Every finding on record at Hampton Health & Rehab Center, LLC

Based on observation, staff interview, and facility document review, the facility staff failed to ensure the safe and secure storage of medications and biologicals for 2 of 4 medication carts (Unit 1/Cart 1 and Unit 2/Cart 1) and 1 of 2 medication storage rooms (Unit 1). The findings included: 1. For Unit 1/Medication Cart 1, the facility staff left a Colestipol tablet (medication used to lower cholesterol) unattended on top of the medication cart. On [DATE] at 8:26 AM during a medication pass observation, surveyor observed Licensed Practical Nurse (LPN) #1 place a Colestipol tablet in a separate medication cup as it appeared damaged and obtained a replacement tablet for administration. LPN #1 left the cup containing the damaged tablet on top of the medication cart unattended and entered a resident's room. While in the resident's room, LPN #1 provided care and administered medications with the door closed leaving the Colestipol tablet unattended in the hall for approximately nine (9) minutes. When asked about the unattended medication, LPN #1 placed the cup containing the medication in the medication cart and stated they wanted to show other staff members the damaged tablet. Surveyor requested and received the facility policy titled General Dose Preparation and Medication Administration with a last revision date of [DATE] which read in part, .2.8 Facility staff should not leave medications or chemicals unattended . On [DATE] at 10:40 AM, the survey team met with the Administrator, Director of Nursing, and Clinical Services Manager and discussed the concern of the unattended medication. No further information regarding this concern was presented to the survey team prior to the exit conference on [DATE]. 2. For Unit 2/Medication Cart 1, the facility staff failed to label a multi-dose insulin pen with the date of opening and/or discard date. On [DATE] at 1:40 PM, surveyor observed an open, partially used Aspart ,d+[DATE] Insulin pen in the Unit 2/Medication Cart 1. The insulin pen was not labeled with an opened or discard date. Registered Nurse (RN) #4 stated there were two doses remaining and they were ordering a new insulin pen for the resident. Surveyor requested and received the facility policy titled General Dose Preparation and Medication Administration with a last revision date of [DATE] which read in part .2.10 Facility staff should enter the date opened on the label of medications with shortened expiration dates (e.g., insulins, irrigation solutions, etc.). 2.10.1 Facility staff may enter the expiration date based on date opened on the label of medications with shortened expiration dates . On [DATE] at 5:00 PM, the survey team met with the Administrator, Director of Nursing, Clinical Services Manager, and the [NAME] President of Operations and discussed the concern of the undated insulin pen. No further information regarding this concern was presented to the survey team prior to the exit conference on [DATE]. 3. For the Unit 1 Medication Storage Room, the facility staff failed to discard expired COVID-19 testing cards. On [DATE] at 1:16 PM, surveyor observed an opened box containing 30 [NAME] BinaxNOW COVID-19 Ag tests (Lot #220976) with a printed expiration date of [DATE]. According to the [NAME] product website (https://www.globalpointofcare.[NAME]/us/en/product-details/binaxnow-covid-19.html), [NAME] BinaxNOW COVID-19 Ag testing cards Lot #220976 with an original expiry date of [DATE] had been extended to a 22 month expiry date of [DATE]. Surveyor spoke with Registered Nurse (RN) #3 on [DATE] at 2:34 PM and discussed the extended expiry date of [DATE]. RN #3 stated they were discarding the tests. Surveyor requested and received the facility policy titled Storage and Expiration Dating of Medications and Biologicals with a last revision date of [DATE] which read in part, .10. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines .are stored separate from other medications until destroyed or returned to the pharmacy or supplier . On [DATE] at 5:00 PM, the survey team met with the Administrator, Director of Nursing, Clinical Services Manager, and the [NAME] President of Operations and discussed the concern of the expired COVID-19 tests. No further information regarding this concern was presented to the survey team prior to the exit conference on [DATE].

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure that written transfer notices were provided for 4 of 31 Residents, Residents #26, #129, #71, and #72. The findings included: 1. For resident # 26 the facility failed to notify the resident and/or the resident's representative(s) of the transfer and the reasons in writing, and in a language and manner they understand. The facility staff also failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. Resident # 26's diagnoses included but were not limited to, history of cerebral infarction (stroke), chronic obstructive pulmonary disease, hypertension, moderate protein calorie malnutrition, depression, vitamin deficiency and depression. The minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/21/23 assigned the resident a brief interview for mental status (BIMS) score of 15 out of 15 indicating intact cognition. During a review of the clinical record, a progress note dated 3/31/24 at 11:16 PM read, Patient present with confusion and hallucination. Patient daughter called requesting that the patient be sent out. ____ called and stated that another course of action needed to be taken and to not send the patient out. Writer went into patient room again and patient is still hallucinating. Patient states that kids are in her room and that things are crawling on the ceiling and the walls trying to get her. Writer is waiting on call back from ____ as to course of action to take. ____ called back and stated to send patient to the ER. No further information was documented in the notes. Surveyor was unable to locate a transfer form in the record. On 9/5/24 at 9:25 AM a surveyor interviewed Licensed Practical Nurse (LPN) # 4. They stated the Social Worker is not notifying the Ombudsman of transfers to hospitals, only the transfers to homes. On 9/5/24 at 10:28 AM a surveyor interviewed the Regional Director of Clinical Services who stated the social worker is not notifying the Ombudsman of transfers to the hospital. On 9/5/24 at 11:14 AM this surveyor interviewed Corporate staff # 4. Surveyor asked for evidence that the staff notified the resident and/or the resident's representative(s) of the transfer and the reasons for the transfer in writing, and in a language and manner they understand. They stated, They didn't even do the transfer form or anything. On 9/5/24 at 4:44 PM the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultant, and Regional VP of Operations. This concern was discussed with them at that time. No further information was provided to the survey team prior to the exit conference. 2. For resident # 129, the facility failed to notify the resident and/or the resident's representative(s) of the transfer and the reasons in writing, and in a language and manner they understand. The facility staff also failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. Resident # 129's diagnoses included but were not limited to history of cerebral infarction (stroke), chronic obstructive pulmonary disease, hypertension, moderate protein calorie malnutrition, depression, vitamin deficiency and depression. The minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/21/23 assigned the resident a brief interview for mental status (BIMS) score of 15 out of 15 indicating intact cognition. A nurse progress note dated 6/8/23 at 1:15 PM read, at 0830, CNA informed this nurse, that the resident was c/o tightness in her chest and chest pain on the left side. Nurse assessed pt and pt complain of chest pain 4/10. Vitals: 127/74-bp, 97-HR, 16-R, 94%RA. Pt emergency contact was called and informed and she requested that the pt be sent out to ER for further eval. Dr. [NAME] was informed and made aware of the family request to send pt out to ER. Pt was sent out to ER at 0930 and paperwork(care plan, bed hold, med list, face sheet) was given to EMT. On 9/5/24 at 9:25 AM a surveyor interviewed Licensed Practical Nurse (LPN) # 4. They stated the Social Worker is not notifying the Ombudsman of transfers to hospitals, only the transfers to homes. On 9/5/24 at 10:28 AM a surveyor interviewed the Regional Director of Clinical Services who stated the social worker is not notifying the Ombudsman of transfers to the hospital. On 9/5/24 at 11:14 AM this surveyor interviewed Corporate staff # 4. Surveyor asked for evidence that the staff notified the resident and/or the resident's representative(s) of the transfer and the reasons for the transfer in writing, and in a language and manner they understand. They stated, They didn't even do the transfer form or anything. On 9/5/24 at 4:44 PM the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultant, and Regional VP of Operations. This concern was discussed with them at that time. No further information was provided to the survey team prior to the exit conference. 49622 3. For Resident #71, the facility staff failed to provide the resident and the resident's representative written notice of the reason(s) of transfer/discharge to the hospital on 5/8/24 and 7/5/24 and failed to notify the Office of the State Long-Term Care Ombudsman of the transfer/discharge on 5/8/24 and 7/5/24. Resident #71's diagnosis list indicated diagnoses that included, but were not limited to, Prostate Cancer, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Congestive Heart Failure, Depression and Candidal Cystitis, and Urethritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/15/24, assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating Resident #71 was cognitively intact. A review of the clinical record indicated Resident #71 was transferred to the hospital on 5/8/24 and on 7/5/24. No evidence of written notice of the transfer being provided to the resident and the resident's representative could be located. On 9/5/24 at 10:15 AM, surveyor interviewed the social worker-other staff #1 (OS#1) and she informed surveyor she notifies the ombudsman once a month of transfers and discharges via fax and that she would look for notification of the transfer for Resident #71 for the 5/8/24 and 7/5/24 discharges to the hospital. On 9/5/24 at 11:05 AM, corporate staff #4 (CS#4) informed surveyor that no evidence of written notification for the reason of transfer could be located for Resident #71 and resident's representative for 5/8/24 or 7/5/24, and there was no evidence of notification of transfer or discharge for the ombudsman for the transfers for 5/8/24 and 7/5/24. This concern was discussed at the pre-exit meeting on 9/5/24 at 5:03 PM with the administrator, director of nursing, regional director of clinical services, and regional vice president of operations. Surveyor requested and received a facility document, titled, Resident Discharge/Transfer Letter Policy, that read in part, .The facility will complete discharge letters .according to all federal, state, and local regulations .C .3. Completed and signed letters will be uploaded back to the electronic chart .D. Discharge notices must have the following components: 1. The reason for discharge/transfer .E. Social Service or designee will assure the original discharge/transfer letter is given to the resident .1. Copies will be sent to .Ombudsman Office .and/or scanned into the electronic chart .F. Social service or designee will document in the chart all discharge/transfer reasons, any notices given .G. The resident .responsible party will receive .discharge/transfer letter . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/5/24. 4. For Resident #72, the facility staff failed to provide the resident and the resident's representative written notice of the reason(s) of transfer to the hospital on 5/17/24 and 7/18/24 and failed to notify the Office of the State Long-Term Care Ombudsman of the transfer/discharge on 5/17/24 and 7/18/24. Resident #72's diagnosis list indicated diagnoses that included, but were not limited to, Encounter for surgical aftercare following surgery on the digestive system, Diabetes Mellitus Type 2, Difficulty Walking, Transient Ischemic Attack (TIA), Dementia, Atherosclerotic Heart Disease, Hyperlipidemia, Osteoarthritis of Knee, and Depression. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/13/24, assigned the resident a brief interview for mental status (BIMS) summary score of 10 out of 15 for cognitive abilities, indicating Resident #72 was moderately impaired in cognition. A review of the clinical record indicated Resident #72 was transferred to the hospital on 5/17/24 and on 7/18/24. No evidence of written notice of the transfer being provided to the resident and the resident's representative could be located. On 9/5/24 at 9:25 AM, surveyor interviewed licensed practical nurse #4 (LPN#4) and she stated the social worker is not notifying the ombudsman of transfers to the hospital, she is only notifying the ombudsman of discharges home. LPN#4 stated she would look for evidence of written reason for transfer/discharge to the resident and resident representative. LPN#4 returned to surveyor at 9:53 AM and stated there was no evidence that written notice of the reason for transfer was given to Resident #72 or resident's representative. On 9/5/24 at 10:15 AM, surveyor interviewed the social worker-other staff #1 (OS#1) and she informed surveyor she notifies the ombudsman once a month of transfers and discharges via fax and that she would look for notification of the transfer for Resident #72 for the 5/17/24 and 7/18/24 discharges to the hospital. On 9/5/24 at 10:28 AM, regional director of clinical services informed surveyor that OS#1 is not sending transfer notifications to the ombudsman. This concern was discussed at the pre-exit meeting on 9/5/24 at 5:03 PM with the administrator, director of nursing, regional director of clinical services, and regional vice president of operations. Surveyor requested and received a facility document, titled, Resident Discharge/Transfer Letter Policy, that read in part, .The facility will complete discharge letters .according to all federal, state, and local regulations .C .3. Completed and signed letters will be uploaded back to the electronic chart .D. Discharge notices must have the following components: 1. The reason for discharge/transfer .E. Social Service or designee will assure the original discharge/transfer letter is given to the resident .1. Copies will be sent to .Ombudsman Office .and/or scanned into the electronic chart .F. Social service or designee will document in the chart all discharge/transfer reasons, any notices given .G. The resident .responsible party will receive .discharge/transfer letter . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/5/24.

Based on staff interview, clinical record review, and facility document review the facility staff failed to ensure that residents and/or resident representatives had the opportunity to develop an Advanced Directive for 12 of 22 residents, Residents #3, 5, 29, 47, 4, 16, 62, 2, 38, 42, 50, and 75 and failed to honor an Advance Directive for 1 of 22 Residents, Resident #23. The findings include: On [DATE], the facility administrative staff provided the survey team with a copy of a policy titled, ADVANCE DIRECTIVES PROTOCOL. This policy read in part, .Upon Admission during Your Path Meetings, advance directives will be discussed with resident and/or resident representative to determine if any advance directives have be [sic] chosen .Advance directives will be reviewed at minimum annually according to MDS [minimum data set] schedule . 1. For Resident #3, the facility staff failed to provide the resident and/or the resident representative with information concerning the right to accept or refuse medical or surgical treatment and the option to formulate an advance directive. Resident #3's diagnoses included, but were not limited to, mild protein calorie nutrition and diabetes. Section C (cognitive patterns) of Resident #3's significant change in status MDS assessment with an assessment reference date (ARD) of [DATE] included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Per the MDS manual a score of 15=cognitively intact. During the clinical record review, the surveyor was unable to locate any evidence to indicate the facility staff had provided the resident and/or their representative the option to formulate an advance directive. On [DATE] at 2:30 p.m., during a meeting with the Administrator, Director of Nursing, and Regional Nurse Consultant the concern with the missing information regarding advance directives was reviewed. On [DATE] at 12:04 p.m., the Administrator stated they were unable to find any information on advance directives. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #5, the facility staff failed to provide the resident and/or the resident representative with information concerning the right to accept or refuse medical or surgical treatment and the option to formulate an advance directive. Resident #5's diagnoses included acute ischemic heart disease and congestive heart failure. Section C (cognitive patterns) of Resident #5's quarterly MDS assessment with an assessment reference date (ARD) of [DATE] had been coded [DATE] to indicate this resident had problems with long- and short-term memory and was severely impaired in cognitive skills for daily decision making. During the clinical record review, the surveyor was unable to locate any evidence to indicate the facility staff had provided the resident and/or their representative the option to formulate an advance directive. On [DATE] at 2:30 p.m., during a meeting with the Administrator, Director of Nursing, and Regional Nurse Consultant the concern with the missing information regarding advance directives was reviewed. On [DATE] at 12:04 p.m., the Administrator stated they were unable to find any information on advance directives. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #29, the facility staff failed to provide the resident and/or the resident representative with information concerning the right to accept or refuse medical or surgical treatment and the option to formulate an advance directive. Resident #29's diagnoses included, but were not limited to, Schizoaffective disorder. Section C (cognitive patterns) of Resident #29's quarterly MDS assessment with an assessment reference date (ARD) of [DATE] included a brief interview for mental status (BIMS) score of 1 out of a possible 15 points. Per the MDS manual a score of 1=severe impairment. During the clinical record review, the surveyor was unable to locate any evidence to indicate the facility staff had provided the resident and/or their representative the option to formulate an advance directive. On [DATE] at 2:30 p.m., during a meeting with the Administrator, Director of Nursing, and Regional Nurse Consultant the concern with the missing information regarding advance directive was reviewed. On [DATE] at 12:04 p.m., the Administrator stated they were unable to find any information on advance directives. No further information regarding this issue was provided to the survey team prior to the exit conference. 4. For Resident #47, the facility staff failed to provide the resident and/or the resident representative with information concerning the right to accept or refuse medical or surgical treatment and the option to formulate an advance directive. Resident #47's diagnoses included, but were not limited to, cerebral infarction and chronic obstructive pulmonary disease. Section C (cognitive patterns) of Resident #47's quarterly MDS assessment with an assessment reference date (ARD) of [DATE] included a brief interview for mental status (BIMS) score of 14 out of a possible 15 points. Per the MDS manual a score of 14=cognitively intact. During the clinical record review, the surveyor was unable to locate any evidence to indicate the facility staff had provided the resident and/or their representative the option to formulate an advance directive. On [DATE] at 2:30 p.m., during a meeting with the Administrator, Director of Nursing, and Regional Nurse Consultant the concern with the missing information regarding advance directives was reviewed. On [DATE] at 12:04 p.m., the Administrator stated they were unable to find any information on advance directives. No further information regarding this issue was provided to the survey team prior to the exit conference. 5. For Resident #23, the facility staff failed to honor the residents advance directive wishes. Resident #23's diagnoses included, but were not limited to, diabetes and neuropathy. Section C (cognitive patterns) of Resident #23's quarterly MDS assessment with an assessment reference date (ARD) of [DATE] included a brief interview for mental status (BIMS) score of 5 out of a possible 15 points. Per the MDS manual a score of 5=severe impairment. Resident #23's clinical record included a Virginia Advance Directive for Health Care form signed and notarized on [DATE]. Resident #23 had been admitted to this facility on [DATE]. Under the section MY HEALTH CARE INSTRUCTIONS the box that read in part, I do not want any treatments to prolong my life. This includes .cardiopulmonary (CPR) . had been marked with an X. All the other boxes were left blank. Resident #23's clinical record included the following information: Face sheet that indicated this resident was a full code. Provider order dated [DATE] that read full code. Comprehensive Care Plan (CCP) revised on [DATE] indicating this resident was a full code. On [DATE] at 9:35 a.m., the concern with the residents code status not being honored was shared with the Social Worker. This staff person never provided the surveyor with any updated information. On [DATE] at 2:30 p.m., during a meeting with the Administrator, Director of Nursing, and Regional Nurse Consultant the concern regarding Resident #23's code status was reviewed. On [DATE], the administrative staff provided the surveyor with the following, updated face sheet indicating the resident was a do not resuscitate (DNR), provider order dated [DATE] that read Code Status DNR, updated CCP indicating the Resident had chosen to be a DNR, and a progress note that read in part, .spoke with RP [responsible party] .in regards to a code status audit for [Resident #23] .We discussed her prior advanced directive and her RP wishes to respect her wishes of being a DNR. No further information regarding this issue was provided to the survey team prior to the exit conference. 