four times daily PRN (as needed) for pain 20. guifenesin 600 mg every 6 hours (prn) for cough 21. [MEDICATION NAME] 100 mg every 12 hours antibiotic 22. [MEDICATION NAME] 4 mg every 6 hours PRN (as needed) nausea/vomiting On 5-17-17 the Director of Nursing (DON), and administrator were asked to allow an interview with LPN L. They stated that the employee was terminated in January 2017, shortly after the incident. Her employee record was reviewed, and revealed a termination date of 1-12-17. On 5-17-17 copies of the physician's orders [REDACTED]. On 5-18-17 at the end of day, the DON and Administrator delivered the October, and December 2016 POS, and MAR indicated [REDACTED]. The medical records staff, and nursing staff had searched the entire building for 2 days, and only this part of the clinical record was missing. The October 31, 2016 POS, revealed 16 medications ordered, including 2 kinds of injectable insulin for diabetes. The DON was asked why staff had not called the doctor to clarify orders when only 5 medications were ordered for November, and the insulin that the Resident had been taking was abruptly stopped. Her response was I don't know, they should have. The facility policy on medication administration stated Obtain, and verify physician's orders [REDACTED]. The Administrator and DON were made aware of these findings at a harm level, at the end of day debrief on 5-18-17, and 5-19-17. Harm occurred as the Resident was repeatedly hospitalized with symptoms related to the facility staff omission of the Residents needed, and ordered significant medications for 5 days. No further information was able to be provided by the facility. COMPLAINT DEFICIENCY 2. For Resident #2, [MEDICATION NAME] was not administered per physician order. Resident #2, a [AGE] year old, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 3/16/17. Resident #2 was coded with a Brief Interview of Mental Status score of 13 indicating no cognitive impairment. He required assistance with his activities of daily living. On 3/21/17, Resident #2 was evaluated by the Psychiatric- Mental Health Nurse Practitioner (PMHNP). The consult note read (Name), FNP (family nurse practitioner) asked to evaluate the necessity of [MEDICATION NAME]. The section MED listed all of Resident #2's current medications. The section read [MEDICATION NAME] 200 mg (milligram) QHS (at night) and [MEDICATION NAME] 50 mg QAM (every morning). At the time of the consult, according to the physician orders [REDACTED]. The PMHNP medication list included [MEDICATION NAME] 50 mg as being administered only once a day rather than twice a day. On 3/21/17, the PMHNP wrote an order to Taper [MEDICATION NAME] 100 mg (milligram) QHS (every night) for 2 weeks then stop. This order was transcribed on to a telephone order form which read 3/21/17 Taper [MEDICATION NAME] 100 mg (milligram) QHS (every evening) for 2 wks then STOP. D/C [MEDICATION NAME] 50 mg (milligram) QAM (every morning). It was signed by the prescribing PMHNP on 3/21/17. According to the March 2017 Medication Administration Record [REDACTED]. The [MEDICATION NAME] 100 mg was not started until 3/24/17, two days after it was supposed to be started. A nursing note written on 3/23/17 at 10 p.m. regarding the [MEDICATION NAME] taper read Resident currently in bed appears to be resting at this time, resident has new orders and per pharmacy the meds were sent out on the 10 am run, no meds in the cart so writer unable to administer new taper at this time writer called pharmacy & S/W (name) to advise that meds need to be resent per pharmacy a manifest will need to be supplied showing that it was not recvd (sic) or the facility will need to pay for the meds, left notification for unit manager. In addition to being started two days late (according to the April 2017 MAR) the 100 mg of [MEDICATION NAME] was not administered on 4/1-4/3/17. [MEDICATION NAME] 100 mg was not administered a total of five days out of the 14 day (2 week) taper. The Administrator and Director of Nursing were notified at the end of day meeting on 5/17/17 that the [MEDICATION NAME] was unavailable for two days and then not administered on three other occasions. The facility staff were asked to provide any additional information regarding the issue. No further information was provided.

Based on observation, staff interview, clinical record review, facility documentation review and in the course of a complaint investigation, the facility staff failed to perform services to prevent, identify, and appropriately treat pressure ulcers in three Residents (Residents' #2, #11 and #8) resulting in harm for one Resident (Resident #2) in the survey sample of 26 Residents. 1. For Resident #2, the facility staff failed to identify two pressure ulcers 1) on the Left Ischium found as a stage 3 on [DATE], and 2) a right hip pressure ulcer was found at Eschar and unstageable. The staff further failed to complete preventive weekly skin checks, every shift skin checks, and did not provide available treatment interventions (low air loss mattress, and ROHO cushion to wheel chair) until 3 weeks after identification. 2. For Resident #11, the facility staff failed to ensure treatment supplies were available for administration for pressure ulcer wound care and failed to ensure a physician's orders [REDACTED]. 3. For Resident #8, the facility staff failed to ensure prevalon boots were worn. The findings included: 1. Resident #2 was initially admitted to the facility on [DATE], and readmitted on [DATE]. [DIAGNOSES REDACTED]. Resident #2's most recent MDS (minimum data set) with an ARD (assessment reference date) of [DATE] was coded as a significant change assessment. This assessment was compared to the previous assessment which was also a significant change assessment with an ARD date of [DATE]. Resident #2 was coded as having a brief interview for mental status (BIMS) score of 11 of a possible 15 points revealing independence to modified independence in making daily life decisions. Resident #2 was his own responsible party. Resident #2 was also coded as requiring extensive assistance of one staff member to perform his activities of daily living. Resident #2 was coded on the [DATE] MDS in section M as being at risk for the development of pressure ulcers. Further coding in section M revealed many errors and are as follows; M0300B coded one pressure ulcer as stage 2, located on the right ischium found on [DATE]. M0300C coded one pressure ulcer as stage 3, located on the left ischium found on [DATE]. M0300F (1) coded one pressure ulcer as Unstageable, located on the right hip found on [DATE]. Which was the only pressure ulcer the Resident had during this time staged as an unstageable wound. M0300F (2) stated the unstageable ulcer was on admission/entry, or reentry, which is incorrect, it was not identified until [DATE], and the Resident had only one hospital visit during this time on [DATE], and returned the same day on [DATE]. The unstageable wound, was acquired in the facility 4 days after the single day hospital visit. M0700 coded the most severe tissue type for any pressure ulcer as a 3, however this entry was incorrect as the correct coding should have been 4 Eschar. M0800 coded the number of current pressure ulcers that were not present or were at a lesser stage on the prior assessment. The facility coded 0, which meant the ulcers would have been coded on the previous assessment. This was incorrect, as no pressure ulcers were coded on the previous assessment of [DATE]. M0900 (A) coded that pressure ulcers were coded on the previous [DATE] assessment, this was incorrect, as they were not. M0900 (B,C,and D) all coded 0 for any previous pressure ulcers at stages 2, 3, and 4. M coded 0 venous and arterial ulcers, even though the Resident had a right heel venous/arterial ulcer found [DATE], which was coded on the previous [DATE] assessment. The only three wounds Resident #2 had before [DATE], were located on the (1) Right ischium (under the buttocks) identified on [DATE] as a stage 2, on the (2) penis identified on [DATE] as a stage 2, and on the (3) right heel (long standing) and identified in 2014 with ongoing treatment These ulcers were present before going to the hospital, according to doctor's orders, nursing notes, and assessment and evaluation before being seen at the hospital on [DATE], and on readmission to the facility on [DATE]. The right ischium and penis wounds were healed by the time of wound care observation on [DATE]. The right heel vascular/arterial wound is healing and continues to be treated. The Left Ischium at stage three, and the right hip at unstageable were both identified first on [DATE]. Resident #2 had a history of [REDACTED]. The Resident also had a long standing Foley catheter for [MEDICAL CONDITION] due to [MEDICAL CONDITION]. Preventative skin measures ordered by the physician, and denoted on the most recent recapitulation of orders dated [DATE], and continued after the hospital evaluation on [DATE], were as follows; 1) Ordered [DATE] Med pass Supplement 120 ml (milliliters) po (by mouth) BID (twice per day) Record amount consumed. 2) Ordered [DATE] fortified foods. 3) Ordered [DATE] Multivitamin Thera tab 1 daily, given for 20 days, and was then placed on hold [DATE]. The Multivitamin was not given after [DATE], with no documented physician order [REDACTED]. No further interventions were ordered by the physician prior to development of the Stage 3 left Ischium, and the unstageable right hip pressure ulcers. It is notable to mention that the fortified foods, and supplement were ordered secondary to weight loss as stated by nursing notes [DATE] when the Resident had lost 20 lbs (pounds) in one month. Review of the Vital signs, and Weight Record revealed that from [DATE] to [DATE] the Resident lost 18.5 lbs, but had begun to regain the weight he lost. The weight on [DATE] was the last weight recorded in the clinical record through the time of survey, and no further weight loss interventions were added. Recorded weights were as follows; [DATE] (157.9) [DATE] (155.0) [DATE] (153.8) [DATE] (141.2) [DATE] (137.5) [DATE] (139.4) [DATE] (138.2) The nursing Care plan denoted the following interventions for skin/wound care; 1) Serve diet as ordered (regular). 2) Administer meds & treatments as ordered. 3) Assist with turning and repositioning every 2 hours & as needed, handle and position to reduce friction. 4) Inform physician, family, Resident, care givers of any new areas of breakdown. 5) Supplements as ordered. 6) Encourage fluid intake. 7) Provide incontinence care. 8) Weekly skin checks. 9) Report skin changes to nurse. No documentation exists in the clinical record that after ordered, on [DATE], that the Resident's skin was assessed each shift. The order does not appear in the care plan to be instituted, nor did it appear on the Treatment and Medication Administration Records (TAR/MAR). Review of Resident #6's nursing notes, in the clinical record revealed on [DATE] a stage 3 pressure ulcer on the left ischium (under the buttocks), and an unstageable pressure ulcer on the right hip (trochanter) was first identified and observed on Resident #2. Treatments were ordered by the physician on [DATE] in telephone orders and on the Guidelines for unavoidable wounds after identification, and included; 1) Wedge for repositioning in bed. per nursing notes introduced, and in place [DATE]. 2) Right hip cleanse with moist normal saline 4x4 (gauze pad), pat dry, apply santyl (a [MEDICATION NAME] ointment), cover with dry dressing every day. 3) Left Ischium cleanse with moist normal saline 4x4 (gauze pad), pat dry, apply santyl (a [MEDICATION NAME] ointment), cover with dry dressing every day. 4) Weekly skin assessments to be done now on every shift. No documentation exists in the clinical record that after ordered on [DATE], the Resident's skin was assessed each shift. After the development of the stage 3 Left ischium, and the unstageable pressure ulcer to Resident #2's right hip, further orders were received and were as follows; 1) Ordered [DATE] (23 days after identification) Low air loss mattress check placement and function every shift for wounds. 2) Ordered [DATE] (24 days after identification) ROHO cushion for wheel chair. 3) Bed Wedge for repositioning, was reordered. After the development of the two pressure ulcers, a low loss air mattress was put in place on [DATE]. Prior to the use of the low loss air mattress, a pressure reducing mattress was being used along with a pressure reducing cushion in his wheelchair. The wound nurse (LPN) Licensed Practical Nurse F was asked on [DATE], if the pressure reducing mattress was a specialty mattress, and she stated that it was the same mattress used on all beds for all residents to reduce pressure. The regular wheel chair cushion was also replaced with a specialty pressure relieving ROHO cushion, on [DATE] which the wound nurse LPN F stated was traded out at the same time of the specialty low air loss mattress. Nursing notes revealed that on [DATE], and on [DATE] a ROHO cushion was in place, however, the wound nurse stated that the entry was an error on part of the documenting nurse as the nurse misstated the name of the cushion, and further stated some staff called the regular pressure reducing cushion a ROHO by mistake. The wound nurse stated the ROHO was not ordered until [DATE], and because of the cost of the cushion, the Resident could not receive it until it was ordered by a physician. A thorough review of Resident #6's clinical record revealed Weekly Skin Integrity Review Sheets, with no documentation of skin checks being completed from the skin assessment completed on [DATE], until the assessment on [DATE]. These documents revealed no new areas of breakdown. The stage 3 ulcer to the left ischium, and the unstageable pressure ulcer to the right hip were not documented in these weekly skin reviews until [DATE]. The Pressure Ulcer Record sheets did document the 2 newly acquired pressure ulcers to the right hip and left ischium, which were identified on [DATE] and described them as; 1) Left Ischium, stage 3, wound bed granulation and slough, color red and yellow, edges firm/no redness, small amount of serous (bloody) drainage which was clear without odor. 2) Right Hip unable to stage, firm, black eschar, firm/no redness, and no drainage. The Facility policy and procedure was reviewed The policy Skin Care Protocols- Alteration in Skin Integrity (Pressure Sore Staging) read Policy: To outline nursing management of the identified, at risk resident who have actual alteration in skin. The policy defined the stages of wounds. Stage 2 was defined as A Stage 2 is a partial thickness skin loss of dermis presenting as a shallow open ulcer with a red- pink wound bed, without slough. The pressure ulcer may also present as an intact or open/ ruptured serum filled blister. If the blister is blood filled then it is a deep tissue injury (DTI). The ulcer is free of necrotic tissue. Stage 3 was defined as A Stage 3 is a full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of the tissue loss. The ulcer may include undermining or tunneling. Stage 4 was defined as A Stage 4 is a full thickness skin loss with exposed bone, tendon or muscle. Slough or eschar (dead, black looking tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling. Undermining and tunneling also may be associated with Stage 4 pressure ulcer. Staging cannot be confirmed until the wound base is visible. If the wound base is not visible this will be coded as an unable to stage pressure ulcer. Guidance provided at www.NPUAP.com defined an unstageable pressure ulcer as follows: The goal for revising the definition of unstageable ulcers was to reduce the tendency to classify an ulcer with any necrotic tissue as unstageable, when the depth of the ulcer can be seen. The new definition is Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Note the phrase the base of the ulcer is used to denote the inability to determine the depth. If necrotic tissue is present, for example, on the edge of the ulcer, but the base is bone, the ulcer should be staged as a Stage IV. Further description of Stage IV ulcers include these phrases: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar serves as ' the body's natural (biological) cover' and should not be removed. LPN (Licensed Practical Nurse) F, the wound care nurse was interviewed during wound observation on [DATE] at 10: 15 a.m., and stated once wounds were identified, the unit manager was responsible for getting a wound treatment. LPN F stated she could remember exactly when she initially assessed Resident #2's wounds and it was on [DATE] at the time the wounds were discovered. On the wound assessment sheet, [DATE] was the date for the initial assessment by LPN F, and it was documented. LPN F did assess the right hip wound as unstageable, with measurements approximately 3.0 cm (centimeters) by 2.9 cm by an unknown depth, as it was covered in eschar. LPN F also documented the stage 3 wound to the left ischium as 1.1 cm long by 1.1 cm wide by 0.3 cm deep, with granulation and slough. During the wound observation on [DATE], only the hip wound remained, and the wound was again measured. The right hip measured 2.5 cm long by 3.0 cm wide by 0.8 cm deep on the edges, and still had eschar in the center of the wound. The right foot heel ulcer was also observed to be healing and almost healed, and was being treated with skin prep to toughen the healing skin. On [DATE] at 10:15 a.m., during wound care observation, LPN F, and Certified Nursing Assistant (CNA) B were asked when skin checks were being completed, and both stated skin checks are done weekly, revealing that staff was unaware that full skin assessments were ordered on [DATE] to be completed every shift, as this order did not appear on the