34307 6. For Resident #4 the facility staff failed to ensure the resident had an opportunity to develop an advance directive. Resident #4's face sheet listed diagnoses which included but not limited to dementia, cerebral infarction, and type 2 diabetes mellitus. Resident #4's most recent minimum data set with an assessment reference date of [DATE] coded the resident has having both long- and short-term memory problems with severely impaired cognitive skills for daily decision making. Resident #4's comprehensive care plan was reviewed and contained a care plan for Resident is DNR (do not resuscitate). Approaches for this care plan included Review advanced directives with resident/family periodically, Involve physician/NP (nurse practitioner) in advanced directives conversations, and document resident's advanced directive. Resident #4's clinical record was reviewed, and surveyor could not locate any information related to an advance directive. Surveyor spoke with the facility administrator on [DATE] at 2 pm regarding Resident #4's advance directive. Administrator stated the facility changed electronic health record software in [DATE], and they haven't completed uploading documents to the new record system. Administrator stated they still have access to the previous electronic health record system. Surveyor could not locate advance directive information in either system. The concern on not offering an opportunity to develop an advance directive was discussed with the administrator, director of nursing, and regional director of clinical services on [DATE] at 10:40 am. The administrator informed the surveyor on [DATE] at 12:05 that they did not have any information related to advance directives for Resident #4. No further information was provided prior to exit. 7. For Resident #16 the facility staff failed to ensure the resident had an opportunity to develop an advance directive. Resident #16's face sheet listed diagnoses which included but not limited to chronic obstructive pulmonary disease, end stage renal disease, and congestive heart failure. Resident #16's most recent minimum data set with an assessment reference date of [DATE] coded the resident as 9 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #16's clinical record was reviewed and contained an Advance Care Planning Tracking Form dated [DATE] which read in part, Resident guardian . (name omitted) stated Resident has a living will. Surveyor reviewed the clinical record and could not locate a living will. Surveyor spoke with the facility administrator on [DATE] at 2 pm regarding Resident #16's living will. Administrator stated the facility changed electronic health record software in [DATE], and they haven't completed uploading documents to the new record system. Administrator stated they still have access to the previous electronic health record system. Surveyor could not locate advance directive information in either system. The concern on not offering an opportunity to develop an advance directive was discussed with the administrator, director of nursing, and regional director of clinical services on [DATE] at 10:40 am. The administrator informed the surveyor on [DATE] at 12:05 that they did not have any information related to advance directives for Resident #16. No further information was provided prior to exit. 8. For Resident #62 the facility staff failed to ensure the resident had an opportunity to develop an advance directive. Resident #62's face sheet listed diagnoses which included but not limited to congestive heart failure, type 2 diabetes mellitus, and peripheral vascular disease. Resident #62's most recent minimum data set with an assessment reference date of [DATE] assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #62 comprehensive care plan was reviewed and contained a care plan for Resident has chosen DNR (do not resuscitate) status. Approaches for this care plan included Review code status as needed, and at least annually with resident and/or responsible party. Resident #62's clinical record was reviewed, and surveyor could not locate any information regarding advance directive planning. Surveyor spoke with the facility administrator on [DATE] at 2 pm regarding Resident #62's advance directive planning. Administrator stated the facility changed electronic health record software in [DATE], and they haven't completed uploading documents to the new record system. Administrator stated they still have access to the previous electronic health record system. Surveyor could not locate advance directive information in either system. The concern on not offering an opportunity to develop an advance directive was discussed with the administrator, director of nursing, and regional director of clinical services on [DATE] at 10:40 am. The administrator informed the surveyor on [DATE] at 12:05 that they did not have any information related to advance directives for Resident #16. No further information was provided prior to exit. 28169 9. For Resident #2, facility staff failed to ensure the resident had an opportunity to develop an advance directive. Resident #2's most recent minimum data set with an assessment reference date of [DATE] coded the resident as having long-term and short-term memory problems with severely impaired cognitive skills for daily decision making. The resident's clinical record contained a Durable Do Not Resuscitate document. The surveyor found no evidence of an advance directive or evidence facility staff provided the resident or representative written information regarding the formulation of an advance directive. The administrator reported the facility transitioned from one clinical record software system to their current software system in [DATE]. The administrator acknowledged facility staff have maintained access to the previous software system. On [DATE] at 2:32 p.m. during a meeting with the administrator, director of nursing, and regional nurse consultant, the concern regarding Resident #2's advance directive was discussed. On [DATE] at 12:05 p.m., the administrator informed the survey team that he was unable to find anything on Advanced Directives for any of the residents the survey team had discussed which included Resident #2. No further information was provided prior to the exit conference. 10. For Resident #38, facility staff failed to ensure the resident had an opportunity to develop an advance directive. Resident #38's most recent minimum data set with an assessment reference date of [DATE] coded the resident's brief interview for mental status score a 5 out of 15 in section C, cognitive patterns. This score indicated a severe cognitive impairment. The resident's clinical record contained a Durable Do Not Resuscitate document. The surveyor found no evidence of an advance directive or evidence facility staff provided the resident or representative written information regarding the formulation of an advance directive. The administrator reported the facility transitioned from one clinical record software system to their current software system in [DATE]. The administrator acknowledged facility staff have maintained access to the previous software system. On [DATE] at 2:32 p.m. during a meeting with the administrator, director of nursing, and regional nurse consultant, the concern regarding Resident #38's advance directive was discussed. On [DATE] at 12:05 p.m., the administrator informed the survey team that he was unable to find anything on Advanced Directives for any of the residents the survey team had discussed with administration which included Resident #38. No further information was provided prior to the exit conference. 11. For Resident #42, facility staff failed to ensure the resident had an opportunity to develop an advance directive. Resident #42's most recent minimum data set with an assessment reference date of [DATE] coded the resident's brief interview for mental status score an 8 out of 15 in section C, cognitive patterns. This score indicated a moderate cognitive impairment. The resident's clinical record contained a Durable Do Not Resuscitate document. The surveyor found no evidence of an advance directive or evidence facility staff provided the resident or representative written information regarding the formulation of an advance directive. The administrator reported the facility transitioned from one clinical record software system to their current software system in [DATE]. The administrator acknowledged facility staff have maintained access to the previous software system. On [DATE] at 2:32 p.m. during a meeting with the administrator, director of nursing, and regional nurse consultant, the concern regarding Resident #42's advance directive was discussed. On [DATE] at 12:05 p.m., the administrator informed the survey team that he was unable to find anything on Advanced Directives for any of the residents the survey team had discussed which included Resident #42. No further information was provided prior to the exit conference. 12. For Resident #50, facility staff failed to ensure the resident had an opportunity to develop an advance directive. Resident #50's most recent minimum data set with an assessment reference date of [DATE] coded the resident as having long-term and short-term memory problems with severely impaired cognitive skills for daily decision making. The resident's clinical record contained a Durable Do Not Resuscitate document. The surveyor found no evidence of an advance directive or evidence facility staff provided the resident or representative written information regarding the formulation of an advance directive. The administrator reported the facility transitioned from one clinical record software system to their current software system in [DATE]. The administrator acknowledged facility staff have maintained access to the previous software system. On [DATE] at 2:32 p.m. during a meeting with the administrator, director of nursing, and regional nurse consultant, the concern regarding Resident #50's advance directive was discussed. On [DATE] at 12:05 p.m., the administrator informed the survey team that he was unable to find anything on Advanced Directives for any of the residents the survey team had discussed which included Resident #50. No further information was provided prior to the exit conference. 49622 13. For Resident #75, the facility staff failed to ensure the resident and/or the resident's representative had the opportunity to develop an advanced directive. Resident #75's diagnosis list indicated diagnoses that included, but were not limited to, Unspecified Dementia, Adult Failure to Thrive, Chronic Kidney Disease, and Herpes Simplex Myelitis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of [DATE], indicated the resident was severely impaired in cognitive skills for daily decision making with short and long-term memory deficits. No BIMS (brief interview for mental status) score was indicated in Section C for cognitive patterns of the MDS. Review of Resident #75's clinical record failed to provide evidence of the facility staff addressing whether the resident and/or the resident's representative desired to formulate an advanced directive. On [DATE] at 11:04 AM, Administrative Staff #4 stated there was no evidence for advance directives or advance directive education for Resident #75 and/or the resident's representative. This concern was discussed at the end of day meeting on [DATE] at 2:32 PM with administrator, director of nursing, and regional director of clinical services, and again at the pre-exit meeting on [DATE] at 5:03 PM with the above noted staff and the regional vice president of operations. No further information was provided to the survey team prior to the exit conference on [DATE].

Based on staff interview and clinical record review, the facility staff failed to ensure residents were free of significant medication errors for 1 of 9 closed record reviews. (Resident #279). The findings were: For Resident #279, facility staff failed to administer Insulin Lispro (1 Unit dial) Solution Pen-Injector 100 UNIT/ML according to hospital discharge orders. Resident #279's stay at the facility was approximately two (2) days. The admission record listed diagnoses which included but not limited to sepsis, and osteomyelitis, left ankle and foot. The acute care hospital discharge summary listed the active problem of type 2 diabetes mellitus with complication, with long-term current use of insulin. Resident #279's minimum data set (MDS) Kardex Report listed the resident's cognition having ok short-term and long-term memory. The resident was able to recall the season, room location, staff names/faces, and that the resident was in a nursing home. The MDS Kardex read the resident was independent with daily decision making. The provider orders included but were not limited to, two (2) insulin orders. One order dated 01/07/2023 was for Insulin Lispro Kwikpen 100 unit/1 ml insulin pen. Inject as per sliding scale: If 100 - 120 = 10 units; 151 - 200 = 14 units; 201 - 250 = 18 units; 251+ = 22 units, subcutaneously three times a day for DMII (diabetes mellitus type 2). This provider order's sliding scale did not address blood sugar results between 121 and 150. The second insulin order read, Basaglar KwikPen Solution Pen-Injector 100 units/ml (Insulin Glargine). Inject 42 units subcutaneously two times a day for diabetes mellitus type 2. The medication administration record (MAR) for January 2023 was reviewed and noted three (3) times when the Insulin Lispro Kwikpen dose was not administered. Those doses were documented as a 3 which the chart code defined as no insulin required. 1. On 01/07/23 at 6:00 a.m., the blood sugar = 137 with no insulin administered. 2. On 01/07/23 at 2:00 p.m., the blood sugar = 143 with no insulin administered. 3. On 01/08/23 at 6:00 a.m., the blood sugar = 75 with no insulin administered. On 09/05/24 at 4:26 p.m., the staff development coordinator, (licensed practical nurse - LPN #4) was interviewed about the insulin and sliding scale provider order that did not include orders for blood sugars between 121 and 150. LPN #4 reported facility staff use hospital discharge orders to document facility admission orders for residents. The nurse stated the insulin sliding scale orders had been transcribed incorrectly which resulted in an insulin administration error. LPN #4 provided the acute care hospital discharge summary and pointed out the Insulin Lispro (1 Unit Dial) 100 unit/ml pen injector order read to inject subcutaneously three times a day before meals using a sliding scale: 100 - 150 = 10 units; 151 - 200 = 14 units; 201 - 250 = 18 units; greater than 250 = 22 units. LPN #4 acknowledged that if facility staff had transcribed the insulin sliding scale from the hospital discharge orders correctly, Resident #279 should have received insulin for two of the three doses when the resident did not receive any insulin: the blood sugar = 137 and the blood sugar = 143. The MAR noted the Basaglar KwikPen Solution (Insulin Glargine) doses were administered on 01/07/23 for both doses however, the 01/08/23 9:00 a.m. dose was not administered with a chart code listed as 19 which was defined as Other/See Nurses Notes. No nurses note for that date and time was found in the progress notes. The surveyor was unable to determine the exact time Resident #279 left the facility. The MAR did not contained documentation to indicate Resident #279 refused insulin. The concern regarding Resident #279's insulin sliding scale transcription error and subsequent missed insulin doses was discussed with the administrator, director of nursing, regional nurse consultant, and vice president of operations on 09/05/24 at 5:05 p.m. On 09/05/24 at 4:16 p.m., this surveyor unsuccessfully attempted to contact the nurse who admitted Resident #279. The nurse who provided care to the resident during day shift no longer worked at the facility. No further information was provided prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure appropriate information is documented and/or communicated to the receiving healthcare institution for 1 of 31 sampled residents Resident #26. The findings included: For resident # 26 the facility staff failed to provide evidence that the receiving healthcare facility was provided adequate information to care for the resident on 3/31/24. Resident # 26's diagnoses included but were not limited to Type 2 diabetes, chronic obstructive pulmonary disease, protein calorie malnutrition, congestive heart failure, hypertension, depression and chronic kidney disease. The minimum data set (MDS) assessment with an assessment reference date of 8/16/24 assigned the resident a brief interview for mental status score of 15 out of 15 indicating intact cognition. During a review of the clinical record, a progress note dated 3/31/24 at 11:16 PM read, Patient present with confusion and hallucination. Patient daughter called requesting that the patient be sent out. ____ called and stated that another course of action needed to be taken and to not send the patient out. Writer went into patient room again and patient is still hallucinating. Patient states that kids are in her room and that things are crawling on the ceiling and the walls trying to get her. Writer is waiting on call back from ____ as to course of action to take. ____ called back and stated to send patient to the ER. No further information was documented in the notes. Surveyor was unable to locate a transfer form in the record. On 9/5/24 at 11:14 AM this surveyor interviewed corporate staff # 4. Surveyor asked for evidence that the staff communicated all pertinent information to the receiving hospital including contact information of the practitioner responsible for the care of the resident, resident representative contact information, advance directives, special instructions and/or precautions for ongoing care; special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions, the resident's comprehensive care plan goals, and all other information necessary to meet the resident's needs. They stated, They didn't even do the transfer form or anything. On 9/5/24 at 4:44 PM the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultant, and Regional VP of Operations. This concern was discussed with them at that time. No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer a pneumococcal vaccine in accordance with nationally recognized standards for 3 of 5 sampled residents reviewed for immunizations (Resident #42, #49, and #72). The findings included: 1. For Resident #42, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 15 (PCV15) or a pneumococcal conjugate vaccine 20 (PCV20) following admission to the facility. Resident #42's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Parkinson's Disease, and Generalized Muscle Weakness. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/02/24 assigned the resident a brief interview for mental status (BIMS) summary score of 8 out of 15 indicating the resident was moderately cognitively impaired. Resident #42 was over the age of [AGE] years when admitted to the facility. Surveyor reviewed Resident #42's clinical record and was unable to locate a pneumococcal vaccination history or evidence the resident was offered a PCV15 or PCV20 following admission to the facility. The Centers for Disease Control and Prevention (CDC) guideline titled, Recommended Adult Immunization Schedule for Ages [AGE] years or Older dated 12/28/23 read in part that adults age [AGE] years or older who have not previously received a dose of PCV13 (pneumococcal conjugate vaccine 13), PCV15, or PCV20 or whose previous vaccination history is unknown should receive one dose of PCV15 or PCV20. Surveyor met with the Infection Preventionist (IP) and Administrative Staff Member (ASM) #4 on 9/04/24 at 2:50 PM and discussed Resident #42's pneumococcal vaccination status. The IP and ASM #4 were unable to provide evidence of the facility offering the resident a PCV15 or PCV20 following admission. Surveyor requested and received the facility policy titled, Resident Vaccination Policy with a last revision date of 5/18/22 which read in part, Resident and/or their responsible party will be asked about prior vaccinations at admission. Prior doses of .pneumococcal .and other vaccines will be documented in the immunization portal in the electronic health record .The Infection Preventionist will track resident immunizations and holds the responsibility for ensuring resident's vaccination history is reviewed with/by their providers and that vaccines are administered timely when ordered . On 9/04/24 at 3:14 PM, the survey team met with the Administrator, Director of Nursing, and Regional Clinical Services Manager and discussed the concern of staff failing to offer Resident #42 a pneumococcal vaccine. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24. 2. For Resident #49, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 20 (PCV20) or a pneumococcal polysaccharide vaccine 23 (PPSV23) following admission to the facility. Resident #49's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Aortic Valve Stenosis, and Essential Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/13/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #49 was over the age of [AGE] years when admitted to the facility. Resident #49's clinical record revealed the resident had previously received a pneumococcal conjugate vaccine 13 (PCV13) in 2016 and a PPSV23 in 2018 prior to admission and before age 65. Surveyor was unable to locate evidence of Resident #49 being offered a PCV20 or PPSV23 following admission to the facility. The Centers for Disease Control and Prevention (CDC) guideline titled, Recommended Adult Immunization Schedule for Ages [AGE] years or Older dated 12/28/23 read in part that adults [AGE] years or older who have previously received both PCV13 and PPSV23 but no PPSV23 was received at age [AGE] years or older should receive 1 dose of PCV20 or 1 dose of PPSV23. Surveyor met with the Infection Preventionist (IP) and Administrative Staff Member (ASM) #4 on 9/04/24 at 2:50 PM and discussed Resident #49's pneumococcal vaccination status. The IP and ASM #4 were unable to provide evidence of the facility offering the resident a PCV20 or PPSV23. Surveyor requested and received the facility policy titled, Resident Vaccination Policy with a last revision date of 5/18/22 which read in part, Resident and/or their responsible party will be asked about prior vaccinations at admission. Prior doses of .pneumococcal .and other vaccines will be documented in the immunization portal in the electronic health record .The Infection Preventionist will track resident immunizations and holds the responsibility for ensuring resident's vaccination history is reviewed with/by their providers and that vaccines are administered timely when ordered . On 9/04/24 at 3:14 PM, the survey team met with the Administrator, Director of Nursing, and Regional Clinical Services Manager and discussed the concern of staff failing to offer Resident #49 a pneumococcal vaccine. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24. 3. For Resident #72, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 15 (PCV15) or a pneumococcal conjugate vaccine 20 (PCV20) following admission to the facility. Resident #72's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease of Native Coronary Artery, Dementia, and Adult Failure to Thrive. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/13/24 assigned the resident a brief interview for mental status (BIMS) summary score of 10 out of 15 indicating the resident was moderately cognitively impaired. The MDS documented Resident #72's pneumococcal vaccination was not up to date with the reason being not offered. Resident #72 was over the age of [AGE] years when admitted to the facility. Surveyor reviewed Resident #72's clinical record and was unable to locate a pneumococcal vaccination history or evidence the resident was offered a PCV15 or PCV20 following admission to the facility. The Centers for Disease Control and Prevention (CDC) guideline titled, Recommended Adult Immunization Schedule for Ages [AGE] years or Older dated 12/28/23 read in part that adults age [AGE] years or older who have not previously received a dose of PCV13 (pneumococcal conjugate vaccine 13), PCV15, or PCV20 or whose previous vaccination history is unknown should receive one dose of PCV15 or PCV20. Surveyor met with the Infection Preventionist (IP) and Administrative Staff Member (ASM) #4 on 9/04/24 at 2:50 PM and discussed Resident #72's pneumococcal vaccination status. The IP and ASM #4 were unable to provide evidence of the facility offering the resident a PCV15 or PCV20 following admission. Surveyor requested and received the facility policy titled, Resident Vaccination Policy with a last revision date of 5/18/22 which read in part, Resident and/or their responsible party will be asked about prior vaccinations at admission. Prior doses of .pneumococcal .and other vaccines will be documented in the immunization portal in the electronic health record .The Infection Preventionist will track resident immunizations and holds the responsibility for ensuring resident's vaccination history is reviewed with/by their providers and that vaccines are administered timely when ordered . On 9/04/24 at 3:14 PM, the survey team met with the Administrator, Director of Nursing, and Regional Clinical Services Manager and discussed the concern of staff failing to offer Resident #72 a pneumococcal vaccine. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24.

Based on observation and staff interview, the facility staff failed to maintain infection prevention and control practices during medication administration for 1 of 2 nursing units, Unit #1. The findings included: For Unit #1, the licensed practical nurse (LPN) placed a resident's inhaler in their uniform pocket to transport into the resident's room prior to administration. On 9/05/24 at 8:43 AM, surveyor observed LPN #5 place a resident's Breo inhaler in the pocket of their uniform top to transport to the resident's room. LPN #5 removed the inhaler from their pocket and handed it to the resident for administration. When asked about placing the Breo inhaler in their pocket, LPN #5 stated they did not know if the resident would have tissues available in their room for use with their eye drops so they took theirs from the medication cart causing them to have extra items in their hands and they did not want to make two trips. On 9/05/24 at 10:40 AM, the survey team met with the Administrator, Director of Nursing, and Clinical Services Manager and discussed the concern of LPN #5 placing a resident's inhaler in their uniform pocket. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24.

Based on staff interviews, clinical record reviews, and facility document review, the facility staff failed to ensure a complete and/or accurate clinical record for 3 of 31 sampled residents, Resident #379, Resident #9, and Resident #62. The findings include: 1. For Resident #379, the facility staff failed to document the resident's allergy to the medication Hydrocodone in the clinical record. This was a closed record review. Resident #379's diagnosis list indicated diagnoses, which included, but not limited to End Stage Renal Disease, Edema, Depression, Dependence on Renal Dialysis, Type 2 (two) Diabetes Mellitus with Diabetic Neuropathy, Chronic Obstructive Pulmonary Disease, Weakness, and Retention of Urine. The minimum data set (MDS) with an assessment reference date (ARD) of 3/22/23 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of the clinical record revealed Resident #379 had no known allergies on the face sheet, provider's orders, care plan, and on the March 2023 MAR (medication administration record). Further review of an H & P (history and physical exam) dated 3/5/23 from the transferring hospital, revealed Resident #379 had an allergy to Hydrocodone-Acetaminophen. A facility document titled, Nursing Admission Report, indicated resident had an allergy to Hydrocodone. This concern was discussed with the administrator and administrative staff #4 on 9/5/24 at 9:45 AM and again at the pre-exit meeting on 9/5/24 at 5:03 PM with the administrator, director of nursing, regional director of clinical services, and regional vice president of operations. Surveyor requested and received a facility policy titled Physician/Provider Orders, that read in part, .PROCEDURE .All information received from the referring facility or agency shall be reviewed. 1. Transcribe all orders from the transfer form to the facility admission physician order form. Orders should include the following .l. Allergies . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/5/24. 47299 2. For resident # 9, the facility staff failed to ensure a complete and accurate Social Services Annual Evaluation. Resident # 9's diagnoses included but were not limited to chronic obstructive pulmonary disease, history of stroke, moderate protein calorie malnutrition, adult failure to thrive and major depressive disorder. During a review of the clinical record an order for DNR (do not resuscitate) status was observed. There were no advanced directives in the record. An annual Social Services Evaluation with an effective date of 5/23/23 was reviewed. The document stated that resident # 9 had a Living Will. On 9/5/24 at 9:29 AM this surveyor asked the Regional Nurse Consultant for a copy of resident # 9's Living Will. On 9/5/24 at 10:26 AM this surveyor asked Registered Nurse (RN) # 3 if they were aware of resident # 9 having a Living Will. They did not and stated it would be in the electronic record if there was one. When informed of the Social Services Annual Assessment they stated, It was marked incorrectly. On 9/5/24 at 4:44 PM the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultant and Regional VP of Operations. This concern was discussed at that time. No other information was provided to the survey team prior to the exit conference. 34307 3. For Resident #62 the facility staff failed to accurately complete a Virginia Department of Health Durable Do Not Resuscitate (DDNR) form. Resident #62's face sheet listed diagnoses which included but not limited to congestive heart failure, diabetes mellitus, and peripheral vascular disease. Resident #62's most recent minimum data set with an assessment reference date of 08/03/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #62's comprehensive care plan was reviewed and contained a care plan for Resident has chosen DNR (do not resuscitate) status. Resident #62's clinical record was reviewed and contained a Virginia Department of Health DDNR for which read in part, I, the undersigned, state that I have a [NAME] fide physician/patient relationship with the patient named above. I have certified in the patient's medical record that he/she or a person authorized to consent on the patient's behalf has directed that life-prolonging procedures be withheld or withdrawn in the event of cardiac or respiratory arrest. I further certify (must check 1 or 2): No boxes were check under this section. The form went on the read, If you checked 2 above, check A, B, or C below: No boxes in this section were checked. Surveyor spoke with the regional director of clinical services (RDCS) on 09/05/24 at 10:20 am regarding Resident #62's DDNR form. RDCS stated that form was incomplete. The concern of the incomplete DDNR form was discussed with the administrator, director or nursing, and RDCS on 09/05/24 at 10:30 am. No further information was provided prior to exit.

Based on observation and staff interview, the facility staff failed to store food in accordance with professional standards for food service safety in the facility kitchen. The findings included: The facility staff failed to discard seven (7) containers of unsweetened coconut milk that had exceeded the best by date of 5/13/24. On 9/04/24 at 9:30 AM, in the presence of the Dietary Manager (DM), the surveyor observed seven (7) 32-ounce containers of unsweetened coconut milk each with a best if used by date of 5/13/24 present in the dry storage area of the facility kitchen. The DM removed the containers of unsweetened coconut milk from the dry storage area. On 9/05/24 at 10:40 AM, the survey team met with the Administrator, Director of Nursing, and the Clinical Services Manager and discussed the concern of out-of-date coconut milk present in the facility kitchen. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to obtain a provider ordered laboratory test for 1 of 22 residents, Resident #20. The findings included: For resident # 20, the facility staff failed to obtain a Depakote level on 11/22/23 per physician's order. Resident # 20's diagnoses included but were not limited to unspecified dementia, bipolar disorder and depression. Resident # 20's minimum data set (MDS) assessment with an assessment reference date of 6/8/24 indicated that resident is severely cognitively impaired, they are rarely/never understood, rarely never understands others and decision making is severely impaired as well. During a review of resident # 20's Medication Regimen Reviews for the last year, a pharmacist Consultation Report with a date of 12/19/23, read in part, .has orders for labs but at the time of this review they were not available in the medical record. The missing lab values include: Depakote level every Wed related to bipolar disorder .Unless otherwise indicated, please ensure that ordered labs are obtained. Please disregard recommendation if these labs have been recently obtained. The report was signed by the Director of Nursing (DON) on 1/16/24. This surveyor was unable to locate the lab results in the clinical record. The orders were reviewed and an order for the lab work was noted, it was dated 11/21/23. The treatment administration record (TAR) for November 2023 was reviewed. The order for the lab was on the TAR to be obtained on 11/22/23. The order had not been signed off as done on the TAR. On 9/5/24 at 2:19 PM this surveyor spoke with the DON and asked if they could provide the results of the Depakote level done on 11/22/23. At 2:26 PM Licensed Practical Nurse (LPN) # 3 brought in labs dated 1/3/24 and 1/10/24. They stated they were not able to locate any labs from 11/22/23 and that they had even checked with the contracted lab provider. When surveyor asked why the lab wasn't done, they stated, I'm not sure. It was missed. The survey team met with the DON, Administrator, Regional Nurse Consultant and Regional VP of Operations on 9/5/24 at 4:44 PM. This concern was discussed at that time. No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to follow provider orders for 2 of 9 closed record reviews, Residents #229 and #379. The findings include: 1. For Resident #229, the facility staff failed to complete provider ordered treatments to a surgical wound. Resident #229's diagnoses included, muscle weakness, need for assistance with personal care, diabetes, and non-pressure related chronic ulcer of other part of left foot. Section C (cognitive patterns) of Resident #229's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 04/04/23 included a brief interview for mental status (BIMS) score of 15. Per the MDS manual a score of 15=cognitively intact. Resident #229's comprehensive care plan included the focus area resident has risk of skin breakdown and actual impaired skin integrity. Interventions included administer medications/treatments as ordered. The clinical record included the following progress note documented on the residents admission to the facility .Wound type is skin graft .Wound Location left heel .Area is community acquired. Skin impairment was present on admission . On 03/08/23 the nursing staff documented a progress note indicating the surgical incision wound location was the left plantar foot and lateral foot. Treatment updated to pack with normal saline moist gauze. A review of the clinical record revealed that on March 9, 10, and 31 the treatment administration blocks where the nursing staff would have documented that they had completed the treatment were left blank. For the month of April, the nursing staff had failed to document they had completed the treatment on April 1 and 11. For the month of May the facility nursing staff failed to document they had completed the provider ordered treatment on May 8 and 19. On 09/04/24 at 4:10 p.m., during an interview with Licensed Practical Nurse #6 this staff stated they remembered this resident having dressings to their feet but did not recall them saying anything about the treatments not being completed. On 09/05/24 at 2:14 p.m., during an interview with the Regional Nurse Consultant this staff was asked what a blank spot (hole) on the treatment administration record (TAR) where nursing would document they had completed a treatment would mean. The Nurse Consultant stated it could mean it wasn't done or they just forgot to sign for the treatment. On 09/05/24 at 2:45 p.m., the Administrator, Director of Nursing (DON), and Regional Nurse Consultant were made aware that there was no evidence to indicate the facility nursing staff had completed the provider ordered treatments to Resident #229's surgical wound for the dates provided in March, April and May of 2023. No evidence was provided to the survey team to indicate these treatments had been completed by the nursing staff prior to the exit conference on 09/05/24. 49622 2. For Resident #379, the facility staff failed to follow a provider's order for the resident to be NPO (nothing by mouth) for a scheduled medical procedure on 3/29/23. This was a closed record review. Resident #379's diagnosis list indicated diagnoses, which included, but not limited to End Stage Renal Disease, Edema, Depression, Dependence on Renal Dialysis, Type 2 (two) Diabetes Mellitus with Diabetic Neuropathy, Chronic Obstructive Pulmonary Disease, Weakness, and Retention of Urine. The minimum data set (MDS) with an assessment reference date (ARD) of 3/22/23 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of the clinical record revealed a nursing progress note dated, 3/28/2023, that read in part, .Follow up appointment made for 3/29/23 with an arrival time of 1130am [sic], surgery time scheduled for 130pm [sic]. Resident is NPO after midnight for the procedure . A provider's order dated 3/28/24, that read in part, .NPO diet NPO texture for Upcoming surgery for 1 (one) Day . Surveyor requested and received Resident #379's meal intake record that revealed a code of 3 (three) on 3/29/23, which indicated the resident had eaten 76%-100% of breakfast on the day of the scheduled surgical procedure. On 9/5/24 at 10:52 AM, administrative staff #4 agreed that resident received breakfast on 3/29/23, prior to the scheduled medical procedure. The medical procedure was performed, but the resident was not able to have anesthesia for the procedure. This concern was discussed with the administrator and administrative staff #4 on 9/5/24 at 9:45AM and again at the pre-exit meeting on 9/5/24 at 5:03 PM with the administrator, director of nursing, regional director of clinical services, and regional vice president of operations Surveyor requested and received a facility policy title, Physician/Provider Orders, that read in part, .The Charge Nurse shall .review all physician/provider orders . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/5/24.