care plan nor on the treatment and Medication Administration Record [REDACTED] LPN (Licensed Practical Nurse) F, the wound care nurse, and CNA (Certified Nursing Assistant) B, a staff member that had cared for Resident #2 since admission, were again interviewed together with the Corporate RN (Registered Nurse) Consultant on [DATE] at 2:12 p.m. They stated that the Foley catheter keeps the wound dry. When asked why the wound was not identified before it became unstagable and, the CNA stated I was off for 4 days before it (the pressure ulcer) was found, and I am not going to say they are bad (other CNA's), but they are not as attentive as I am. CNA B also said if there was anything on any of the Resident's skin, she was to notify the nurse. CNA B stated there was no problem with Resident #2's skin at the time she was caring for him, and that he developed the pressure ulcer while she was out. On [DATE] at the end of day meeting, the DON (director of Nursing), Administrator, and Corporate RN Consultant were asked to show evidence of how Resident #2's wound was unavoidable. On [DATE] at 2:12 p.m. the Corporate RN Consultant provided a document named Guidelines for Unavoidable Wounds. This form completed for Resident #2 on [DATE], was in Resident #27's clinical record, and consisted of 3 areas for documentation by the physician. Those areas follow; 1. Under the section that read The resident has two or more of the following: (check all that apply). 13 options were found that could be checked. Of the 13 options, 4 were checked for Resident #2. They were as follows; 1)immobility, requiring staff assistance to offload pressure. This was found to be credible. 2)history of pressure ulcers (current and healed). This was found to be credible. 3)chronic bowel and/or urine incontinence, The Resident had a Foley cath, so urine incontinence did not impact this Resident, and the pressure ulcer was on the hip/trochanter which was not covered by the brief nor impacted by fecal incontinence. 4) moderate or severe [MEDICAL CONDITIONS], this was the only [DIAGNOSES REDACTED]. 2. The next section read Resident has or is undergoing two of the following: (check all that apply). 13 options were found that could be checked. Of the 13 options, 3 were checked for Resident #2. They were as follows; 1) weight loss of greater than 10 lbs during the last 30 days. This was found to be credible. 2) [MEDICAL CONDITION]. No documentation of [MEDICAL CONDITION] was found in the clinical record. 3) History of refusal of treatments (as in hygiene, wound care, medications, repositioning). No documentation of refusal by the Resident for any of these activities was found in the clinical record. 3. The final section read Facility Interventions in Place prior to development or worsening: (check all that apply). 19 options were found that could be checked. Of the 19 options, 5 were checked for Resident #2. They were as follows; 1) Weekly skin assessments every shift. No documentation of every shift skin assessments was found in the clinical record. 2) Turn and reposition as required. No documentation of turning and repositioning every 2 hours was found in the clinical record. 3) Pillow or positioning device. This was not ordered until the unstageable wound was identified. 4) Lab values monitoring. 5) Nutritional evaluations and interventions. The assessment was signed by the nurse on [DATE], and signed by the physician on [DATE], and on the day the unstageable wound was identified. The form Unavoidable Pressure Sore physician progress notes [REDACTED]. This form was signed by the physician extender on [DATE] . The form read I, Dr._nurse practitioner___, the medical provider for (Name of Resident #2) Have evaluated my patient and determined that he/she has an unavoidable wound as determined by their clinical condition. The results of my findings are: (poor prognosis- untreated [MEDICAL CONDITION] - significant [MEDICAL CONDITION], penile trauma due to chronic Foley, left ischium, right hip). During observations and interview with the Resident, he was found to be alert, oriented to self, place, time, and situation. Further, the Resident stated he was seeking medical intervention and surgical treatment for [REDACTED]. At the time of survey, the penile wound was healed as was the right Ischium ulcer. Comprehensive assessment and treatment were instituted only after development of an unstageable pressure ulcer, and a stage 3 pressure ulcer was identified. Pressure on bony prominence's is the primary reason for development of pressure ulcers. That guidance is given from credible organizations, and follow; Guidance provided at www.NPUAP.com: The article Prevention of ulcers in an orthopedic unit, from Nursing Times .net, [DATE], stated, Although tissue breakdown is a complex multifactorial process, the focus with pressure ulcer development is on extrinsic factors such as pressure, shear and friction, with the most plausible explanation being the failure to relieve pressure. While many advances, such as pressure-relieving mattresses and beds, have greatly reduced the incidence of ulcers (Blasczczyk et al, 1998). Krasner (1987) recognized that, even with pressure reduction, most support surfaces do not adequately relieve pressure. The NPUAP (National Pressure Ulcer Advisory Panel) advises Use devices that eliminate pressure. The administrator, Director of Nursing (DON), and Corporate RN Consultant were advised of the failure of the staff to institute measures, including, appropriate assessment to prevent the development of two pressure ulcers resulting in harm for Resident #2, on [DATE], and [DATE] at the end of the day conference. 2. For Resident #11, the facility staff failed to ensure treatment supplies were available for administration for pressure ulcer wound care and failed to ensure a physician's orders [REDACTED]. Resident #11, a male, was initially admitted to the facility [DATE] and readmitted after a hospitalization , [DATE]. His [DIAGNOSES REDACTED]. Resident #11's most recent MDS (minimum data set) with an ARD (assessment reference date) of [DATE] was coded as a correction to a significant change assessment. Resident #11 was coded as being unable to be assessed for memory deficits and required total assistance with making daily life decisions. He was also coded as needing total assistance of one to two staff members to perform his activities of daily living. Resident #11 was coded as having one unable to stage pressure ulcer. Resident #11 was coded as receiving all of his hydration and nutrition via peg (gastrostomy) tube. A peg tube is defined as a flexible tube surgically inserted through the abdominal wall into the stomach to administer medications, hydration, and nutrition for a Resident unable to swallow. An unable to stage pressure ulcer is defined by NPUAP (National Pressure Ulcer Advisory Panel) as: Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Resident #11 was observed [DATE] during initial tour of the facility. He was lying on his back, slightly turned to his left side, in his bed. Resident #11 had a [MEDICAL CONDITION] with humidifier tubing and bag attached. He was nonverbal and nonresponsive, with his eyes open. His breathing was shallow. A gastrostomy feeding was infusing at 60 cc (cubic centimeters) an hour. Resident #11 was lying on a specialty mattress, later identified as a low air loss mattress. Resident #11 was also observed [DATE] at 7:50 a.m. He was observed the same as on [DATE] during initial tour. Resident #11 died at 8:12 a.m. on [DATE]. Review of Resident #11's clinical record revealed he had been admitted to the hospital [DATE] due to altered mental status and subsequently diagnosed with [REDACTED].#11 was at the hospital from [DATE] until he was readmitted to the facility on [DATE]. His readmission nursing assessment revealed he was readmitted with a stage II pressure ulcer. NPUAP defines a Stage II pressure ulcer as: Category/Stage II: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation.*Bruising indicates deep tissue injury. Review of his readmission orders [REDACTED]. After the Stage II pressure ulcer was identified, a physician's orders [REDACTED]. An entry was placed on the TAR (treatment administration record) for the wound care to begin on [DATE]. Review of the TAR revealed nurses' initials that were circled, with entries on the back of the TAR indicating the [MEDICATION NAME] treatment was not done, as the [MEDICATION NAME] was not available for use. No cleaning or any other wound treatment was included in the physicians order. [MEDICATION NAME] is an all in one: foam dressing used to treat pressure ulcers and other chronic wounds. Review of the nursing notes failed to reveal any information for what treatment was utilized for Resident #11 since [MEDICATION NAME] was not available. Registered Nurse (RN) J was interviewed by phone, [DATE] at 11:56 a.m. RN J was the nurse that completed the nursing assessment. RN J could not recall if there was a dressing on the wound when she assessed the area on readmission. She stated the physician was contacted to obtain wound care orders. LPN I was also interviewed by phone, [DATE] at 11 a.m. She stated she was the nurse caring for Resident #11 on [DATE]. LPN I stated on [DATE], the treatment nurse came to her and stated she (the treatment nurse) could not find the [MEDICATION NAME]. LPN I stated the staff decided to clean the area with soap and water and apply a dry dressing. LPN I said the least we could do was clean it with soap and water. LPN I said she recalled the area was a Stage II. LPN I said [MEDICATION NAME] was not carried as a stock treatment by the facility and would have been ordered through the pharmacy. LPN I also said none of the staff contacted to physician to clarify the order or obtain any other treatment until the [MEDICATION NAME] was available. No entry was evident on the TAR indicating any care was administered to the Stage II on Resident #22's sacrum from his readmission on [DATE] through [DATE]. On [DATE], the treatment was changed to Cleanse sacrum with normal saline moistened 4x4, pat dry, apply Santyl, cover with a dry dressing. wwwrxlist.com defines Santyl: [MEDICATION NAME] Santyl® ([MEDICATION NAME]) Ointment is a sterile enzymatic [MEDICATION NAME] ointment which contains 250 [MEDICATION NAME] units per gram of white [MEDICATION NAME] USP. The enzyme </script/main/art.asp?articlekey=3266> [MEDICATION NAME] is derived from the fermentation by ,[MEDICAL CONDITION]. </script/main/art.asp?articlekey=6539> histolyticum. It possesses the unique ability to digest collagen </script/main/art.asp?articlekey=2786> in necrotic </script/main/art.asp?articlekey=4515> tissue. On [DATE] the wound care nurse assessed the area and determined the pressure ulcer to be an unable to stage with granulation tissue in the middle of the area. The documentation included, red purplish color with granulation to the wound bed. She also documented the area was a DTI (deep tissue injury). The definition of DTI by NPUAP: Suspected Deep Tissue Injury - depth unknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Resident #11's pressure ulcer was unable to be observed during the survey as he had passed away shortly after being observed. Included in Resident #11's care plan was The resident has impaired skin integrity. The Goal was The resident's wound will show signs of healing and remain free from infection. The Approaches and Interventions were: Administer medications as ordered, Inform the physician of any new area of skin breakdown, Inform resident/family/caregivers of any new areas of skin breakdown, The resident will be turned/repositioned Q (every) 2 hour & prn (as needed), Handle and position to reduce friction, Administer treatments as ordered and monitor for effectiveness, Position bed as needed to provide care, Resident required specialty mattress-Air loss mattress, and Resident requires adaptive device-bed wedge. The administrator, DON (director of nursing) and corporate consultant were informed of the failure of the staff to ensure [MEDICATION NAME] was available for administration and failed to obtain a physician's orders [REDACTED].#11, [DATE] at 1:15 p.m. 3. For Resident #8, the facility staff failed to ensure prevalon boots were worn. Resident #8, a [AGE] year old, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #8's most recent Minimum Data Set assessment was an Admit assessment with an assessment reference date of [DATE]. He was coded with severe cognitive impairment. He required extensive assistance with his activities of daily living. On [DATE] at 2:15 p.m., an initial tour of the facility was conducted. Resident #8 was observed in his bed lying on his right side in a fetal position. He was not covered. His prevalon boots were not applied and were laying at the foot of the bed. On [DATE] at 2:40 p.m., Resident #8's heels were observed. The prevalon boots were applied at this time. There were no skin issues with either heel. At this time, the Staff Educator (ADM J) was assisting with the observation. She was asked if Resident #8 could remove the boots himself. She stated no, he could not remove the boots and the boots should be on at all times. Resident #8's care plan was last reviewed on [DATE]. The Skin/ Wound care plan read The resident has impaired skin integrity. Under Approaches & Interventions read prevalon boots. The facility administration was notified of the prevalon boot issue at 4:30 p.m. on [DATE].

Based on observation, staff interview, facility documentation, clinical record review, and in the course of a complaint investigation, the facility failed to prevent/identify, assess and treat Residents in a timely manner for pressure ulcers, for three residents (Resident's #25, #1, and #11) in a survey sample of 33 residents, resulting in harm for Resident's #25 and #11. The findings included: 1. Resident #25 was originally admitted to the facility on [DATE] with a readmission on 3-31-2014 after a brief hospitalization for upper GI (Gastro-intestinal) bleeding. [DIAGNOSES REDACTED]. Resident #25 was discharged and transferred less than 5 miles to the sister facility of this facility on 5-30-14. The Facility Administrator stated the Resident had been discharged , and surveyors requested the entire complete closed clinical record, and a document to show all discharges and admissions for the last 3 months with the destination of the discharges. The Administrator returned with the closed record of Resident #25 and the computerized printed copy of the discharges and admissions. The facility print out of admissions from 3-1-14 to 6-10-14 showed Resident #25 admitted to the facility from the hospital on 3-31-14. The facility print out of discharges from 3-1-14 to 6-10-14, documented Resident #25 discharged to the hospital from the facility on 3-25-14, and documented the Resident being discharged and transferred to "nursing home" which was the sister facility on 5-30-14, however, the physicians order to transfer the Resident was not received by the facility until 5-31-14. Resident #25's most recent Minimum Data Set (MDS) assessment was a significant change full assessment with an Assessment Reference Date (ARD) of 4-14-14. Resident #25 was coded with a Brief Interview of Mental Status score of 8 points out of possible 15 points, indicating moderate cognitive impairment. The Resident required extensive to total assistance of one staff member with all activities of daily living (ADL's) including bed mobility and transferring, with the exception of eating, in which, the Resident required limited assistance of one staff member. Resident #25 was always incontinent of bowel and bladder, and had no previous or current pressure ulcers as of this assessment. Resident #25 was also coded as not refusing care, having no negative behaviors, no restraints, history of falls without injury, range of motion limitations on one side in the upper extremities, and range of motion limitations on both sides in the lower extremities. The care area triggers associated with the MDS assessment which begins the care planning process denoted Resident #25 at risk for pressure ulcers as evidenced by; ADL dependence on staff, bowel and bladder incontinence, weight loss, immobility, altered mental status, stroke with [MEDICAL CONDITIONS] medication use, [MEDICAL CONDITION] disease with shortness of breath and oxygen use, and poor circulation with [MEDICAL CONDITION]. The Resident's full readmission care plan was found in the closed record. The care plan was reviewed and the care plan was dated 4-14-14. The care plan included headings of "Focus Category: Skin/wound." The "Focus area" stated "the Resident has potential for impaired skin integrity" and under the heading "Etiologies:" listed the "disease process reason for the potential for skin breakdown, and listed "[MEDICAL CONDITION]" (stroke). The care plan was inclusive of the problem areas associated with having a Stroke, and did not just plan for skin. The following "Problem" areas were addressed in the interventions: "History of pressure, ulcers, immobility, nutritional (for weight loss) deficiency, fluid balance problem, fragile skin, incontinence, infection, movement disorder, diabetes, vascular insufficiency, cardio-vascular disease, dry skin, [MEDICAL CONDITION], increased friction, does not adhere to diet and fluid recommendations (dysphagia due to stroke), bilateral lower extremity [MEDICAL CONDITION], and unable to maintain optimal positioning;" The interventions for all of these listed problems were: 1. Serve diet as ordered 3-31-14 (pureed diabetic diet, with honey thick liquids due to stroke and dysphagia) assist as needed, monitor intake. Encourage nutrition/hydration. 