Based on staff interview and clinical record review the facility staff failed to ensure an accurate minimum data set (MDS) assessment for 2 of 9 closed record reviews, Resident #76 and Resident #25. The findings included: 1. For Resident #76 the facility staff incorrectly coded the resident's discharge MDS assessment. Resident #76's face sheet listed diagnoses which included but not limited to cellulitis and diabetes mellitus. Resident #76's discharge MDS with an assessment reference date of 06/14/24 coded the resident as being discharged to short-term general hospital (acute hospital). Resident #76's clinical record contained a nurse's progress note dated 06/14/24 which read in part, Resident discharged home with home health services. His transportation via wheelchair took him to his residence. All medications and paperwork was taken by the resident. Resident signed for his narcotics and other medications. Vital signs are within normal limits. All personal belongings were taken by the resident. Nursing educated resident on fall precautions and resident verbalized understanding. NP (nurse practitioner) approved all orders. Surveyor spoke with registered nurse (RN) # 1 on 09/04/24 at 4:40 pm. Surveyor asked RN #1 where resident discharged to, and RN #1 stated, He discharged home on 06/14/24. Surveyor asked RN #1 where resident's MDS read that they were discharged to, and RN #1 looked at MDS and stated, It says he discharged to the hospital, that's not right. RN #1 stated they would do a correction to the MDS. The concern with the incorrectly coded MDS was discussed with the administrator, director of nursing, and regional director of clinical services on 09/05/24 at 10:30 am. No further information was provided prior to exit. 28567 2. For Resident #25, the facility staff failed to complete a discharge minimum data set (MDS) assessment. Resident #25's diagnoses included, but were not limited to, diabetes and dementia. During the Resident Assessment task Resident #25 had flagged for an MDS assessment over 120 days old. During the record review the surveyor was unable to find a discharge MDS assessment when the Resident had been discharged from the facility On 09/04/24 at 4:36 p.m., during an interview with MDS coordinator #1 and #2 both staff were asked about a discharge MDS assessment for Resident #25. After reviewing the clinical record these staff confirmed that a discharge MDS assessment had not completed and stated they had switched software systems in March of 2024. Under the census tab in the clinical record, the facility staff had documented this resident had been discharged in April 2024 return not anticipated. On 09/04/24 at 2:30 p.m., during a meeting with the Administrator, Director of Nursing, and Regional Nurse Consultant the concern with the missing discharge MDS assessment was reviewed. Prior to the exit conference the MDS coordinators provided the surveyor with a copy of a form (no title) indicating they had completed Resident #25's discharge assessment and it had been accepted. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on Staff interview, clinical record review and facility document review, the facility staff failed to provide evidence of a bed hold being provided to 2 of 31 residents, Residents #26 and #71. The findings included: 1. Resident # 26's diagnoses included but were not limited to Type 2 diabetes, chronic obstructive pulmonary disease, protein calorie malnutrition, congestive heart failure, hypertension, depression and chronic kidney disease. The minimum data set (MDS) assessment with an assessment reference date of 8/16/24 assigned the resident a brief interview for mental status score of 15 out of 15 indicating intact cognition. During a review of the clinical record, a progress note dated 3/31/24 at 11:16 PM read, Patient present with confusion and hallucination. Patient daughter called requesting that the patient be sent out. ____ called and stated that another course of action needed to be taken and to not send the patient out. Writer went into patient room again and patient is still hallucinating. Patient states that kids are in her room and that things are crawling on the ceiling and the walls trying to get her. Writer is waiting on call back from ____ as to course of action to take. ____ called back and stated to send patient to the ER. No further information was documented in the notes. Surveyor was unable to locate a transfer form in the record. On 9/5/24 at 11:14 AM this surveyor interviewed Corporate staff # 4. Surveyor asked for evidence that the staff provided the resident or resident representative with the bed hold policy. They stated, They didn't even do the transfer form or anything. On 9/5/24 at 4:44 PM the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultant, and Regional VP of Operations. This concern was discussed with them at that time. No further information was provided to the survey team prior to the exit conference. 49622 2. For Resident #71, the facility staff failed to provide the resident and/or the resident's representative with the facility bed-hold policy upon transfer on 5/8/24 and 7/5/24. Resident #71's diagnosis list indicated diagnoses that included, but were not limited to, Prostate Cancer, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Congestive Heart Failure, Depression and Candidal Cystitis, and Urethritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/15/24, assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating Resident #71 was cognitively intact. A review of the clinical record indicated Resident #71 was transferred to the hospital on 5/8/24 and on 7/5/24. No evidence of the facility's bed-hold policy being provided to the resident and/or the resident's representative could be located. On 9/5/24 at 11:05 AM, corporate staff #4 (CS#4) informed surveyor that no evidence could be located of the bed hold being given to Resident #71 and/or resident's representative for the transfers to the hospital on 5/8/24 and 7/5/24. This concern was discussed at the pre-exit meeting on 9/5/24 at 5:03 PM with the administrator, director of nursing, regional director of clinical services, and regional vice president of operations. Surveyor requested and received a facility document, titled, Resident Discharge/Transfer Letter Policy, that read in part, .G. The resident or responsible party will receive a bed hold notice .3. A copy of the completed bed hold notice will be scanned into the electronic chart . Surveyor also received a facility document titled, BED HOLD NOTICE, that read in part, .This notice is to be provided to the resident and his/her representative at the time of transfer. In the case of an emergency, the paperwork should be provided within 24 (twenty-four) hours . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/5/24.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer an updated 2023-2024 COVID-19 vaccine for 1 of 5 sampled residents (Resident #49), failed to provide evidence of education regarding the risks, benefits and potential side effects of the COVID-19 vaccine prior to the administration for 2 of 5 sampled residents (Resident #2 and #42), and failed to provide evidence of consent prior to the administration of a COVID-19 vaccine for 1 of 5 sampled residents (Resident #42). The findings included: 1. For Resident #49, the facility staff failed to offer the resident an updated 2023-2024 formula COVID-19 vaccine. Resident #49's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Aortic Valve Stenosis with Insufficiency, and Essential Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/13/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. A review of Resident #49's clinical record revealed their most recent COVID-19 vaccine was received on 2/02/23. Surveyor was unable to locate evidence of the resident being offered an updated 2023-2024 COVID-19 vaccine. Surveyor met with the Infection Preventionist (IP) and Administrative Staff Member (ASM) #4 on 9/04/24 at 2:50 PM and discussed Resident #49's COVID-19 vaccination status. The IP and ASM #4 were unable to provide evidence of the facility offering the resident an updated 2023-2024 COVID-19 vaccine. Surveyor requested and received the facility policy titled Resident Vaccination Policy with a last revision date of 5/18/22 which read in part .COVID vaccination will be offered to all residents and administered per provider orders .The Infection Preventionist will track resident immunizations and holds the responsibility for ensuring resident's vaccination history is reviewed with/by their providers and that vaccines are administered timely when ordered . On 9/04/24 at 3:14 PM, the survey team met with the Administrator, Director of Nursing, and the Regional Clinical Services Manager and discussed the concern of staff failing to offer Resident #49 an updated 2023-2024 formula COVID-19 vaccine. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24. 2. For Resident #42, the facility staff failed to provide evidence of the resident/resident representative (RR) receiving education regarding the risks, benefits, and potential side effects and obtaining consent prior to the administration of a COVID-19 vaccine. Resident #42's diagnosis list indicated diagnoses, which included, but not limited to Parkinson's Disease, Type 2 Diabetes Mellitus, and Generalized Muscle Weakness. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/02/24 assigned the resident a brief interview for mental status (BIMS) summary score of 8 out of 15 indicating the resident was moderately cognitively impaired. A review of Resident #42's clinical record revealed they received a COVID-19 vaccine on 6/27/24. Surveyor was unable to locate documentation indicating the resident and/or resident representative was provided education regarding the risks, benefits and potential side effects of the vaccine or consent was obtained prior to administration. On 9/04/24 at 2:50 PM, surveyor met with the Infection Preventionist (IP) and Administrative Staff Member (ASM) #4 who confirmed they were also unable to locate evidence of Resident #42's receiving education or providing consent prior to the administration of the COVID-19 vaccine. Surveyor requested and received the facility policy titled Resident Vaccination Policy with a last revision date of 5/18/22 which read in part .When a vaccination is ordered, a nurse or other licensed clinician/provider will review the CDC Vaccine Information Statement[s] (VIS) or Emergency Use Authorization (EUA) Statement[s] for any recommended vaccines with the resident/resident representative before obtaining consent. The resident/representative will have an opportunity to ask questions . On 9/04/24 at 3:14 PM, the survey team met with the Administrator, Director of Nursing, and the Regional Clinical Services Manager and discussed the concern of staff failing to provide education and obtain consent prior to the administration of a COVID-19 vaccine for Resident #42. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24. 3. For Resident #2, the facility staff failed to provide evidence of the resident/resident representative (RR) receiving education regarding the risks, benefits, and potential side effects prior to the administration of a COVID-19 vaccine. Resident #2's diagnosis list indicated diagnoses, which included, but not limited to Multiple Sclerosis, Schizophrenia, and Dementia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/08/24 assessed the resident as rarely/never able to make self understood and rarely/never able to understand others. Resident #2 was assessed as being severely impaired in cognitive skills for daily decision making. A review of Resident #2's clinical record revealed they received a Moderna Monovalent booster COVID-19 vaccine on 11/16/23. Surveyor was unable to locate documentation indicating the resident representative (RR) was provided education regarding the risks, benefits and potential side effects of the vaccine prior to administration. On 9/04/24 at 2:50 PM, surveyor met with the Infection Preventionist (IP) and Administrative Staff Member (ASM) #4 who confirmed they were also unable to locate evidence of Resident #2's RR receiving education prior to the administration of the COVID-19 vaccine. Surveyor requested and received the facility policy titled Resident Vaccination Policy with a last revision date of 5/18/22 which read in part .When a vaccination is ordered, a nurse or other licensed clinician/provider will review the CDC Vaccine Information Statement[s] (VIS) or Emergency Use Authorization (EUA) Statement[s] for any recommended vaccines with the resident/resident representative before obtaining consent. The resident/representative will have an opportunity to ask questions . On 9/04/24 at 3:14 PM, the survey team met with the Administrator, Director of Nursing, and the Regional Clinical Services Manager and discussed the concern of staff failing to provide education prior to the administration of a COVID-19 vaccine for Resident #2. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to honor the residents preference of eating meals in the dining room for 1 of 22 current residents, Resident #3. The findings include: The facility staff failed to ensure the dining room was available for all three meals 7 days a week. Resident #3's diagnoses included, but were not limited to, mild protein calorie nutrition and diabetes. Section C (cognitive patterns) of Resident #3's significant change in status minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/03/24 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Per the MDS manual a score of 15=cognitively intact. Section GG (functional abilities and goals) was coded to indicate this resident used a wheelchair for mobility and was partial/moderate assist with eating. On 09/04/24 at 11:35 a.m., during an interview with Resident #3, this resident stated they liked to get out of their room and needed to move around. Resident #3 stated they went to the dining room for meals but was unable to go on weekends as the dining room was not open. On 09/04/24 at 11:40 a.m., during an interview with Licensed Practical Nurse (LPN) #1, this staff stated the dining room was not open on weekends due to staffing issues. On 09/04/24 at 12:30 p.m., during an interview with Certified Nursing Assistant (C.N.A.) #1 this staff stated the dining room was not open in the evenings and weekends. It was open if they have a special event. On 09/04/24 at 2:30 p.m., during a meeting with the Administrator, Director of Nursing (DON), and Regional Nurse Consultant (RNC) these staff were asked if the dining room was being utilized on weekends and nights. The Administrator stated they were not aware if it wasn't being utilized and the DON stated they had a big turn out at lunch and for breakfast on Fridays. On 09/05/24 at 8:29 a.m., the surveyor observed the housekeeping staff cleaning the floors in the dining room. No residents were observed to be in the dining area. Housekeeper #1 stated the dining room was not being used this morning and stated COVID was on the rise. This facility did not have any COVID positive cases during the time of the survey. On 09/05/24, the Dietary Manager stated the dining room was always open at mealtimes for the residents and some choose not to come. On 09/05/24 at 10:30 a.m., the Administrator, DON, and RNC, were made aware of Resident #3's concern that the dining room was not opened for all meals and that the dining room was observed by the surveyor not being utilized for breakfast this morning. The Administrator stated they did not know why it was not being used. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review and facility document review, the facility staff failed to notify the provider of a critical lab result for 1 of 9 closed records, Resident #129. The findings included: Resident # 129's diagnoses included but were not limited to history of cerebral infarction (stroke), chronic obstructive pulmonary disease, hypertension, moderate protein calorie malnutrition, depression, vitamin deficiency and depression. The minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/21/23 assigned the resident a brief interview for mental status (BIMS) score of 15 out of 15 indicating intact cognition. A review of resident # 129's medication administration record (MAR) revealed they were on aspirin 81 mg daily for CVA (stroke) prophylaxis and Eliquis (an anticoagulant medication used to treat and prevent blood clots and prevent stroke) 5 mg twice daily. Each of these medications are given to thin the blood and put the patient at risk of bleeding. There was an entry on the treatment administration record (TAR) that read, Monitor for signs and symptoms of bleeding while receiving Eliquis. Notify MD if resident has dark/discolored urine, black tarry stools, nosebleed, vomiting and/or coughing up blood. This nursing intervention is signed as done September 1, 2023, through September 10, 2023. A Nurse Practitioner (NP) progress note dated 9/10/23 read in part, She is being seen today for f/u labs. Pt is sitting up in her bed, appears comfortable and in no acute distress. A&O x3, pleasant and responsive. Resident had recent labs drawn for CBC, CMP & TSH, results were significant for H&H of 6.1/19.2 and elevated LFT's ALT 180, AST 189 & Alk Phos 757. She was sent to the ER for blood transfusion. There have been no reported fevers or hypoxia. Denies CP, abd pain, SOB or N/V. H & H is the abbreviation for hemoglobin and hematocrit. The hemoglobin of 6.1 was a critical low result and this was indicated in red lettering on the lab report. The lab results were reviewed by this surveyor and noted to have a resulted date of 9/9/23 at 5:03 PM. According to the progress notes, the critical results were not given to, or addressed by a practitioner until 9/10/23 at 2:54 PM. According to the National Center for Biotechnology, a hemoglobin of less than 6.5 is life threatening and should be considered a medical emergency. The resident was readmitted to the facility on [DATE], less than 2 weeks later. Hospital records indicate they required two units of blood for a diagnosis of a gastrointestinal bleed. A hospital progress note with a date of service of 9/11/23 read in part, .presented at (hospital name omitted) on September 10 with complaints of vomiting and anemia. She also complained of feeling lightheaded for the past month but denies blood in her stool that she was aware of. She was found to be anemic (not enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) and tachycardic (fast heart rate which is a common symptom of blood loss). On 9/5/24 at 4:44 PM this surveyor interviewed the Director of Nursing (DON) and the Regional Nurse Consultant. Surveyor asked about the delay between the lab results being available in the electronic medical record and actually being seen and addressed by the practitioner. The DON stated, They didn't call us, so we didn't know. It was just a routine lab, so we weren't looking for the results, we didn't expect any problem. They are supposed to call us when they get a critical result and then they put on the actual results who they talked to, but they didn't do that. I just don't feel like that is our fault. The Regional Nurse Consultant stated the facility has been having concerns with the lab service for some time. This surveyor reviewed the policy entitled, Resident Change in Condition Policy with an effective date of 1/27/2011. The document read in part, A Significant Change in Condition is a decline or improvement in the resident's status and 6. In the event of an emergency situation, 911 will be called immediately and the physician or provider/family/responsible party will be notified as soon as practicably possible. The survey team met with the Administrator, DON, Regional Nurse Consultant and the Regional VP of Operations on 9/5/24, this concern was discussed. No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide Notice of Medicare Non-Coverage at least two days prior to the end of a Medicare covered Part A stay when benefit days were not exhausted for 1 of 3 sampled residents, Resident #45. The findings included: For Resident #45, the facility staff failed to provide Notice of Medicare Non-Coverage at least two days prior to the end of their Medicare covered Part A stay. Resident #45's diagnosis list indicated diagnoses, which included, but not limited to Sepsis, Generalized Muscle Weakness, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Chronic Kidney Disease, and Type 2 Diabetes Mellitus. The minimum data set (MDS) with an assessment reference date (ARD) of 3/14/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #45's last covered day of Medicare Part A services was 4/03/24. A Notice of Medicare Non-Coverage (NOMNC) was issued and signed by the resident on 4/02/24. An 4/02/24 2:37 PM social services progress note read in part Notice of Medicare Non Coverage [sic] given to resident on this date. Last covered day of skilled care will be 4/03/24. Appeals and denials process explained to resident. [Resident #45] states [he/she] does not want to appeal this denial and will discharge home . On 9/05/24 at 12:57 PM, surveyor spoke with the facility social worker (SW) and inquired reason why Resident #45 was not issued a NOMNC at least two days prior to their last cover day. SW stated the NOMNC should have been signed 48 hours prior and they were not sure why it was not. Surveyor requested and received the facility policy titled Medicare Cut Letter Policy with a last revision date of 8/24/23 which read in part The Facility will assure all residents receive timely and appropriate notification of Medicare non-coverage for services in accordance with State and Federal guidelines .Notice must be issued prior to, but no later than 2 days before the termination of such services .For Residents who have days remaining in their benefit period, and will be discharged the first calendar day following their last Medicare covered day, the Social Worker, or Designee, will notify the Resident/Authorized Representative when the resident is approaching the end of coverage, but no later than 2 days prior to the last covered Medicare Part A day, by issuing the Notice of Medicare Provider Non-Coverage CMS-10123 . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24.

Based on staff interviews, clinical record review and facility's documentation, the facility staff failed to ensure 1 out of 2 residents (Resident #2) in the survey was free from abuse. Resident #2 was physically restrained to his wheelchair by tying the strings of his hospital gown to the rear bars on his wheelchair. This deficiency is cited as past non-compliance (PNC.) The finding included: Resident #2 was originally admitted the nursing facility on 04/20/22. Diagnosis for Resident #2 included but not limited to Dementia with behavioral disturbance, history of falling and muscle weakness. The most recent Minimum Data Set (MDS - an assessment protocol) a significant change assessment with an Assessment Reference Date (ARD) of 04/27/23 coded Resident #2 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. The MDS coded Resident #2 total dependence of one with bathing, extensive assistance of one with toilet use and personal hygiene, limited assistance of two with transfer, limited assistance of one with bed mobility and supervision with one assist with eating for Activities of Daily Living (ADL) care. A review of Resident #2's nurses note entered on 03/11/23 by License Practical Nurse (LPN) #2 indicated the resident was observed sitting in his wheelchair at the nurses' station. The resident had on a hospital gown with the strings of the hospital gown tied to the back of the wheelchair bar. Once the observation was made, the strings were released and the resident assessed. On 06/07/23 at 12:46 p.m., an interview was conducted with Certified Nursing Assistant (CNA) #1. The CNA stated he was not assigned to Resident #2 on 03/11/23 (7a-3p) shift. He stated Resident #2 had fallen earlier that morning but without injury. The resident kept getting out of bed without assistance, so he bathed the resident. After he had finished bathing the resident, he placed a hospital gown over top the resident's clothes and tied the strings of hospital gown to back of his wheelchair bar. He said by tying the hospital gown to the wheelchair, that would stop the resident from getting up and falling again. He stated a CNA noticed Resident #2's hospital gown was tied to the resident's wheelchair and reported it to the nurse. He stated he was told by the nurse to clock out, leave the unit and wait for the Administrator in the front lobby which he did. He stated did not realize tying the strings of a hospital gown to the resident's wheelchair was a form of abuse until he was interviewed by the Administrator that same day. License Practical Nurse (LPN) #2 was interviewed on 06/07/23 at 11:49 a.m. She stated she was assigned to Resident #2 on 03/11/23 (day shift.) She stated Resident #2 was placed at the nurse's station and was observed without any behaviors/agitation. She said Certified Nursing Assistant (CNA) #4 informed her that Resident #2 was in a hospital gown with the strings of the gown tied to the back of the wheelchair. She said she and CNA #3 and #4 rolled Resident #2 to his room, cut the hospital gown strings from the wheelchair bars, placed the resident in the bed, completed an assessment and contacted Administration of the incident. She stated the CNA #1 was informed to leave the patient care area and wait in the front lobby until Administration arrived. She stated restraining the resident using the strings of his hospital gown in a form of abuse. The Administrator was interviewed on 06/07/23 at approximately 2:25 p.m. He stated he received a phone call from the Director of Nursing (DON) on 03/11/23 around noon. He was informed Resident #2 had been observed by staff to be in a hospital gown with the strings of the gown tied to his wheelchair. He stated the staff member who had restrained Resident #2 to his wheelchair was CNA #1. He said CNA #1 was informed to immediately clock out but to remain in the front lobby, out of the resident's care area until he arrived at the facility. He stated once he arrived at the facility, the CNA was sitting in the front lobby as instructed. The CNA was taken to his office and interviewed. The CNA stated he tied the strings on Resident #2's hospital gown to the bars on the back of his wheelchair because he kept falling. The CNA stated he thought he was keeping the resident safe. On the same day, the Administrator presented a Quality Assurance and Performance Improvement (QAPI) plan dated 03/11/23. The QAPI documented the Root Cause Analysis (RCA) results for the improper use of restraints and improper/improper keep safe interventions for post fall interventions. On 06/08/23 at 12:15 p.m., a final interview was conducted with the Administrator. It was determined that the facility implemented its Corrective Action Plan, and there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of the current survey for the regulatory requirement, F-600. Corrective Action Plan, 3/11/23: Step 1a. What was done to the resident that was affected? Resident was observed by staff with the strings of a hospital gown tied to the rear bars of his wheelchair. Step 1b. What immediate interventions were for affected resident? Once the staff observed Resident #2's hospital gown strings were tied to the rear bars on his wheelchair, he was immediately taken to his room, ties were cut, assessed for injury and change in condition started on 03/11/23. The CNA who tied the strings of the resident's hospital gown was immediately taken out of the resident's care area and was interviewed and suspended by the Administrator. Step 2a. What immediate actions were taken to identify all potential affected? All interviewable residents were interviewed for the use of any type of restraints were ever used. For non-interviewable residents, skin assessments were completed for skin impairment started on 03/11/23. Step 2b. What continued and immediate interventions were implemented for identified resident or systems? All staff were educated on the facility's Abuse policy and procedures for reporting in a timely manner. All newly hired staff and agency will be educated before working in patient care areas started on 03/11/23. Step 2c. Results of all monitoring will be presented to the monthly QA Committee for analysis and recommendations for further monitoring, education, or recommendations. The facility's policy titled Abuse, Neglect and Exploitation revised 05/26/23. It is the facility policy not to tolerate abuse, neglect, mistreatment, exploitations of resident, and misappropriation of the resident's property by anyone. Definition -Abuse includes actions such as he willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It includes physical and chemical restraints.