2. Supplements ordered 3-31-14 (SF Med Pass 120 milliliters twice daily for supplement) (Magnesium oxide 400 milligrams twice daily, and Thera-M multivitamin one tablet every day) due to weight loss. RD (Registered Dietician) consult as needed. The SF Med Pass supplement was discontinued 4-30-14. 3. Assist resident with turning and positioning to reduce friction as "indicated" (not specified what this means). If resident refuses treatment wait and try again. Notify nurse of any new areas of breakdown. Weekly skin checks. Provide incontinence care post episode, keep skin clean and dry. Maintain short fingernails. 4. Administer medications as ordered, Monitor blood sugars as ordered. Obtain and monitor lab work as ordered. Notify MD (doctor) and family for change in condition as needed. The Resident was receiving Occupational therapy prior to hospitalization and it was discontinued on 3-12-14. Prior to hospitalization on [DATE], Resident #24 had as positioning devices; a seatbelt, anti tipping wheel chair wheels, a lap tray which the Resident could remove, and a seat cushion. Occupational therapy notes revealed that the Resident's positioning was in place, and was able to self propel the wheel chair for short distances on 3-12-14. Upon return to the facility on [DATE] none of the previous positioning devices were ordered. Resident #25 was hospitalized from 3-24-14 to 3-31-14, and was again ordered to have Occupational therapy (OT) upon return from the hospital on 3-31-14. The Resident was to receive the OT services for increased range of motion and strength in the upper extremities, upright sitting tolerance in wheel chair and to maintain trunk strength with body positioning, and increase ability to propel wheel chair. On 4-1-14 the Resident started care for these interventions with OT, and OT was discontinued on 4-21-14. Physicians orders were reviewed and revealed that on 4-1-14 Barrier cream was ordered for Resident #25's buttocks after each incontinence episode, every shift, and as needed. This order was discontinued on 4-2-14 stating nursing intervention. The 4-1-14 Barrier cream order was reissued on 4-10-14. On 4-23-14 a new telephone doctor's order was received for; "Vest for positioning while up in wheel chair as tolerated release every 2 hours PRN (as needed) for at-least 10 minutes encourage offloading with release of vest." The telephone order had not been signed by the physician as of the date of survey. On 4-23-14 the care plan was revised to state apply "Stock moisturizer as needed to Residents skin.", and to "Apply barrier cream" after peri care and as needed. Also added to the care plan on 4-23-14, was to monitor skin areas, remove as needed (vest) to check skin condition, and application of device (vest restraint) which changes pressure points The Treatment Administration Record (TAR) revealed that barrier cream was signed as applied from 4-1-14 through 5-30-14. On 5-15-14 a new physicians order for a "Vest" restraint for positioning was obtained and further specified that the vest be removed every 2 hours to assess skin for alteration/breakdown. on 7 a.m.-3 p.m. and 3 p.m.-11 p.m. shifts. No documentation existed for the removal of the vest by nursing intervention every 2 hours, or that the skin was assessed at this removal time as the doctor ordered. On 5-16-14 the Occupational therapist discharged the Resident from services, as documented that Resident #25 had met the highest potential of sitting in the wheel chair with the vest restraint. On the 5-18-14 at 2:30 p.m. a nursing note documentation by LPN (Licensed Practical Nurse) C, first identified and described Resident #25's two "Quarter sized areas to buttocks". No measurement or staging was included, however, the note did state that there was no bleeding, no complaints of pain, or discomfort. The note further stated "treatment in place for cream after each incontinent episode", the doctor and family were made aware of the finding. The Barrier cream treatment had been in place since the physician order [REDACTED]. On 5-20-14 the wound nurse LPN B made a first evaluation of the wounds and her findings were documented on the "Pressure Ulcer Record" and follow below: Wound 1.) 5-20-14 - Location Sacrum, not present on admission, stage 3, tissue type granulation and slough, color pink and yellow, small amount of pink/red serous drainage, no odor, measures 3.8 centimeters (cm) long x 6.1 cm wide x 0.1 cm deep. Wound 2.) 5-20-14 - Location Right Buttock, not present on admission, stage 3, tissue type granulation and slough, color red and yellow, small amount of pink/red serous drainage, no odor, measures 2.8 centimeters (cm) long x 2.2 cm wide x 0.1 cm deep. Weekly Skin Integrity review sheet documented skin checks being completed weekly each week after readmission on; 4-2-14, 4-9-14, 4-16-14, 4-23-14, 4-30-14, 5-7-14, 5-21-14, and 5-28-14. The week of 5-14-14 the weekly skin assessment was not completed, and the Resident developed the two pressure ulcers on 5-18-14. The Resident was discharged [DATE], so no further checks were completed after 5-28-14. Nurse's Notes dated 5-20-14 at 7:00 a.m. revealed that the wound nurse documented a new physicians order for duoderm treatment to the sacrum and buttocks wounds, 2 days after identification of the wounds. The physicians order stated "change every 3 days/ PRN (as needed) until healed". The nursing note went on to say the order was received and faxed to the pharmacy, and that the TAR was updated with the new treatment order to be performed. On 5-20-14 the care plan was updated and stated the Resident has a pressure ulcer, and as new interventions, "encourage Resident to offload when vest released rest periods from wheel chair to bed, administer treatments as ordered and monitor for effectiveness, vest change in pressure points." A Physicians order dated 5-21-14 ordered a bed air mattress, and a cut out cushion for the Resident's wheel chair, 3 days after identification of the wounds. On 5-21-14 the care plan was updated with interventions for "no briefs at bedtime, air mattress, and cut out cushion for wheel chair, 3 days after first identification of the wounds. On 5-22-14 the Registered Dietician (RD) evaluated Resident #25 and stated in the nutrition progress note document, stage 3 wounds, and recommended Vitamin C, SF Med Pass supplement, and laboratory blood tests for Hemaglobin A1C, [MEDICATION NAME], and complete metabolic profile. On 5-23-14 the doctor re-ordered the previously discontinued (4-30-14), SF Med Pass supplement 120 ml (milliliters) by mouth two times per day thickened to a honey consistency, and Vitamin C 500 mg (milligrams) by mouth every day. These interventions were ordered 5 days after first identification of the wounds, and included, to check hemoglobin A1C, pre-[MEDICATION NAME], and complete metabolic profile blood laboratory testing, on the next lab day. On 5-26-14 the doctor ordered the duoderm treatment be discontinued, and a new treatment begun for [MEDICATION NAME] gel after washing with wound cleanser, pat dry, and cover with dry dressing every day as needed for both wounds. On 5-27-14 the care plan was updated and the vest intervention was kept with reason stated on page 1 of five, as " Resident leans forward and is unable to control trunk/vest to help positioning. " On page 4 of five dated 5-27-14, the care plan stated, " trunk control improved-vest PRN (as needed) " , which are contradictory interventions, on the same dates. The purpose of the comprehensive care plan is to provide specific measurable interventions for nursing staff to be able to provide continuity of resident care. This care plan stated the Resident was unable to control trunk/use vest, and also trunk control improved/vest only as needed, on the same dates. These contradictory interventions do not instruct staff on when the vest was needed, when it should be removed, or when to do skin checks, and which staff were responsible for these interventions. On 5-27-14 the Resident was seen by the wound specialist doctor who documented the wound at a stage 3, and noted [MEDICATION NAME] 40 mg as a ([MEDICAL CONDITION]) medication that affects wound healing, and also documented it as being given 40 mg (milligrams) twice per day. On 5-23-14 (4 days before the wound doctor evaluated the Resident) the order for [MEDICATION NAME] had been changed, and decreased to 20 mg twice per day, and was signed as given on the MAR. On 5-27-14 a new order was received from the doctor to "change vest when up in wheel chair as needed, unable to maintain trunk control". CNA ' s (certified nursing aids) were unable to define what this meant, and when asked, they were inclined to think that if the vest became soiled it could be changed for a clean one. The "Nurse Tech Information Kardex" for CNA use, was reviewed. The document revealed the assigned responsibilities of the CNA's, for each resident. The DON stated this was like the CNA ' s care plan for each resident. The document for Resident #25 described in