Based on staff interviews, clinical record review and facility's documentation, the facility staff failed to ensure 1 out of 2 residents (Resident #2) in the survey sample was free from physical restraint. The Certified Nursing Assistant (CNA) used the strings from the resident's hospital gown, tied them to the rear bars of his wheelchair restricting freedom of movement. This deficiency is cited as past non-compliance (PNC.) The finding included: Resident #2 was originally admitted the nursing facility on 04/20/22. Diagnosis for Resident #2 included but not limited to Dementia with behavioral disturbance, history of falling and muscle weakness. The most recent Minimum Data Set (MDS - an assessment protocol) a significant change assessment with an Assessment Reference Date (ARD) of 04/27/23 coded Resident #2 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. The MDS coded Resident #2 total dependence of one with bathing, extensive assistance of one with toilet use and personal hygiene, limited assistance of two with transfer, limited assistance of one with bed mobility and supervision with one assist with eating for Activities of Daily Living (ADL) care. A review of Resident #2's nurses note entered on 03/11/23 by License Practical Nurse (LPN) #2 indicated the resident was observed sitting in his wheelchair at the nurses' station. The resident had on a hospital gown with the strings of the hospital gown tied to the back of the wheelchair bar. Once the observation was made, the strings were released and the resident assessed. On 06/07/23 at 12:46 p.m., an interview was conducted with CNA #1. The CNA stated he was not assigned to Resident #2 on 03/11/23 (7a-3p) shift. He stated Resident #2 had fallen earlier that morning but without injury. The resident kept getting out of bed without assistance, so he bathed the resident. After he had finished bathing the resident, he placed a hospital gown over top the resident's clothes and tied the strings of hospital gown to back of his wheelchair bar. He said by tying the hospital gown to the wheelchair, that would stop the resident from getting up and falling again. He stated a CNA noticed Resident #2's hospital gown was tied to the resident's wheelchair and reported it to the nurse. He stated he was told by the nurse to clock out, leave the unit and wait for the Administrator in the front lobby which he did. On 06/07/23 at 11:46 a.m., CNA #4 was interviewed who stated on 03/11/23, she was passing out trays when saw Resident #2 trying to raise up from his wheelchair but was unable. She stated she walked over towards the resident and observed he had on a hospital gown with the strings of the gown tied to the bar to the back of his wheelchair. She stated she immediately informed his nurse LPN #2. She stated Resident #2 was immediately taken to his room, the hospital gown strings were cut from the bars on the wheelchair. License Practical Nurse (LPN) #2 was interviewed on 06/07/23 at 11:52 a.m. She stated she was assigned to Resident #2 on 03/11/23 (day shift.) She stated Resident #2 was placed at the nurse's station and was observed without any behaviors/agitation. She said Certified Nursing Assistant (CNA) #4 informed her that Resident #2 was in a hospital gown with the strings of the gown tied to the back of the wheelchair. She said she and CNA #3 and #4 rolled Resident #2 to his room, cut the hospital gown strings from the wheelchair bars, placed the resident in the bed, completed an assessment and contacted Administration of the incident. She stated the CNA #1 was informed to leave the patient care area and wait in the front lobby until Administration arrived. An interview was conducted with CNA #3 on 06/07/23 at 12:15 p.m. CNA was assigned to Resident #2 on 03/11/23 (7a-3p) shift who stated Resident #2 was left in bed because he was combative during his morning care. She stated Resident #2 stays up late so if he is agitated, he will get up right before lunch. She stated she was shocked to see Resident #2 in a hospital gown restrained in his wheelchair. She stated she another CNA along with the resident's nurse took him to his room and cut him out of the restraints (hospital gown strings that were tied to his wheelchair.) The Administrator was interviewed on 06/07/23 at approximately 2:25 p.m. He stated he received a phone call from the Director of Nursing (DON) on 03/11/23 around noon. He was informed Resident #2 had been observed by staff to be in a hospital gown with the strings of the gown tied to his wheelchair. He stated the staff member who had restrained Resident #2 to his wheelchair was CNA #1. He said CNA #1 was informed to immediately clock out but to remain in the front lobby, out of the resident's care area until he arrived at the facility. He stated once he arrived at the facility, the CNA was sitting in the front lobby as instructed. The CNA was taken to his office and interviewed. The CNA stated he tied the strings on Resident #2's hospital gown to the bars on the back of his wheelchair because he kept falling. The CNA stated he thought he was keeping the resident safe. On the same day, the Administrator presented a Quality Assurance and Performance Improvement (QAPI) plan dated 03/11/23. The QAPI documented the Root Cause Analysis (RCA) results for the improper use of restraints and improper/improper keep safe interventions for post fall interventions. On 06/08/23 at 12:15 p.m., a final interview was conducted with the Administrator. It was determined that the facility implemented its Corrective Action Plan, and there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of the current survey for the regulatory requirement, F-604. Corrective Action Plan, 3/11/23. Step 1a. What was done to the resident that was affected? Resident was observed by staff with the strings of a hospital gown tied to the rear bars of his wheelchair. Step 1b. What immediate interventions were for affected resident? Once the staff observed Resident #2's hospital gown ties were used as a restraint, he was immediately taken to his room, ties were cut and assessed for injury or change in condition started on 03/11/23. Step 2a. What immediate actions were taken to identify all potential affected? All interviewable residents were interviewed for the use of any type of restraints were ever used. For non-interviewable residents, skin assessments were completed assessing for skin impairment started on 03/11/23. Step 2b. What continued and immediate interventions were implemented for identified resident or systems? Interviews to be completed on five (5) random residents weekly with BIMS score 12 and above concerning abuse for 12 weeks to ensure no signs/symptoms of mistreatment has occurred and 5 random skin assessment will be completed weekly on residents whose BIMS are below 12 for 12 weeks. Random staff members will be audited weekly for 6 weeks to ensure reporting and restraint policy is understood and followed started on 03/13/23. Step 2c. Results of all monitoring will be presented to the monthly QA Committee for analysis and recommendations for further monitoring, education, or recommendations. The facility policy titled Restraint revised on 03/03/23. Policy: Physical and/or chemical restraints will be initiated only after a comprehensive review determines that they are necessary to treat the resident's medical symptoms that warrant their use. Definitions -Freedom of Movement is the ability of the resident to move around within the context of the resident's functional capacity as assessed by the facility (e.g., Does the item prevent the resident from performing an action that they are otherwise capable of performing?). -Physical Restraint is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to notify the physician of missed medication for one of 15 sampled residents, Resident #212. The findings included: Resident #212 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #212's most recent comprehensive MDS (Minimum data set) assessment was an admission assessment with an ARD (assessment reference date) of 7/4/21. Resident #212 was coded as being cognitively intact in the ability to make daily decisions; scoring 13 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #212 was coded in Section J0100. (Pain Management) as not receiving scheduled pain medications in the last 5 days from the ARD date (7/4/21). Resident #212 was coded as receiving prn (as needed) pain medications in the last 5 days AND recieved non medication interventions for pain in the last 5 days. Resident #212 was coded as not having pain. Review of Resident #212's medical record revealed that Resident #212 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #212's July 2021 MAR (Medication Administration Record) revealed that Resident #212 received Tylenol 325 mg 3 tablets on 7/1/21 through 7/11/21. Review of the Emar Administration notes revealed that the Tylenol was effective on these dates for pain relief. Review of a therapy note dated 7/13/21 revealed that Resident #212 was having a pain of 8/10 during her therapy session. The following was documented in part, .Pt (patient) declined participation in therapy 2/2 (two attempts) to increased pain and fatigue. PTA (Physicial Therapy Assistant) encouraged pt (patient) to engage in seated therex (therpapy exercies), however, pt continued to decline at this time .Pt reported 8/10p (pain) in R (right knee) and requested pain meds (medications), NRSG (Nursing) made aware. Review of a note from the NP (Nurse Practitioner) dated 7/13/21 documented in part, the following: She is being seen today for c/o(complaints) right knee pain. Pt is sitting up in her w/c (wheelchair), appears comfortable and in no acute distress. A&O x3 (Alert and Oriented x3), pleasant and responsive. She has a history of repeated falls where she has a displaced fracture of her right tibia. She is c/o right knee pain that is unrelieved by Tylenol. Right knee is currently stable in a right knee brace. She currently c/o (complaints) 3-4/10 right knee pain, but tolerable . 1. Right knee pain: will give [MEDICATION(S)] (1) 50 mg 1 tab po (by mouth) Q (every) 12 x10 days. Review of Resident #212's July 2021 POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Start Date: 7/13/21 2100 (9 p.m.). Further review of Resident #212's July 2021 MAR (Medication Administration Record) revealed that her [MEDICATION(S)] was to be scheduled for 9 AM and 2100 (9:00 PM). Resident #212 did not receive her 9 p.m. dose of [MEDICATION(S)] on 7/13/21. Review of Resident #212's July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Evidence could not be shown that the nurses obtained the ordered [MEDICATION(S)] from the Omnicell (STAT box). Review of Resident #212's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #212's clincial record revealed that she was discharged home on 7/15/21 at 1:40 p.m. Review of the Omnicell list of STAT medications revealed that [MEDICATION(S)] 50 mg was a medication available in the Omnicell. On 8/4/21 at 12:02 p.m., and 4 p.m., a telephone interview was attempted with Resident #212's representative. She could not be reached for an interview. On 8/4/21 at 2:23 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #2, the nurse who worked day shift on 7/14/21. When asked the process if she were to go administer a scheduled medication; more specifically a narcotic, and it was not in the medication cart, LPN #2 stated that she would check to see if the medication was available in the STAT Omnicell. LPN #2 stated that she would then pull the medication from the Omnicell. When asked if [MEDICATION(S)] 50 mg was in the Omnicell, LPN #2 stated, Yes, I know that is in the STAT box. When asked if that is where she pulled Resident's #212's [MEDICATION(S)] on 7/14/21, LPN #2 stated, Yes, I pulled from the STAT box. On 8/4/21 at 2:30 p.m., an interview was conducted with LPN #3, the nurse who worked with Resident #212 on 7/13/21 evening shift. When asked why Resident #212 did not receive her ordered [MEDICATION(S)] on 7/13/21 at 9:00 p.m.; LPN #3 stated that the medication was not up from pharmacy. When asked the process if a medication such as a narcotic is not yet up from pharmacy and it is due to be administered, LPN #3 stated that she was new to the facility and did not have a code to get into the Omnicell system. When asked if she had asked for help regarding pulling the medication from the Omnicell system; LPN #3 stated that she told a nurse on the floor. LPN #3 stated that she wasn't sure what had happened after that. On 8/4/21 at 2:59 p.m., an interview was conducted with RN (Registererd Nurse) #2, the nurse who did not administer the scheduled [MEDICATION(S)] on 7/15/21. When asked if residents are to receive all scheduled medications prior to their discharge that are due prior to discharge; RN #2 stated, Yes. When asked if this included scheduled pain medications, RN #2 stated, Yes. When asked why Resident #212 did not receive her scheduled [MEDICATION(S)] on 7/15/21 at 9:00 a.m. prior to her discharge; RN #2 stated, She didn't have [MEDICATION(S)]. When asked what she had meant by that statement, RN #2 stated, She didn't have a narcotic card at all. RN #2 then stated that she had told the nurse (LPN #1) that she had been shadowing that day that Resident #212 did not have [MEDICATION(S)] on the medication cart. RN #2 stated that she did not have a code to access the Omnicell to see if the medication was in there. RN #2 stated that she was not sure if [MEDICATION(S)] was in the Omnicell as she still did not have a code to access Omnicell. RN #2 stated that she believed her preceptor did not administer the [MEDICATION(S)] because the resident was being sent home with a script for [MEDICATION(S)] anyway.When asked if it was acceptable for residents to not receive their ordered medications, RN #2 stated that it wasn't. On 8/4/21 at 4:30 p.m., an interview was conducted with LPN #1, the nurse who was precepting RN #2. When asked what happened to Resident #212's [MEDICATION(S)] on 7/15/21; why it was not administered, LPN #1 stated that it was not available in the medication cart. When asked the process if the medication is not in the medication cart, LPN #1 stated that she would call pharmacy to inquire about where the medication is, or what is needed to get the medication, such as a script. When asked if she recalled inquiring about Resident #212's [MEDICATION(S)], LPN #1 stated that she did not. When asked if she attempted to pull the [MEDICATION(S)] from the Omnicell, LPN #1 stated that she did not have access to the Omnicell. LPN #1 stated that they have only had the Omnicell since June of 2021. When asked who she could ask to obtain a medication from the Omnicell, LPN #1 stated that she could ask LPN #2, who was also the unit manager. LPN #1 stated that she did not ask LPN #1 to obtain the [MEDICATION(S)] from the Omnicell. When asked if she should notify the MD (Medical Doctor) that a medication was missed, LPN #1 stated that the medical doctor should be aware of every missed dose of a medication. LPN #1 stated that she did not notify the MD at the time of the missed dose of [MEDICATION(S)]. On 8/4/21 at 4:40 p.m., an interview was conducted with ASM (Administrative Staff Member) #4, the Nurse Practitioner. She could not recall being made aware that Resident #211 had missed all her doses of scheduled ordered [MEDICATION(S)]. ASM #4 stated that the physician may have been aware. ASM #4 stated that she expected the nursing staff to make her aware in order for her to give further direction. On 8/5/21 at 5 p.m., an interview was conducted with ASM (Administrative Staff Member) #2, the DON (Director of Nursing). When asked the process if a scheduled narcotic is not available in the medication cart, what nursing staff should do, ASM #2 stated that the nurses should be calling pharmacy to see the status of the medication and whether or not the medication needs a prescription. ASM #2 stated that she would expect nursing staff to obtain a script from the physician, if that is what was needed and send to pharmacy. ASM #2 stated that it takes sometime for pharmacy to verify the prescription so the nurse may not be able to get it from the Omnicell system immediately. ASM #2 stated she would then expect nursing staff to alert the physician if a medication cannot be administered for further direction. ASM #2 stated that she did expect staff to pull the medication from Omnicell if a script was available. ASM #2 confirmed that not all nurses had access to the Omnicell but that there was always someone in the building who could assist. When asked if all nurses should have access to the Omnicell if they are adminisering medications, ASM #2 stated, Yes. When asked who was responsible for ensuring all nurses had access to the Omnicell, ASM #2 stated that she was as the DON. When asked what had happened to Resident #212's [MEDICATION(S)], ASM #2 stated that she didn't see where the [MEDICATION(S)] was ever delivered to the facility. ASM #2 stated that she remembered personally getting the script for the [MEDICATION(S)] has she recalled telling the NP (Nurse Practitioner) to assess Resident #212 for an increase in pain and yelling out. ASM #2 stated that she didn't personally hear the resident yell out, but that she recalled hearing a nurse tell her this information that day. ASM #2 could not recall the nurse. ASM #2 stated that she recalled putting the order into the electronic system and scheduling it for 9:00 p.m. because the medication would have had plenty of time to get to the facility by then. ASM #2 could not recall if she was the nurse who faxed the script to the pharmacy. On 8/5/21 at 10:25 a.m., an interview was conducted with the medical records personnel at the facility's pharmacy (OSM (Other Staff Member) #3). OSM #3 stated that the pharmacy had never received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . OSM #3 stated that a script must also be in place for the nurse to access a STAT dose from the Omnicell. On 8/5/21 at 11:19 a.m., an interview was conducted with ASM #5, the physician. He could not recall being made aware that Resident #211 had missed all her scheduled doses of [MEDICATION(S)]. On 8/5/21 during a pre-exit meeting at 12:30 p.m., ASM (Administrative Staff Member) #1, the administrator, and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. Facility policy titled, Facility policy titled, Medication Shortage/Unavailable Medications documents in part, the following: Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication shortage is discovered at the time of medication administration facility staff should immediately take the action specified . 2. If a medication shortage is discovered during normal pharmacy hours: 2.1 Facility nurse should call pharmacy to determine the status of the order. If the medication has not been ordered, the licensed facility nurse should place the order or reorder for the next scheduled delivery. 2.2 If the next available delivery causes delay or missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. 2.3 If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery. 3. If the medication shortage is discovered after normal pharmacy hours: 3.1 A licensed nurse should obtain the ordered medication from the Emergency Medication Supply. 3.2 If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: 3.2.1 Emergency Delivery 3.2.2 Use of an emergency (back up) third party pharmacy. 4. If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions. (1) [MEDICATION(S)]- [MEDICATION(S)] used to treat moderate to severe pain. This information was obtained from Davis's Drug Guide for Nurses, 11th edition p. 1197. COMPLAINT DEFICIENCY