the "Adaptive Devices" area "Apply vest for position, correctly with assist, if needed while up in wheel chair, release every two hours for 10 minutes." On 5-28-14 a new order was received from the doctor for the occupational therapist to treat the Resident five times per week for eight weeks for wound healing along with wheel chair seating for wound healing with diathermy/E stim (electrical stimulation). On 5-29-14 the RD evaluated Resident # 25 again and only recommended a diet change to d/c (discontinue) low concentrated sweets, and only provide sugar substitute on tray if needed. On 5-29-14 the doctor ordered the [MEDICATION NAME] gel treatment be discontinued, and a new treatment begun for [MEDICATION NAME] ointment after washing with wound cleanser, pat dry, and cover with dry dressing every day as needed for both wounds. On 5-30-14 A new doctors order was received for a "physical therapist evaluation only as patient is at max potential level." On 5-31-14 The final doctor's order was received to "Transfer Resident to (name of facility)" from this sister facility. No nursing note regarding transfer or condition nor assessment of the Resident was documented on the day of discharge 5-30-14. The facility form "Discharge instructions for care" was reviewed and revealed the Resident was transferred on 5-30-14 at 3:00 p.m., and the skin issues section was blank. The area for treatment orders stated "see attached orders" On 6-12-14 at 2:00 p.m. An interview was held with LPN B during wound observations for the measuring of new bilateral heel ulcers found by the Physical Therapist for a different resident in the survey sample ( Resident #1). The observation revealed large black hard eschar dead tissue, and drainage on both heels. LPN B was asked if Resident #25's wounds looked like this upon identification, and she responded no, they were much smaller and were a stage 3, with slough present in the wounds, but no eschar. When asked about the lack of a pressure ulcer prevention care plan, LPN B stated as if surprised, that she "thought skin was included in the care plan." On 6-12-14 at 2:30 p.m. An interview was held with LPN B the wound care nurse, LPN C unit nurse, the Director of Nursing (DON) and Admin C- the Regional Clinical Corporate RN (Registered Nurse). The DON stated that LPN C wrote the first nursing note on 5-18-14. LPN C stated she did not remember what the wounds looked like but she had reviewed her note on that day and felt the wounds were a stage 2. The process for notifying the wound nurse of a new wound was via the 24 hour report and it was reviewed every day so the wound nurse would be aware and evaluate the wound and get an order for [REDACTED].#25 should have then been assessed on 5-19-14, instead of 5-20-14, and she responded "Correct". The DON further stated all wounds are discussed in morning meeting every day, and LPN B was there every morning. The DON stated LPN B had been educated on identifying, staging and treating wounds in LPN school, and by the DON upon hire. The DON further described LPN B as having been trained as a wound care nurse at other facilities, was very knowledgeable and had received high accolades from two wound care specialist doctor's for her technique. LPN B stated she had been employed at this facility with no problems since February 2013. The DON was further asked why the care plan had conflicting entries on the 5-27-14 update about the vest restraint, and she replied that the vest had changed the Resident's pressure points in the wheel chair, as he had always previously leaned forward in the chair while propelling, and as a result, had some falls. The vest was obtained to keep him more upright and prevent falls, but she felt the vest had changed the Resident's pressure points and had been a contributor to the buttock and sacral skin breakdown. Thus, she got the vest order changed to PRN. The DON was asked for wound policies used for the facility, and she delivered a copy of each. On 6-12-14 at 3:30 p.m. review was conducted of Facility policy and procedure guidelines for "Pressure Sore Staging", "Assessment and Documentation of Wounds", and "Pressure Ulcer Record policy", along with Wound staging and treatment guidelines documents retrieved from the treatment book. The review of these documents revealed the (3) following excerpts: 1. "Stage 2 pressure sores do not have slough, and a stage three pressure sore may have slough but does not obscure the depth of tissue loss." 2. On the "WC-170 Attachment A--wound care-Assessment and Documentation- Decision Tree page 3 of 7, the protocol stated in the "STAGE 3": bulleted list, on "Initial assessment/ (do a)Pressure Sore Progress Note and assessment (which was not completed upon identifying the wound on 5-18-14), increase frequency of positioning protocols, and incontinence status (not completed and not specified in the care plan), Protect bony prominence's (duoderm is a cushioned dressing to protect areas such as the sacrum and was ordered 5-20-14, (2) days after identification) Risk assessment tool nutritional assessment (not done until 5-22-14, (4) days after identification)/vitamins(recommend Vitamin C [PHONE NUMBER] mg every day, not done until 5-23-14, (5) days after identification)/minerals (recommend Zinc sulfate, never done)/increase protein (never done). Moisture barrier, (ordered and provided since 4-1-14), assess for pressure relieving product (specialty bed/ mattresses/cushions (ordered 5-21-14, (3) days after identification). 3. Treatment options for stage 3 pressure sores were listed under "Basic preparation of wound" stated in the protocol document and were numbered accordingly: 1. cleanse wound with normal saline and allow to dry. 2. Evaluate debridement intervention. 3. Apply skin prep to peri wound skin and allow to dry. The protocol document further stated to assess skin daily unless otherwise indicated. (Document, noting site, size and stage descriptions of affected area(s). None of these preparation steps were ever ordered or applied. On 6-13-14 at 12:27 p.m. RN (Registered Nurse) Corporate nurse Admin C stated during interview that nurses are expected to look at the staging information to make sure wounds are staged correctly and treated appropriately. She stated that the protocol guidelines are always in the treatment book that tell them how to stage. She further stated that LPN (Licensed Practical Nurse) B had misidentified the wounds for Resident #25, and that they were a stage 2 upon identification, because moisture barrier cream was being used, and that would only be ordered for a stage 2 wound and never a stage 3 wound according to policy and procedure guidelines. This was incorrect according to the policy and procedural guidelines which stated to use moisture barrier with stage 3 wounds. The Director of Nursing and Administrator were asked for the pressure ulcer prevention care plan if any, and any other documents related to Resident #25's skin at the end of day meeting on 6-12-14 at 2:00 p.m.. The only additions to already received documents were written on 6-12-14, and 6-13-14 and included the following: A "Non-Decubitus Skin Condition Record" completed during survey by LPN C on 6-12-14 describing the "2 quarter size areas open to buttocks" date first observed 5-18-14, with no other measurements, treatments, or descriptions of the wounds, and a late entry nursing note dated 6-12-14 stating "note clarification 5-18-14 "on nursing note written at 2:30 p.m. "Resident with two quarter size area stage two to buttocks, (she further stated in a hand written statement that she left the room and checked the treatment book for the appropriate treatment and returned to the room and applied) Barrier cream zinc oxide applied." This was incorrect as the wounds were not both located on the buttocks. One was on the buttocks and one was on the sacrum. Three other hand written statements completed on 6-13-14, from LPN B and two CNA's (who were not available for interview on 6-13-14), were delivered by the Corporate RN Admin C. The first CNA (Certified Nursing Assistant) statement documented that there were no wounds on 5-17-14. LPN B's statement documented that the wounds were a stage 2, recanting her original assessment and document, and considering statements made by staff that she was a very knowledgeable and educated wound nurse. The second CNA stated that she found the wound and reported it to LPN C who immediately entered the room and put cream on the Resident's "bottom", and told the CNA to lay the Resident down after meals, which the CNA stated she did. No measurement or leaving to check the treatment book was documented in this statement and conflicts with LPN C's statement. Guidance provided at www.NPUAP.com: The article "Prevention of ulcers in an orthopedic unit", from Nursing Times .net, June 18, 2002, stated, "Although tissue breakdown is a complex multifactorial process, the