Based on a complaint investigation, observations, staff and resident interviews and facility documentation, the facility staff failed to provide care and services to prevent pressure ulcers prior to identification at an advanced stage for 2 of 36 residents (R#13 and #408) in the survey sample which constituted harm for both residents. Resident #13's sacral pressure ulcer was first identified on 3/18/21 by senior nursing management as unstageable, as well as Resident #408's sacral pressure ulcer first identified on 3/7/20 at a Stage III. The findings included: 1. Resident #13 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment was dated 1/5/21 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident was intact with the cognitive skills for daily decision making. The resident was coded to require limited assistance of one person for bed mobility, and extensive assistance from one staff for transfers, dressing, personal hygiene, toilet use and bathing. The resident was not assessed to have pressure ulcers. The resident was coded for Hospice upon admission. Resident #13 was coded continent of bowel and bladder. The care plan dated 12/30/20 and revised on 3/18/21 identified that the resident was at risk for the development of pressure ulcers. The goal set by the staff for the resident was that she would maintain intact skin. Some of the approaches the staff would implement to accomplish this goal included complete Braden Scale per protocol, skin assessments per protocol, use pressure releasing devices as indicated, turn and reposition as indicated and diet as indicated. The care plan dated 3/18/21 also identified actual skin breakdown, unstageable. The goal set by the staff for the resident was that she would have no further preventable skin breakdown thru next review. Some of the approaches the staff would implement to accomplish this goal were to add an air mattress, treatment initiated on 3/18/21 and notify medical doctor if treatment was ineffective. The Braden scale dated 1/13/21 scored the resident with a score of 17 that indicated Resident #13 was at risk for pressure ulcers, need to implement preventative interventions. The significant areas on the Braden Scale were in sensory perception, activity, mobility and friction and shear. Some of the preventative interventions that should address these specific areas and would include skin assessment and inspection every shift, regular turning schedule, enable as much activity as possible, protect heels, use pressure redistribution surfaces, nutrition consult (supplements, monitor intake, small frequent meals) and advance to a higher level of risk if other major risk factors are present (information obtained on 3/19/21 from reference dated 2014 https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar5_pu_riskassesst-tools.pdf). Review of The Bi-Weekly Skin Checks dated 3/5/21, 3/8/21, 3/11/21, 3/14/21 and 3/17/21 indicated Resident #13 did not have any current or newly identified skin issues. The following observations were made of Resident #13: On 3/16/21 at approximately 12:30 p.m., the resident was in bed with lunch tray on overbed table. On 3/16/21 at approximately 3:00 p.m., the resident was again observed in bed lying on a regular pressure reducing mattress. During the interview with the resident she was asked if there was anything this surveyor could do for her, to which she responded, I feel like something different is going on with my tailbone, maybe it is due to a fall I had, but I am not sure. I did fall out of bed straight on my [NAME]. They put cream on where I hit on the floor, but over the last couple of weeks, the pain continues a couple hours later. Now, it is giving me a fit, but I will get some more cream tonight, but it is not going to last. The Treatment Administration Record (TAR) indicated that the cream the resident was referring to was *Lidocaine 4 percent (%) to right hip and sacrum three times a day, ordered by the physician on 3/2/21. The fall the resident experienced was on 2/10/21 with no identified injuries or fractures from assessment and X-rays. *Lidocaine 4% cream is a non-greasy cream specially formulated with soothing agents, indicated as a topical anesthetic for use on normal intact skin for local [MEDICATION(S)] (Retrieved on 3/22/21 from reference dated 2019 https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a3216e25-82bb-4905-ac0b-b2ef4aa32ea0). On 3/17/21 at approximately 11:30 a.m., Resident #13 was again observed in bed. When asked how her bottom was she stated, If you do anything for me today, please have someone check my bottom, it hurts worse and worse. This is what hurts me the most now. I am trying to stay off it as best as I can. I have told my nurse, but I need them to do something other than pain medication. The pain assessment documentation indicated that the resident scored her pain on 3/17/21 for the 7:00 a.m. to 7:00 p.m. shift at a 6 out of a possible score of 10 (moderately strong pain). This surveyor approached LPN #3 and relayed the resident's complaint about her bottom. The LPN stated she would do a full skin assessment before she finished her shift at 7:00 p.m. LPN#3 filled out a Bi-Weekly Skin Check signed off on 3/17/21 at 3:02 p.m. that there were no current or new skin issues. No further nurse's notes were written by LPN #3. On 3/18/21 at 1:10 p.m., Resident #13 was observed in bed. Certified Nursing Assistant (CNA) #3 and LPN #5, who was giving the resident medications, were at the bedside. When asked how the resident was feeling, she stated, Last night a nurse put a wonderful pad on my bottom and it felt glorious, but I think it needs to be changed because it is crumpling up and starting to hurt again. CNA#3 assisted the resident to turn on her left side and a large pink foam boarded dressing was on the resident's sacral area. The distal portion of the dressing was crumpled, which enabled the CNA to peel it back and spread her buttocks. An obvious open area was identified on the resident's sacrum. The CNA said she was assigned the resident, but did not remove the pink dressing. LPN #5 also looked and stated, I have only been here 3 days. I don't know what that is. I am from the agency and I am not qualified to assess this. The LPN did not contact another nurse to assess the open area. The resident was wearing a brief and stated that sometimes she is incontinent of urine. The resident was not assessed or care planned for incontinence. On 3/18/21 at 1:40 p.m., the aforementioned concerns were shared with the Director of Nursing (DON). She stated that she nor the Unit Manager (UM) LPN #1 were made aware by any aide or nurse of the resident's complaints about her bottom or that there was an open area on the resident's sacrum, but all licensed nurses were able to assess and stage wounds. The DON said she was going to check with the agency to find out what their skills were related to assessing alteration in skin integrity to include pressure ulcers. It was shared with the DON that this surveyor told LPN #3 specifically about the resident's complaint on 3/17/21 and that the LPN stated she would complete a full skin assessment. The information was also shared with the DON that someone put a large pink foam dressing on the resident's sacrum as observed on 3/18/21 at 1:10 p.m. During the above interview, the DON called LPN #3 and asked if she performed a full skin assessment on 3/17/21 to include the resident's bottom and sacral area. LPN #3 said, I tilted her propped up some pillows at her back and gave her some pain medication, but I did not spread her buttocks to assess her sacral area. The LPN stated she was not the nurse that placed a pink foam dressing on the resident's sacrum. LPN #3 was the nurse that completed the Bi-Weekly Skin-Check dated 3/17/21 that indicated no current or new skin issues were identified. At no time did this surveyor give an opinion to the DON regarding the area identified, so that she could make her own assessment without any influence. On 3/18/21 at 15:01 p.m., the DON assessed the resident's skin to identify an *unstageable sacral pressure ulcer with 100% yellow (slough/soft dead tissue) wound bed that was not present upon admission, 0.4 centimeters (cm) length by (x) 0.3 cm width and 0.1 depth. with periwound appearance red. The DON documented that the resident's pain level was a 6 out of a possible score of 10. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated she would apply a smaller foam dressing that would conform to the resident's sacral area. The DON stated she found out from the 7:00 p.m. (3/17/21) to 7:00 a.m. (3/18/21) LPN #7 that said she did not see an open area on the resident's sacrum, and only applied a pink foam pad, without an order, for comfort because the resident stated her bottom was hurting. On 3/18/21 at 4:14 p.m., a debriefing was held with the Administrator, DON and Regional Vice President of Operations (RVPO). The UMLPN #1 stated that she expected the nurses to have informed her of Resident #13's consistent complaints of sacral pain that was different from her normal pain, but she was not made aware. The UMLPN#1 stated, The purpose of the bi-weekly skin assessments is to identify any skin problems early that are quickly treatable. It was a consensus of the group that it was acceptable to first identify pressure ulcers at an advanced stage. The DON said all in house regular mattresses are pressure reducing, and she would be communicating with Hospice to obtain an air mattress for Resident #13. They stated they have standards of care meetings in the morning, but did not have one on 3/18/21, but staff could have passed on the resident's complaints and notified the Unit Manager or the DON. The DON and the Regional Administrator stated It is obvious, we need to do some training. On 3/18/21 at 5:15 p.m., Resident #13 was observed in bed and stated she was thankful that she finally knew what the problem was and treatment would heal the area. On 3/18/21 at approximately 5:30 p.m., the DON stated she called the Hospice nurse to ask if when she came to see the resident, on 3/18/21 at 11:30 a.m., did she identify the pressure ulcer on the resident's sacrum. According to the DON, the Hospice nurse said she completed a full skin assessment and did not identify any pressure ulcer, but she was on her way back to nursing facility. The DON stated, It is clear that it that a thorough skin assessments are not being performed by the nurses to include the Hospice nurse, especially along with the resident's complaint of pain in that area where the pressure ulcer was located. Because of the laxity of her skin, they needed to have spread her buttocks apart, not just turn her and take a look. You would not see anything otherwise. On 3/18/21 at approximately 6:45 p.m., the RVPO presented an action plan with Root Cause Analysis for pressure ulcers that identified Not repositioning every 2 hours, increase in agency usage and early identification. It incorporated education of clinical staff on the importance of turning and repositioning residents, educate clinical staff on pressure ulcer staging, including agency staff and to educate C.N.A. to inform nurses of any identified skin issues. The following information was retrieved on 3/22/21 from the 2020 National Pressure Injury Advisory Panel (NPIAP) www.npiap.com 1. Consider bedfast and chairfast individuals to be at risk for development of pressure injury. Inspect the skin at least daily for early signs of pressure injury, especially nonblanchable [CONDITION(S)]. Assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters, elbows and beneath medical devices. Consider bedfast and chairfast individuals to be at risk for development of pressure injury. 2. Use a structured risk assessment, such as the Braden Scale, to identify individuals at risk for pressure injury as soon as possible. Refine the assessment by including these additional risk factors: Fragile skin. Existing pressure injury of any stage, including those ulcers that have healed or are closed. Pain in areas of the body exposed to pressure Repeat the risk assessment at regular intervals and with any change in condition. 3. Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface . Consider level of immobility, exposure to shear, skin moisture, perfusion, body size and weight of the individual when choosing a support surface. Continue to reposition an individual when placed on any support surface. Use a breathable incontinence pad when using microclimate management surfaces. 2. The facility's staff failed to identify Resident #408's sacral pressure ulcer until it advanced to a stage 3 deteriorating to unstageable by 3/12/20 and the facility staff failed to demonstrate it was unavoidable. Resident #408 was originally admitted to the facility 2/6/20. The Resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/3/20 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicated Resident #408's cognitive abilities for daily decision making were moderately impaired. In section G (Physical functioning) the resident was coded as requiring extensive assistance of one person with bed mobility, transfers, personal hygiene, bathing, dressing, and toileting, and supervision after set-up with eating. Resident #408 was no longer a resident of the facility therefore; a closed record review was conducted. Resident #408 had the following risk factors for skin breakdown; fragile skin, a low body weight with fair intake, decreased bed mobility related to a fractured right tibial plateau, and episodes of incontinence. Review of the resident's current care plan dated 2/19/20, addressed skin tears only not a potential for pressure ulcers or an actual pressure ulcer was present, with a goal date through 5/19/20. The problem read; (name of resident) has impaired skin integrity as evidenced by skin tears to the right forearm. The goal read; Resident will demonstrate improvement of skin integrity within 30 days 5/19/20. The interventions included; encourage meal consumption and fluid intake, monitor nutritional parameters, assist resident to eat/drink an adequate amount of nutrition, monitor lab values, follow prescribed treatment regimen, protective measures when in chair or bed, observe skin condition daily for skin excoriation, apply protective undergarments/pads, avoid constricting clothes, use bed cradle, foam mattress to avoid skin breakdown, provide adequate hydration, provide adequate nutrition, vitamins, protein carbohydrates, avoid pressure on extremities with skin protectors, assess actual areas of breakdown and document on skin sheet, keep skin clean and dry, position resident for comfort and minimal pressure on bony prominences. Braden and Skin assessments were requested for Resident #408, but only skin assessments dated 3/9/20, 3/22/20 and 3/31/20 were provided after multiple request. The 3/9/20 Daily Skilled Nurse's Note skin assessment was coded for abnormal skin color, macerated bottom and turn and reposition. The 3/22/20 skin assessment was coded for having fair, pale and moist skin, skin [CONDITION(S)] or open wounds, bruises and ecchymosis. A 3/31/20, Daily Skilled Nurse's Note skin assessment was coded for assessment pressure ulcers only. A nurses's note dated 3/7/20 at 6:40 p.m., revealed the resident required one person assistance with activities of daily living, and the resident uses a bedpan but experiences episodes of incontinence. The nurse's note also stated the resident was identified with a facility acquired stage 3 pressure ulcer measuring 3 centimeters x 2 centimeters. The wound care assessment dated [DATE] further described the sacral pressure ulcer as having 70% granulation tissue and 30% soft adherent necrotic tissue. The 3/7/20 pressure ulcer assessment further revealed the sacral pressure was with moderate serosanguineous exudate with distinct and attached edges. The following order was obtained; clean the wound to the sacrum with normal saline, apply calcium alginate, cover with Allevyn. The sacral wound's etiology was determined to be pressure related and the pressure ulcer continued to deteriorate based on the wound care physician assessment dated [DATE]. It measured 2.2 centimeters by 1.6 centimeters, and was unstageable as revealed by 70% thick adherent black necrotic tissue (eschar) and 30% thick adherent devitalized necrotic tissue. Surgical excision of the devitalized and necrotic subcutaneous tissue was performed. A new treatment order was ordered by the wound care physician, it read; clean the wound with normal saline, apply Santyl ointment, apply Dakins moist gauze and cover. The wound care physician's progress note also stated the resident verbalized pain of a 6 out of 10. The wound care physician offered further recommendations to off-load the wound, reposition the resident per facility protocol and use of a low air loss mattress. On 3/18/20 at approximately 3:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultants. An opportunity was offered to the facility's staff to present additional information. It appears in the body of this writing. Assessment 1. Consider bedfast and chairfast individuals to be at risk for development of pressure injury. 2. Use a structured risk assessment, such as the Braden Scale, to identify individuals at risk for pressure injury as soon as possible (but within 8 hours after admission). 3. Refine the assessment by including these additional risk factors; Fragile skin, Existing pressure injury of any stage, including those ulcers that have healed or are closed, Impairments in blood flow to the extremities from vascular disease, diabetes or tobacco use, Pain in areas of the body exposed to pressure. 4. Repeat the risk assessment at regular intervals and with any change in condition. Base the frequency of regular assessments on acuity levels: Acute care . Every shift, Long term care . Weekly for 4 weeks, then quarterly, Home care . At every nurse visit (https://npiap.com/general/custom.asp?page=PreventionPoints) 5. Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. If the risk is from malnutrition, address those problems. Preventing pressure ulcers Pressure ulcers are also called bedsores, or pressure sores. They can form when your skin and soft tissue press against a harder surface, such as a chair or bed, for a prolonged time. This pressure reduces blood supply to that area. Lack of blood supply can cause the skin tissue in this area to become damaged or die. When this happens, a pressure ulcer may form. You have a risk of developing a pressure ulcer if you: · Spend most of your day in a bed or a chair with minimal movement · Are overweight or underweight · Are not able to control your bowels or bladder · Have decreased feeling in an area of your body · Spend a lot of time in one position You will need to take steps to prevent these problems; You, or your caregiver, need to check your body every day from head to toe. Pay special attention to the areas where pressure ulcers often form. These areas are the: · Heels and ankles, Knees, Hips, Spine, Tailbone area, Elbows, Shoulders and shoulder blades, Back of the head Ears. After urinating or having a bowel movement; Clean the area right away. Dry well., Ask your provider about creams to help protect your skin in this area. *Call your health care provider if you see early signs of pressure ulcers. These signs are: Skin redness, Warm areas, Spongy or hard skin, Breakdown of the top layers of skin or a sore. (https://medlineplus.gov/ency/patientinstructions/ 7.htm) *Unstageable pressure ulcer/injury is a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage III or Stage IV pressure injury will be revealed (retrieved on 3/22/21 from document Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 42, 2019). *Dakins solution is a dilute sodium [MEDICATION(S)] (NaClO) solution that is commonly known as bleach. The mixture of sodium peroxide (NaO) and [MEDICATION(S)] acid (HCl) produces sodium [MEDICATION(S)]. It has a solvent action on dead cells that hastens the separation of dead tissue from living tissue (retrieved on 3/22/21 from reference dated 2021 https://www.ncbi.nlm.nih.gov/books/NBK 6/). COMPLAINT DEFICIENCY

Based on observations, clinical record reviews, facility documentation, and staff interviews the facility staff failed to identify facility acquired pressure ulcers prior to them developing to an advanced stage resulting in harm for 2 of 22 residents in the survey sample, Resident #5 and #13. 1. The facility staff failed to identify a Stage III Sacrum Pressure Ulcer prior to it developing to an Advanced Stage on 2/17/16 for Resident #5, which constitutes harm. 2. The facility staff failed to identify a Stage III Left Ankle Pressure Ulcer prior to it developing to an Advanced Stage on 1/13/16 for Resident #13, which constitutes harm. The findings included: 1. Resident #5 was a [AGE] year old admitted to the facility initially on 6/20/07 and readmitted on [DATE] with [DIAGNOSES REDACTED].**Diabetes Mellitus, ***Chronic Pain, ****[MEDICAL CONDITION], *****Depression, and ******Obesity. The most recent comprehensive Minimum Data Set (MDS) assessment was a Significant Change with an Assessment Reference Date (ARD) of 3/1/16. The Brief Interview for Mental Status (BIMS) was a 15 out of a possible 15 which indicated that Resident #5 was cognitively intact and capable of daily decision making. Under Section G Functional Status the resident was coded extensive two person assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. Under Balance During Transitions and Walking the resident was coded as follows: Moving from seated to standing position = 2, not steady, only able to stabilize with staff assistance; Walking, Turning around, Moving on and off toilet = 8, Activity did not occur; Surface to surface transfer = 2, not steady, only able to stabilize with staff assistance. Under Section H Bladder and Bowel Resident #5 was coded 1= occasionally incontinent (less than 7 episodes of incontinence) for both. The resident was coded under Section K as 63 inches in height and 248 pounds in weight. Under Weight Loss/Weight Gain the resident was coded 0, indicating that there was no gain or loss of 5% in the last month or 10% in the last 6 months. Under Skin Conditions Resident #5 was coded as having one Stage III pressure ulcer measuring 1.5 cm (centimeters) x 1.0 cm x 0.3 cm. The most severe tissue type for any pressure ulcer being a 4 indicating Eschar-black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin. Resident was also coded to have pressure reducing devices for her chair and bed, on a turning and repositioning program, pressure ulcer care with application of ointments/medications other than to feet. Resident #5's Comprehensive Care Plan dated 11/27/15-3/21/16 documented in part, as follows: Problems: Resident #5 at risk of pressure ulcer r/t (related to) her decreased mobility and history of incontinence/skin impairment. (9/23/15). Interventions: -weekly skin inspections with referrals to wound care specialist/pcp (patient care provider) as indicated. -Check skin for redness, skin tears, swelling, or pressure areas. Report any signs of skin breakdown. Problems: Stage 3 pressure ulcer SACRUM onset 2/17/16 Interventions: -Assess and record the size (L x W x D) (length x width x depth), amount and characteristics of exudates, and pain status. 1 Time Weekly Starting 2/17/16. -Perform complete skin assessment and record. I Time Weekly Starting 2/17/16. -Provided care according to the protocol for Stage 3 Pressure Ulcer. -ROHO cushion to chair when OOB (out of bed). During the survey Resident #5 was observed up in the wheelchair on 4/26/16, 4/27/16, 4/28/16, and 4/29/16 throughout the day with no ROHO cushion (pressure relief cushion) in place for pressure relief. Resident #5's April 2016 Physician order [REDACTED]. The Director of Nursing was asked for all Braden Scales for Predicting Pressure Sore Risk for Resident #5 that had been completed the past year. Only 2 Braden Scales were completed and documented in part, as follows: 5/13/15 Sensory Perception-No Impairment Moisture-Rarely Moist Activity-Chair Fast Mobility-Slightly Limited Nutrition-Adequate Friction and Shear-No Apparent Problem Braden Score-19=No Risk 9/1/15 Sensory Perception-No Impairment Moisture-Occasionally Moist Activity-Chair Fast Mobility-Slightly Limited Nutrition-Adequate Friction and Shear-Potential Problem Braden Score-17=At Risk The Director of Nursing was asked for a copy of all Weekly Skin Assessments for Resident #5 for February and March 2016. The following Weekly Skin Assessments were reviewed and documented in part, as follows: Date Created: 2/9/16 11:02 p.m. Does this patient have a Pressure Ulcer?-0-No Completed Signature: (Nurse's Name) Date/Time Stamped 2/10/16 12:02 a.m. Date Created: 2/17/16 1:08 a.m. Does this patient have a Pressure Ulcer?-0-No Completed Signature: (Nurse's Name) Date/Time Stamped 2/17/16 2:08 a.m. Date Created: 3/9/16 5:22 a.m. Does this patient have a [MEDICAL CONDITION] or an Open Wound?-1-Yes Does this patient have a Pressure Ulcer?-1-Yes Completed Signature: (Nurse's Name) Date/Time Stamped 3/9/16 6:22 a.m. Weekly Skin Assessments for Resident #5 dated 2/23/15 and 3/2/16 could not be found per the Director of Nursing. Resident #5's Clinical Note dated 2/17/16 at 12:15 p.m., approximately 10 hours after the Weekly Skin Assessment was signed completed with no identified Pressure Ulcers, documented in part, as follows: Writer in with wound MD (Medical Doctor) this am to assess patients sacral wound. Patients sacrum has 50% necrotic tissue and 50% granulation tissue and has moderate amount of serous drainage. We will do santyl daily. Patient refuses debridement and made aware of risks of not having wound debrided. Patient tolerated well and denies pain. (Wound Nurse name) Resident #5's Weekly Skin Condition Progress Report was reviewed and documented in part, as follows: Type of Wound: Pressure Ulcer Wound Location: sacrum Date of Onset: 2/17/16 Contributing Factors: Incontinence Assessment Date: 2/17/16 Stage of Ulcer: Stage III Wound Size: length (cm) 2.0 Width (cm) 1.0 Depth (cm) 0.3 Tissue Type: Granulating 50%, Necrotic 50% Exudate: Moderate Exudate Color: Straw/Red Assessment Date: 2/24/16 Stage of Ulcer: Stage III Wound Size: length (cm) 1.5 Width (cm) 1.0 Depth (cm) 0.3 Tissue Type: Granulating 40%, Necrotic 10% Exudate: Moderate Exudate Color: Straw/Red Assessment Date: 3/2/16 Stage of Ulcer: Stage III Wound Size: length (cm) 1. Width (cm) 0.5 Depth (cm) 0.3 Tissue Type: Granulating 80%, Slough 20% Exudate: Moderate Exudate Color: Straw Assessment Date: 3/9/16 Stage of Ulcer: Stage III Wound Size: length (cm) 0.5 Width (cm) 0.3 Depth (cm) 0.2 Tissue Type: Granulating 95%, Slough 5% Exudate: Moderate Exudate Color: Straw/Red The Wound Care Specialist Evaluations for Resident #5 were reviewed and documented in part, as follows: 2/17/16 History of Present Illness: Chief Complaint: Patient has a wound on their sacrum. HPI (history of physical illness) Statement: She presents with a stage 3 pressure wound of the sacrum of at least 1 days duration. Appetite: Good Focused Wound Exam: Etiology: Pressure MDS 3.0 Stage: 3 Duration >1 days Wound Size: 2.0 x 1.0 x 0.3 cm Surface Area: 2.00 cm (centimeter) squared Exudate: Moderate Serous Yellow Necrotic: 50% Granulation Tissue: 50% Dressing: Santyl-Once Daily Coordination of Care: Data and history pertinent to this patient's care were obtained via Nursing Staff, Patient. This patient's care was discussed with another health care provider Nursing Staff Member during this visit. 3/16/16 History of Present Illness: Chief Complaint: Patient has a wound on their sacrum. HPI (history of physical illness) Statement: She presents with a stage 3 pressure wound of the sacrum of at least 25 days duration. Prior healing wound has improved and required confirmation of current clinical status and evaluation with preventive recommendations to prevent recurrence. Appetite: Good Focused Wound Exam: Etiology: Pressure MDS 3.0 Stage: 3 Duration >25 days Objective: Healing Wound Progress: Resolved 3/16/16 Coordination of Care: Data and history pertinent to this patient's care were obtained via Nursing Staff, Patient. This patient's care was discussed with another health care provider Nursing Staff Member during this visit. The facility policy titled Physician Approved Pressure Ulcer-Prevention Orders/Protocol not dated , documented in part: All Residents 3. All Residents are assessed for pressure ulcer risk on admission; weekly times four weeks, then quarterly, with significant change and annually using the Braden scale. Re-evaluate if a pressure ulcer is identified. 6. Weekly skin inspections. 7. Apply Moisture/barrier after incontinence episodes. 8. Develop patient-specific written care plan for pressure ulcer prevention. The facility policy titled Pressure Ulcer Prevention revised 11/12/16 documented in part; Policy Statement: To prevent development of pressure ulcers. *All Residents are assessed for pressure ulcer risk on admission, every week times 4 after admission, quarterly, with significant change and annually using the Braden scale. *Weekly skin inspections are conducted and documented on all residents by licensed staff. *Complete weekly skin inspection form. *Turning and repositioning frequency is dependent on resident assessment and chart on TAR (Treatment Administration Record). *Pressure ulcer prevention order set is implemented based on need. The facility policy titled Guidelines of Care-Pressure Sores revised 2/10/15 documented in part: Purpose: Residents entering facility without pressure sores do not develop them unless the individual's condition demonstrates that they were unavoidable. Procedure: 1. Facilities will provide routine preventive and daily care including turning and proper positioning, application of pressure reduction or relief devices, skin care, provision of clean and dry bed linens, and maintenance of adequate nutrition and hydration. 2. A determination that development of a pressure sore was unavoidable may be made only if aggressive routine preventive and daily care, and appropriate preventive measures and care specific to the resident ' s unique risk factors, were provided. 3. Nursing facilities will document interventions, based on each resident ' s risk factors and strengths, on the interdisciplinary plan of care. If objectives are not met, alternative approaches will be developed. The facility policy titled Standard and Required Characteristics-Skin Conditions revised 6/18/15 documented in part: Purpose: Resident's are provided with care to prevent and treat skin breakdown. Procedure: 3. Residents do not develop skin breakdown unless their medical condition makes breakdown unavoidable. The facility policy titled Skin Inspection revised 5/13/14 documented in part: 1. Weekly skin inspections must be completed on all residents. On 4/28/16 at approximately 5:30 p.m. a pre-exit debriefing was held with the Administrator and the Director of Nursing and the above information was shared. The Director of Nursing was asked what were her expectations of her staff in regards to pressure ulcers. The Director of Nursing stated, I expect the nurses to assess the residents and recognize them (pressure ulcers) early on before they get to an advanced stage. When asked what was expected in regards to Resident #5's physician ordered ROHO cushion, the Director of Nursing stated, I expect the nurses to follow the physician orders. The following outline document was provided by the Administrator prior to exit documented in part, as follows: Allegation: Facility did not identify pressure ulcer until it reached a Stage III level. 2/16/16 Skin assessment completed indicating no pressure ulcer. Care Plan meeting with family-no indication of Pressure Ulcer Discussed with patient diet recommendations and patient agrees to follow. Patient non-compliant with diet, 2/17/16 Pressure ulcer to sacrum identified as Stage III by Name (Wound Care Physician). This assessment places doubt regarding the accuracy that this was, in fact a Stage III. 3/3/16 Dietary note indicates non-compliant with diet. 3/4/16 Patient non-compliant with care. 3/11/16 Patient continues to be non-compliant with care. This patient is alert and oriented with a BIMS score of 15. On 5/2/16 at 11:48 a.m. a phone interview was conducted with the Wound Care Physician. The Wound Care Physician was made aware of the above statement regarding the accuracy of her wound care assessment of Resident #5 on 2/17/16. The Wound Care Physician stated, That was never brought to my attention that they were questioning my assessments of any resident. I'm visible every week to them if they have a concern. I touch base with the Director of Nursing and the Clinical Manager weekly of anything new, worse, or changed, I give updates. This was definitely a Stage III pressure ulcer. On 5/2/16 at approximately 2:00 p.m. after reviewing the above document presented by the Administrator, the Administrator was informed of the Wound Care Physician's comments. The Administrator was also reminded that the skin assessment was not completed until the 11-7 shift on 2/16/16 with it being signed completed on 2/17/16. In regards to the Care Plan meeting with the family on 2/16/16 there was no documentation to show a skin check was completed during this meeting and it is not the family's responsibility to monitor for pressure ulcers. The resident's MDS addressed no significant gains or loss of weight in the past 6 months. The findings dated 3/3/16, 3/4/16, and 3/11/16 regarding non-compliance of the resident were identified 16 days after the facility acquired Stage III sacrum pressure ulcer was identified. On 5/2/16 at approximately 2:30 p.m. the Administrator and the Director Of Nursing provided documentation indicating on 2/10/16 a Mock Survey Audit was conducted in the facility. The Mock Survey Audit revealed issues with pressure ulcers. On 2/29/16 an Action Plan was developed stating: Problem Pressure Ulcers are at unfavorable targets. The facility plan of correction was reviewed by 2 surveyors, the Administrator, and the Director of Nursing. During the review of the Plan of Correction it was noted under Weekly Skin Assessments audits were only completed for one week in March , and under Braden Scale there were no March audits. Under action, Clinical Manager to audit treatments weekly no audits were available. Under action, Assessment of Adequate Surfaces for Treatment Prevention no audits had been completed. Based on the lack of audits to show that a functioning corrective Action Plan was in place and the fact the identified deficient areas had not been corrected prior to the start of the survey Past Non-Compliance was not offered at exit. Prior to exit no further information was provided. *Stage III Pressure Ulcer: Full thickness tissue 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 tissue loss. May include undermining and tunneling. Definition derived from the Minimum Data Set (MDS) Assessment-Version 3.0 **Diabetes Mellitus: a complex disorder of carbohydrates, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion by the beta cells of the pancreas or resistance to insulin. ***Chronic Pain: pain that continues or recurs over a prolonged period, caused by various diseases or abnormal conditions. *****[MEDICAL CONDITION]: a form of arthritis in which one or many joints undergo [MEDICAL CONDITION] changes, including bony [MEDICAL CONDITION], loss of cartilage, bone spurs, and cartilage in the joints. ******Depression: a decrease of vital functional activity, a mood disturbance characterized by feelings of sadness, despair, and discouragement resulting from and normally proportionate to some personal loss or tragedy. *******Obesity: an abnormal increase in the proportion of fat cells, mainly in the viscera and subcutaneous tissues of the body. The above definitions were derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition. 2. Resident #13 was a [AGE] year old originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED].**Hypertension, ***[MEDICAL CONDITION], and ****[MEDICAL CONDITION]. The most recent Minimum Data Set (MDS) assessment was a Quarterly with an Assessment Reference Date (ARD) of 3/1/16. The Brief Interview for Mental Status (BIMS) was a 15 out of a possible 15 which indicated that Resident #5 was cognitively intact and capable of daily decision making. Under Section G Functional Status the resident was coded extensive two person assist for bed mobility and total dependence for bathing. Under Functional Limitation in Range of Motion Resident #3 was coded as having Upper and Lower extremity impairment on both sides. The resident was 65 inches in height and 146 pounds in weight. Under Weight Loss/Weight Gain the resident was coded 0, indicating that there was no gain or loss of 5% in the last month or 10% in the last 6 months. Under Skin Conditions the resident was coded as being at risk of developing pressure ulcers. Resident #5's Comprehensive Care Plan dated 9/22/14-3/7/16 documented in part, as follows: Problems: Resident #13 at risk of pressure ulcer r/t (related to) his being mostly bedfast. Goal: Resident #13 will remain free of skin breakdown over the next 90 days. Goal date: 3/3/16 Interventions: *Use pillows, pads, or wedges to reduce pressure on heels and pressure points. Turn/reposition. *Weekly skin assessments, Check skin for redness, skin tears, swelling, or pressure areas. Report any signs of skin breakdown The Director of Nursing was asked for all Braden Scales for Predicting Pressure Sore Risk for Resident #13 that had been completed the past year. Only 1 Braden Scale was completed and documented in part, as follows: 11/30/15 Sensory Perception-Slightly Limited Moisture-Occasionally Moist Activity-Chair Fast Mobility-Very Limited Nutrition-Adequate Friction and Shear-Potential Problem Braden Score-15=At Risk The Director of Nursing was asked for a copy of all Weekly Skin Assessments for Resident #13 for December 2015, January 2016, and February 2016. Based on the surveyor's observation in the electronic medical record for Resident #13, there was no evidence of documented Weekly Skin Assessments for the above months. The Director of Nursing also stated, We did not find any Weekly Skin Assessments for the time frame you requested for the resident. Resident #13's April Physician order [REDACTED]. The Wound Care Specialist Evaluations for Resident #13 were reviewed and documented in part, as follows: 1/13/16 History of Present Illness: Chief Complaint: Patient has a wound on their ankle. HPI (history of physical illness) Statement: He presents with a stage 3 pressure wound of the left lateral ankle of at least 1 days duration. Appetite: Good Focused Wound Exam: Etiology: Pressure MDS 3.0 Stage: 3 Duration >1 days Wound Size: 0.4 x 0.5 x 0.2 cm (centimeter) Surface Area: 0.20 cm squared Exudate: Light Sero-Sanguinous Yellow Necrotic: 30% Granulation Tissue: 70% Dressing: Santyl-Once Daily Coordination of Care: Data and history pertinent to this patient's care were obtained via Nursing Staff, Patient. This patient's care was discussed with another health care provider Nursing Staff Member during this visit. 1/20/16 History of Present Illness: Chief Complaint: Patient has a wound on their ankle. HPI (history of physical illness) Statement: He presents with a stage 3 pressure wound of the left , lateral ankle of at least 7 days duration. Appetite: Good Focused Wound Exam: Etiology: Pressure MDS 3.0 Stage: 3 Duration >7 days Wound Size: 0.3 x 0.2 x 0.2 cm Surface Area: 0.06 cm squared Exudate: Light Sero-Sanguinous Yellow Necrotic: 15% Granulation Tissue: 85% Wound Progress: Improved Dressing: Santyl-Once Daily Coordination of Care: Data and history pertinent to this patient' s care were obtained via Nursing Staff, Patient. This patient's care was discussed with another health care provider Nursing Staff Member during this visit. 