focus with pressure ulcer development is on extrinsic factors such as pressure, shear and friction, with the most plausible explanation being the failure to relieve pressure. While many advances, such as pressure-relieving mattresses and beds, have greatly reduced the incidence of sacral ulcers (Blasczczyk et al, 1998). Krasner (1987) recognized that, even with pressure reduction, most support surfaces do not adequately relieve pressure.: The NPUAP (National Pressure Ulcer Advisory Panel) advises "Use devices that eliminate pressure." The issues with Resident #25's sacral and buttock wounds, include lack of a pressure ulcer prevention care plan, late identification, late timing of interventions and initial treatment, and lack of preventive assessment and treatment. Assessment and treatment were instituted, only after development of a stage 3 pressure ulcer. CNA's were expected to apply, release, and leave the vest restraint off for 10 minutes with no documentation of this being completed, and no nursing assessment of the skin after the vest was released was documented. Findings were reviewed with the DON and Administrator at end of day debrief on 6-12-14, and 6-13-14, denoting a harm level finding and complaint deficiency. The administration presented no further information. COMPLAINT DEFICIENCY The Food and Drug Administration (FDA) describes Silva Sorb gel as a topical anti-infective, used for; Protecting burns, cuts, scrapes, and other wounds from infections. It may also be used for other conditions, as determined by your doctor. Silva Sorb gel is a wound dressing. It works by providing moisture for the healing process and protecting the healing wound from contamination. Do not use Silva Sorb gel if; you are allergic to any ingredient in Silva Sorb gel, if you have a bleeding wound, or you have a skin rash caused by an allergic reaction to food or medicine. The Food and Drug Administration (FDA) describes [MEDICATION NAME] cream as a soft, white, water-miscible cream containing the antimicrobial agent silver [MEDICATION NAME] in [MEDICATION NAME] form. INDICATIONS AND USAGE states [MEDICATION NAME] Cream 1% (silver [MEDICATION NAME]) is a topical antimicrobial drug indicated as an adjunct for the prevention and treatment of [REDACTED]. National guidelines for Pressure ulcer staging as designated by the 2007 NPUAP Definitions and 2007 NPUAP Descriptions to Accompany Revised Definitions are as follows; Stage 2 pressure ulcers; Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed without slough. They may also present as an intact or open/ruptured serum-filled blister. These wounds can presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration, or excoriation. Stage 3 pressure ulcers; Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle, are not exposed. Slough may be present but does not obscure the depth of tissue loss. The wound may include undermining and tunneling. The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. 2. For Resident #1, the facility staff failed to identify a pressure ulcer before the tissue became necrotic. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 05/30/2014 coded Resident #1 with moderate cognitive impairment. In addition, the Minimum Data Set coded Resident #1 requiring supervision and limited assistance for Activities of Daily Living care. A review of Resident #1's clinical record was conducted during the survey. The review showed an document titled, " Admission/Readmission Data Collection " dated 05/23/2014. The document showed that Resident #1 had dry heels. The review showed a care plan dated 05/30/2014. The care plan read that Resident #1 had the " potential for impaired skin integrity. " The review showed a document titled, " Weekly Skin Integrity Review. " The review showed that on 05/23/2014 and 05/30/2014 Resident #1 was documented as having dry and peeling dry skin on the heels. The review showed a Physical Therapy noted dated 06/06/2014. The note read that the Physical Therapist , " Noticed stain on socks on L(left) lateral heel, (Resident #1) has a pressure wound, (Resident #1) was not aware, R(right) lateral heel blister. Nursing notified about it. " The review showed a nursing note dated 06/06/2014. The note read that an " open/dry area " was noted on Resident #1's left heel. The review showed a document titled, " Pressure Ulcer Record " for the left heel dated 06/06/2014. For the left heel, the pressure sore was documented as a Deep Tissue Injury that measured 5 by 5 centimeters. The wound bed was described as a blister and the color of the wound bed was red and black. The wound edges were described as having redness and there was no drainage noted. The peri-wound area was noted to have hardness/Induration. The review showed a document titled, " Pressure Ulcer Record " for the right heel dated 06/06/2014. For the right heel, the pressure sore was documented as a Deep Tissue Injury that measured 3 by 5.2 centimeters. The wound bed was described as a blister and the color of the wound bed was red and black. The wound edges were described as having redness and there was no drainage noted. The peri-wound area was noted to be intact. The review showed a physician order [REDACTED].#1's heels every day. On 06/11/2014 at approximately 4:45 p.m., an interview was conducted with Other Employee-B, a physician therapist. The physical therapist stated that he found the pressure ulcers on Resident #1. The physical therapist stated that because of the pressure ulcers, Resident #1 has to perform physical therapy sitting down. On 06/11/2014 at approximately 5:25 p.m., an interview was conducted with Licensed Practical Nurse-B (LPN-B). LPN-B is the wound nurse who made the observations and completed the document titled, " Pressure Ulcer Record " for both the left and right heel. LPN-B stated that the black color that was noted on the wound bed, for both heels, was necrotic tissue. LPN-B stated that she thought the pressure ulcers were caused by Resident #1's new shoes. On 06/11/2014 at approximately 5:00 p.m., an observation of Resident #1's heels was conducted with the LPN-B. LPN-B described the left heel as measuring 6.3 by 3.3 centimeters. The wound bed was described as a blister and the color of the wound bed was red and black. The wound edges were described as having redness and there was a small amount of pink/red serosanguineous drainage noted. The peri-wound area was noted to be intact. LPN-B described the right heel as measuring 3.5 by 6.2 centimeters. The wound bed was described as a blister and the color of the wound bed was red and black. The wound edges were described as having redness and there was a small amount of pink/red serosanguineous drainage noted. The peri-wound area was noted to be intact. During the observation, Resident #1 stated that it hurt when LPN-B touched his heels. LPN-B note dated 06/11/2014 at 5:10 p.m., read, Resident alert and verbal stated he had been medicated for pain. Resident stated that he does have pain to bil(ateral) heels. Left heel measures @ 6.3 x 3.3 (centimeters) dry loose skin at top of wound. Wound black and red (with) necrotic area serosang(uineous) drainage (small) amount. Base of wound mushy and tender to touch. Right heel measures 3.5 x 6.2 (centimeters) area noted (with) necrotic mushy tender to touch small amount of serosang(uineous) drainage. Red edges. Will continue (with) current (treatment) as improvement noted (with) wounds. Wounds are noted not as inflamed. " The facility administration was informed of the findings during a briefing on 06/13/2014 at approximately 1:00 p.m. The facility did not present any further information about the findings. Harm deficiency. 3. Resident #11's air mattress pump was off for several observations (8.5 hours). The air mattress was used for pressure sore prevention. Resident #11 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed most recent MDS (minimum data set) with an ARD (assessment reference date) of 3/28/14. The resident was coded as having a BIMS (brief interview of mental status) of "0" out of a possible 15. In this case, Resident #11 refused to participate in the BIMS testing. Her score on the 12/30/13 MDS was "14" or no cognitive impairment. The resident was coded as requiring total assistance for her ADLs (activities of daily living), such as bathing. The resident was coded as having a pressure reducing mattress in place for the look back period. The resident did have any pressure sores coded. On 6/10/14 at 4:15 PM, Resident #11 was observed in the bed. The one half side rail on the left side of the bed was hanging off the side of the bed. The bed was also in the high position. On 6/11/4 at 8:30 AM, the resident was observed in the bed, with the half side rail off the bed, and was in the floor against the wall. The bed was observed in the high p