1/27/16 History of Present Illness: Chief Complaint: Patient has a wound on their ankle. HPI (history of physical illness) Statement: He presents with a stage 3 pressure wound of the left lateral ankle of at least 13 days duration. Appetite: Good Focused Wound Exam: Etiology: Pressure MDS 3.0 Stage: 3 Duration >13 days Wound Progress: Resolved 1/21/16 Coordination of Care: Data and history pertinent to this patient's care were obtained via Nursing Staff, Patient. This patient's care was discussed with another health care provider Nursing Staff Member during this visit. On 4/28/16 at 4:15 p.m. a phone interview was conducted with the Wound Care Physician after Resident #13's Wound Care Specialist Evaluations were reviewed. The Wound Care Physician was asked if Resident #13's pressure ulcer to the left lateral ankle was indeed a pressure area. The Wound Care Physician stated, If I document pressure, it's pressure. I call it like I see it. Resident #13's Clinical Notes were reviewed and documented in part, as follows 1/14/16 at 3:43 p.m. Writer in with wound MD (Medical Doctor) on 1/13/16 to assess area to patients left lateral ankle. Patient in bed at the time and ankle had light amount of sero sangious drainage with no foul odor. Patient has 30% yellow necrotic tissue and 70 % granulation tissue. Patient tolerated well and denied pain and treatment provided as ordered. Wound Nurse 1/19/16 at 9:45 a.m. Discussed in SOC (standards of care) mtg (meeting); new stg (stage ) 3 to left ankle rlt (related to) positioning; resident is contracted. Dietary 1/21/16 at 11:14 a.m. Writer in patients room with wound MD on 1/20/16 to see patients left lateral ankle. Patients left ankle has 15% yellow necrotic tissue and 85% granulation tissue with light sero sangious drainage. Patients ankle is improving with decreased surface area and increased granulation. We will continue with santyl daily and patient tolerated well and denied any pain. Patient continues to wear prevalon boots. Resident #13's Weekly Skin Condition Progress Report was reviewed and documented in part, as follows: Type of Wound: Pressure Ulcer Wound Location: Left Lat (lateral) Ankle Date of Onset: NO DATE Contributing Factors: Immobility Assessment Date: 1/14/16 Stage of Ulcer: Stage III Wound Size: length (cm) 0.4 Width (cm) 0.5 Depth (cm) 0.2 Tissue Type: Granulating 70%, Slough 30% Exudate: Small Exudate Color: Straw/Red Odor Present: No Assessment Date: 1/20/16 Stage of Ulcer: Stage III Wound Size: length (cm) 0.3 Width (cm) 0.2 Depth (cm) 0.2 Tissue Type: Granulating 85%, Necrotic 15% Exudate: Small Exudate Color: Straw/Red Odor Present: No The facility policy titled Physician Approved Pressure Ulcer-Prevention Orders/Protocol not dated, documented in part, read as: All Residents 3. All Residents are assessed for pressure ulcer risk on admission; weekly times four weeks, then quarterly, with significant change and annually using the Braden scale. Re-evaluate if a pressure ulcer is identified. 6. Weekly skin inspections. 7. Apply Moisture/barrier after incontinence episodes. 8. Develop patient-specific written care plan for pressure ulcer prevention. The facility policy titled Pressure Ulcer Prevention revised 11/12/16 documented in part, read as; Policy Statement: To prevent development of pressure ulcers. *All Residents are assessed for pressure ulcer risk on admission, every week times 4 after admission, quarterly, with significant change and annually using the Braden scale. *Weekly skin inspections are conducted and documented on all residents by licensed staff. *Complete weekly skin inspection form. *Turning and repositioning frequency is dependent on resident assessment and chart on TAR (Treatment Administration Record). *Pressure ulcer prevention order set is implemented based on need. The facility policy titled Guidelines of Care-Pressure Sores revised 2/10/15 documented in part: Purpose: Residents entering facility without pressure sores do not develop them unless the individual's condition demonstrates that they were unavoidable. Procedure: 1. Facilities will provide routine preventive and daily care including turning and proper positioning, application of pressure reduction or relief devices, skin care, provision of clean and dry bed linens, and maintenance of adequate nutrition and hydration. 2. A determination that development of a pressure sore was unavoidable may be made only if aggressive routine preventive and daily care, and appropriate preventive measures and care specific to the resident ' s unique risk factors, were provided. 3. Nursing facilities will document interventions, based on each resident ' s risk factors and strengths, on the interdisciplinary plan of care. If objectives are not met, alternative approaches will be develope The facility policy titled Standard and Required Characteristics-Skin Conditions revised 6/18/15 documented in part: Purpose: Resident's are provided with care to prevent and treat skin breakdown. Procedure: 3. Residents do not develop skin breakdown unless their medical condition makes breakdown unavoidable. The facility policy titled Skin Inspection revised 5/13/14 documented in part: 1. Weekly skin inspections must be completed on all residents. On 4/28/16 at approximately 5:30 p.m. a pre-exit debriefing was held with the Administrator and the Director of Nursing and the above information was shared. The Director of Nursing was asked what were her expectations of her staff in regards to pressure ulcers. The Director of Nursing stated, I expect the nurses to assess the residents and recognize them (pressure ulcers) early on before they get to an advanced stage. The following outline document was provided by the Administrator prior to exit documented in part, as follows: Allegation: Facility did not identify pressure ulcer until it reached a Stage III level. 1/13/16 Pressure ulcer to left lateral ankle identified as Stage III by (Name Wound Care Physician). Depth of .2 would indicate doubt regarding the accuracy that this was, in fact a Stage III. 1/27/16 Pressure area noted as healed. This short healing time would further lead to doubt that assessment on 1/13/16 was accurately classified as a Stage III. On 5/2/16 at 11:48 a.m. a phone interview was conducted with the Wound Care Physician. The Wound Care Physician was made aware of the above statement regarding the accuracy of her wound care assessment including depth of pressure area of Resident #13 on 1/13/16 by the facility. The Wound Care Physician stated, That was never brought to my attention that they were questioning my assessments of any resident. I'm visible every week to them if they have a concern. I touch base with the Director of Nursing and the Clinical Manager weekly of anything new, worse, or changed, I give updates. This was definitely a Stage III pressure ulcer. I also have a problem with that because there is no extra tissue on an ankle, a 0.2 depth can absolutely be a Stage III. On 5/2/16 at approximately 2:00 p.m. after reviewing the above document presented by the Administrator, the Administrator was informed of the Wound Care Physician's comments. On 5/2/16 at approximately 2:30 p.m. the Administrator and the Director Of Nursing provided documentation indicating on 2/10/16 a Mock Survey Audit was conducted in the facility. The Mock Survey Audit revealed issues with pressure ulcers. On 2/29/16 an Action Plan was developed stating: Problem Pressure Ulcers are at unfavorable targets. The facility plan of correction was reviewed by 2 surveyors, the Administrator, and the Director of Nursing. During the review of the Plan of Correction it was noted under Weekly Skin Assessments audits were only completed for one week in March. On the Skin Assessment Audit dated 4/5/26 for Resident #13, all boxes were unchecked indicating the audit had not been completed. Under Braden Scale there were no March audits. Under Action, Clinical Manager to audit treatments weekly, no audits were available. Under Action, Assessment of Adequate Surfaces for Treatment Prevention, no audits had been completed. Based on the lack of audits to show that a functioning corrective Action Plan was in place and the fact the identified deficient areas had not been corrected prior to the start of the survey Past Non-Compliance was not offered at exit. Prior to exit no further information was provided. *Stage III Pressure Ulcer: Full thickness tissue 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 tissue loss. May include undermining and tunneling. Definition derived from the Minimum Data Set (MDS) Assessment-Version 3.0 **Hypertension: a common disorder that is a known cardiovascular disease risk factor, characterized by elevated blood pressure over normal values of 120/80 mmHg (milligrams of mercury) in an adult. ***[MEDICAL CONDITION]: paralysis of one side of the body. ****[MEDICAL CONDITION]: muscular weakness of one half of the body. The above definitions were derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition.

Based on observation, staff interview, clinical record review, facility document review and in the course of a complaint investigation, the facility staff failed to provide supervision to prevent falls for 2 of 17 residents in the survey sample, (Residents # 1 and Resident # 10), resulting in the need for emergency care requiring sutures. 1. The facility staff failed to implement new interventions following each of 4 falls (3/1/12, 7/27/12, 10/6/12 and 12/27/12) prior to a fall on 1/5/13 when Resident # 1 sustained a forehead laceration requiring emergency care and 5 stitches. 2. The facility staff failed to implement new interventions following each of 5 falls (11/27/12, 12/1/12, 1/22/13, 2/10/13) prior to a fall on 2/25/13 when Resident # 10 sustained a forehead laceration requiring an emergency care and 7 stitches. Findings included: 1. The facility staff failed to implement new interventions following each of 4 falls (3/1/12, 7/27/12, 10/6/12 and 12/27/12) prior to a fall on 1/5/13 when Resident # 1 sustained a forehead laceration requiring emergency care and 5 stitches. Resident # 1, an [AGE] year old resident was re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. According to Resident # 1's last MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/28/13, the resident was coded as unable to respond to questions on the BIMS (Brief Interview for Mental Status) and was coded as moderately impaired in daily decision-making. The resident was coded as sometimes understanding and being understood by others. Resident # 1 was coded as being totally dependent and requiring the assistance of at least 2 staff members in bed mobility and transfers. The resident was coded as requiring the assistance of at least one staff member for other activities of daily living. Resident #1's balance was coded as "not steady, only able to stabilize with staff assistance. The resident was coded as having lower extremity impairment on both sides. Falls since admission/entry or reentry was coded as "0". According to the previous MDS, done as a status change with an ARD of 9/5/12, Resident # 1 was coded as severely impaired cognitively. Balance and functional limitation were coded the same as in the 2/28/13 assessment. Falls were coded as "1 with injury". On 4/17/13 at 10:45 am, Resident # 1 was observed in bed with eyes closed. The resident did not respond to the surveyor when spoken to. Mats and alarms were in place. On 4/18/13 at 9:15 the resident was observed in a wheelchair "yelling out". Staff stated the resident was asking for water and a staff member was obtaining water for resident. Resident # 1 was observed at the Nurses Station on 4/18/13 slumped in the wheelchair. Resident # 1 was leaning slightly to the left and was yelling for " Aqua " . Review of a facility-provided document entitled "Facility Tracking Report by Event Type" from 3/1/12 through 3/31/1, indicated Resident # 1 sustained at least 5 falls: 1. 3/1/12 fell from wheelchair in dining room 2. 7/27/12 fell from wheelchair in nurses station 3. 10/6/12 Found on floor at the nurses station 4. 12/27/12 Found on floor in Activities 5. 1/5/13 fell from wheel chair in Corridor Review of the Nurses Notes for 1/5/13 at 6:30 pm revealed Resident # 1 had sustained a fall resulting in a laceration to the "left side of head" and was transported to an acute care facility (ACF). A second note on 1/5/13 at 11:00 pm indicated the resident was returned from the ACF with "a bandage wrapped around her head and 5 stitches to the left side of her forehead". Review of Resident # 1 ' s Care Plan revealed a Problem : "Fall/Injury Risk" dated 1/26/12. Interventions included: ? OT/PT to treat as appropriate 1/26/12 ? Assess the use /need of side rails for transfers 1/26/12 ? Evaluate current medication usage 1/26/12 ? Observe for side effects from medications 1/26/12 ? Report falls/injuries and treat per order 1/26/12 ? Assess ability to see and identify surroundings 1/26/12 ? Supervise and assist with transfers as needed 1/26/12 ? Assess abilities and needs - formulate interventions ? Keep call button and regularly used items in reach 1/26/12 Review of the Care Plan revealed a hand-written entry on the left side of the Care Plan dated 3/1/12 indicating Resident #1 sustained an actual fall without injury on that date. Below that entry another hand-written note on 1/5/13 identified the 5th fall from the wheelchair on 1/5/13 from sustaining a " laceration to head " . Falls 2, 3 and 4 were not listed on the Care Plan. No new interventions were listed on the Care Plan for fall # 1 through fall # 4. Review of the resident ' s Care Plan indicated no new interventions following the fall on 3/1/12. A hand written note on the left side of the Care Plan that read, " Bed Alarm and Chair Alarm to aide in fall prevention " . No new interventions were listed on the Care Plan from the origination date of the problem on 1/26/12 until after the fall with laceration on 1/5/13 although falls were recorded for Resident #1 on the facility Fall Log for 7/27/12, 10/6/12 and 12/27/12. The facility was able to provide a fall investigation for the 7/27/12 and 1/5/13 fall. Fall investigations for the remaining falls could not be found. Review of the Fall Investigation Assessment form for the 7/27/12 fall, page #2, under the heading Follow Up Action, item # 6 read "Has the Care Plan been reviewed and updated?". Item # 7 read : What suggestions do you have to reduce the potential for another fall?". Neither Item # 6 or Item # 7 were completed. Review of the Fall Investigation Assessment form for the 1/5/13 fall, did not include page # 2 that included the heading Follow Up Actions. The facility was unable to provide any other Fall Investigations. An interview with the daughter of the Resident # 1 on 4/17/13 revealed that the daughter arrived on the unit on 1/5/13 around 4:30 pm and observed her mother falling out of her chair. She said there was no chair alarm on the resident at the time. She stated the staff took several minutes to arrive to assist her with her mother. The Unit Manager who was responsible for care on the unit during the dates of the fall no longer worked in the facility and no other staff remembered what was done. Review of the Clinical Record and Fall Tracking and Fall Investigation Reports did not include any new interventions for falls that occurred on 3/1/12, 7/27/12, 10/6/12, or 12/27/12 prior to the fall on 1/5/13 where Resident # 1 fell from the wheelchair in the corridor and sustained a forehead laceration requiring emergency care and 5 stitches. On 4/18/13 at 8:40 am, the Director of Nursing stated she had no other information on the falls that occurred. 2. The facility staff failed to implement new interventions following each of 5 falls (11/27/12, 12/1/12, 1/22/13, 2/10/13) prior to a fall on 2/25/13 when Resident # 10 sustained a forehead laceration requiring an emergency care and 7 stitches. Resident # 10, an [AGE] year old resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #10's MDS (Minimum Data Set) assessment done as a quarterly review with an ARD (Assessment Reference Date) of 9/21/12, indicated Resident # 10 was coded as a 3 of 15 on the BIMS Scale (Brief Interview for Mental Status). The resident was coded as understanding and being understood by others. Resident # 10 was coded as needing supervision of at least one staff member in bed mobility, transfers, and toilet use. Resident # 10 was coded as requiring extensive assistance of at least one staff member in bathing and dressing. Resident # 6 was coded as not demonstrating delirium. Under the area of Behaviors the resident was coded as demonstrating wandering. Under the area of Medications (N 0410) the resident was coded as receiving antipsychotic, antidepressant and anti-anxiety drugs. Resident # 10 was coded as not demonstrating any balance or functional impairment. On 4/17/13 at 10:00 am, Resident # 10 was observed in bed. Mats were found on both sides of the bed. The resident spoke when spoken to. Review of a facility-provided document entitled "Facility Tracking Report by Event Type" from 3/1/12 through 3/31/1, indicated Resident # 1 sustained at least 8 falls: 1. 11/27/12 Found on floor in Rehab 2. 12/1/12 Found on floor in resident room 3. 1/22/13 Found on floor in resident room 4. 2/10/13 Found on floor in bathroom 5. 2/22/13 Found on floor-no location 6. 2/25/13 Found on floor in resident room, with injury 7. 2/26/13 Found on floor in resident room 8. 3/26/13 Found on floor in resident room Review of the Nurses Notes for 2/25/13 at 1:50 pm revealed Resident # 10 had been found on the floor "with large open area to head". At 1:55 pm an entry read : "...laceration to left side of forehead with indentation present. Pt very lethargic and wanting to go to sleep...Pt keeps grabbing forehead and moaning. LPN (Licensed Practical Nurse) instructed to call 911". A note at 10:30 pm indicated "Resident was returned from ER ...with 7 stitches to forehead...". Review of Resident # 10's Care Plan revealed a Problem: "Risk for Falls with Actual Falls" dated 2/6/13. The original care plan received from staff on 4/17/13 did not reveal any hand-written notes. Hand-written entries on Care Plan received by this surveyor on 4/18/13 included entries for: 2/22/13 Bed alarm placed 2/25/13 Mats placed beside bed 3/26/13 Bed alarm, armband, falling leaf, bed in lowest position, mat on floor beside bed to aide in prevention of injuries Prior to the 6th fall on 2/25/13, when the resident sustained [REDACTED]. Falls 1 through 5 listed no new interventions documented on the Care Plan. The hand written notes, including the new interventions for falls on 2/22/13, 2/25/13 and 3/26/13 were was placed on the care plan after the first day of the survey, according to the DON. Review of the Fall Investigations indicated: > Review of the 1/22/13 fall, did not have a page #2, where Follow-Up Action would have been documented. > Review of the 2/10/13 fall revealed - Follow Up Action, item # 6 read yes to the question "Has the Care Plan been reviewed and updated?". Item # 7 read : What suggestions do you have to reduce the potential for another fall?". Item # 7 was not answered. > Review of the 2/25/13 fall revealed - Follow Up Action, item # 6 read yes to the question "Has the Care Plan been reviewed and updated?". Item # 7 read : What suggestions do you have to reduce the potential for another fall?". Item # 7 was not answered. > Review of the 3/26/13 fall revealed - Follow Up Action, item # 6 read yes to the question "Has the Care Plan been reviewed and updated?". Item # 7 read : What suggestions do you have to reduce the potential for another fall?". Item # 7 was not answered. On 4/18/13 at 8:40 am, the Director of Nursing stated she had no other information on the falls that occurred.