Based on observation, resident and staff interview, facility documentation, clinical record review and in the course of a complaint investigation, the facility staff failed to provide adequate supervision for 2 residents ( Resident #3 and #10) in the survey sample of 36 residents. 1. Resident #3, who was coded and care planned as a two person assist, was transferred with one CNA (certified nursing assistant) from the wheelchair to a shower chair and sustained a left ankle fracture. 2. For Resident #10, the facility staff failed to prevent a fracture by not using safety and assistance devices. The resident was transferred to a manual wheel chair that had no foot rests by staff. Resident #10 ' s left leg was dragged underneath the manual wheelchair while being pushed down the hall by a volunteer. The findings included: Resident #3, a [AGE] year old female, was admitted on [DATE]. [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) with an ARD (assessment reference date) of 2/28/12 coded the resident as having short and long term memory loss and unable to make decisions regarding daily care. The resident required extensive to total assistance with all ADL's (activities of daily living such as bathing, dressing and toileting). The resident was coded as requiring a 2 person assist with bed mobility and transfers. The resident was also coded as having impairments of lower extremities, and needing human assistance for stability. The annual MDS assessment with an ARD of 12/5/11 coded the resident as a 3/3 assist, meaning the resident required extensive assistance of two persons for transferring. Review of the resident's clinical record revealed on 2/28/12, swelling of the left lower extremity was noted. An X-ray was done on the same day, revealing osteoporosis and questionable age of the fracture; "may be old, may be new." Review of the investigation of the incident revealed that one CNA was questioned regarding the incident. The statement from the CNA made reference to transferring the resident from the wheelchair to the shower chair with another CNA between 5:45 AM to 6:00 AM. During the shower, the swelling was noted. The DON (director of nursing) was questioned as to why the second CNA had no signed statement. The DON replied: "The second CNA would not sign because she had not assisted in the transfer. We knew the fracture was due to the transfer." She went on to state that the CNA was terminated "because she was not entirely truthful." Review of the resident's care plan dated 12/9/11 revealed, under the section heading of "self care deficit-ambulation, that the resident required "extensive" assistance. There was no mention as to number of staff needed to transfer the resident. A CNA care sheet did show the resident required 1 person assistance for transfers, but did not contain a date. On 5/12/12, the surveyor was presented with a transfer/mobility status criteria sheet for Resident #3 which was dated 11/10. The area of (2) was circled under limited assistance. It also read:"Gait belt with assist of one. If support of individual is unreliable, then use 2 person support." On 5/12/12 at 10:20 AM, an interview was conducted with CNA (G) was conducted. She stated, "it takes two people to get her up- she can assist a little." On 5/12/12 at 10:30 AM, CNA (H) was interviewed. She stated, "It takes 2 person assist." The CNA was asked prior to the ankle fracture how many staff were needed for transfer. She stated, "It still took 2 people to transfer." While unable to view Resident #3's transfers, a 2 person transfer was conducted on 5/10/12 at 2:10 PM for Resident #21. Two CNA's were present. The wheelchair brakes were locked. The resident was grasped under the arms and stood/pivoted her to the bed. The 1/2 side rails were elevated and the call bell was placed in reach of the resident. The DON was asked what measures were taken after the fracture to prevent further occurrences. She stated, "We did not do inservices for all staff after the fracture. The CNA was terminated." On 5/12/12 at approximately 1:30 PM, the Administrator and DON were notified of harm level findings. 2. For Resident #10, the facility staff failed to prevent a fracture by not using safety and assistance devices. The resident was transferred to a manual w/c that had no foot rests. Resident #10 ' s left leg was dragged underneath the manual wheelchair while being pushed down the hall by a staff member. Resident #10 was admitted to the facility on [DATE] then re-admitted on [DATE]. [DIAGNOSES REDACTED]. Resident #10 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 03/09/2012 coded Resident #10 with no cognitive impairment. In addition, the Minimum Data Set coded Resident #10 requiring mostly total dependence, on staff, for Activities of Daily Living care and incontinent of bowel. A review of Resident #10 ' s clinical record was conducted during the survey. The review showed nursing note dated 02/28/2012 at 3:00 p.m. The note read that Resident #10 reported left knee pain after a wheelchair-to-wheelchair transfer that occurred earlier in the morning. The note read that Resident #10 felt pain immediately after the event and currently reported a pain level of 8 out of 10 (with 10 being the most pain). The note read that the nurse assessed the left knee and noted swelling, purplish discoloration, and tender to the touch. The note read that the nurse could not perform a range of motion assessment due to Resident #10 ' s current pain. The note read that the nurse contacted Resident #10 ' s physician and an order was given to have an x-ray done of the left knee. The review showed an x-ray report dated 02/28/2012. The report read that Resident #10 had an acute fracture of the left distal femur. An interview was conducted with Resident #10 on 05/10/2012 at approximately 11:00 a.m. Resident #10 stated that on the morning of 02/28/2012 she was getting ready to go to out shopping. Resident #10 stated that because the stores are crowded, she requested to be put in a manual wheelchair instead of using her power wheelchair because she worried about going too fast in the store. Resident #10 stated that usually the Certified Nursing Assistants (CNA) transfer her with a mechanical lift, however on this day (02/28/2012), she was transferred from her power wheelchair to a manual wheelchair by three CNAs. Resident #10 stated that the CNAs did not use a mechanical lift. (A mechanical lift is a device in which some or all of a Resident ' s weight is supported by the lift during transfers.) The review showed a nursing note dated 02/28/2012 at 7:50 p.m. The note read that Resident #10 was transported to the emergency room due to a fracture. A review of the CNA plan of care for Resident #10 showed that Resident #10 was to be transferred using a mechanical lift. On 05/10/2012 at approximately 2:40 p.m., the Director of Nursing (DON) stated that Resident #10 ' s fracture was caused when Resident #10 ' s left leg was dragged underneath the manual wheelchair while being pushed down the hall by a staff member. A review of the facility ' s investigation into Resident 10 ' s fracture was conducted. The review showed a document titled " Witness Statement by (Volunteer " A " ) " . Volunteer " A " stated that she witness three CNAs transferring Resident #10 from power wheelchair to a manual wheelchair without using a lift. Volunteer " A " stated that when she pushed Resident #10 in the manual wheelchair, Resident #10 ' s leg " got hurt. " Volunteer " A " stated that the manual wheelchair did not have any " leg holders " i.e. foot rests on it. The investigation showed a document titled " Witness Statement by (CNA " J " ) " . CNA " J " stated that Resident #10 was being transfer from power wheelchair to a manual wheelchair. CNA " J " stated that during the transfer, one CNA held Resident #10 under the arms on one side, a second CNA held Resident #10 under the arms on the other side, while CNA " J " held Resident #10 under the legs. CNA " J " stated that they transferred Resident #10 by sliding Resident #10 from the power wheelchair to the manual wheelchair while both wheelchairs were at equal levels. CNA " J " stated that Volunteer " A " proceeded to transport Resident #10 down the hall and that Resident #10 ' s leg started to drag. CNA " J " stated that there were no foot rests on the manual wheelchair and that some had to be found after Resident #10 ' s leg started to drag. The review showed an MDS with and ARD date of 02/20/2012. The MDS showed that Resident #10 has Range of Motion impairment on both sides in her lower extremities. An interview was conducted with the Physical Therapist (Administration Employee " D " ), on 05/10/2012 at approximately 4:55 p.m. The Physical Therapist stated that foot rests are required when transporting people in wheelchairs. The facility administration was informed of the findings during a briefing on 05/10/2012 at approximately 6:58 p.m. The facility did not present any further information about the findings.