Every finding on record at Hiram W Davis Medical CTR

Based on staff interview, clinical record review, and facility document review, the facility staff failed to complete monthly medication regimen reviews for (4) four of (5) five sampled residents, Resident #1, Resident #6, Resident #4, and Resident #5. The findings included:1. For Resident #1 the facility failed to ensure a monthly medication regimen review (MRR) was completed for the month of March 2025. Resident #1's diagnosis list indicated diagnoses that included, but were not limited to, chronic heart failure, atrial fibrillation, mild neurocognitive disorder, anxiety, agitation, peripheral vascular disease, psychosis, and visual hallucinations. The most recent annual minimum data set (MDS) with an assessment reference date (ARD) of 11/18/25, assigned the resident a BIMS (brief interview for mental status) summary score of 13 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of Resident #1's MRRs did not disclose a MRR was completed for March 2025. On 2/11/26 at 12:23 PM, the pharmacy director (PD) was interviewed and agreed the MRR was not completed for March 2025 for Resident #1. This concern was discussed at the end of day meeting on 2/11/26 at 4:21 PM with the administrator and interim director of nursing. On 2/12/26 at 9:11 AM, pharmacist #1 (P#1) was interviewed and stated after speaking with the pharmacist responsible for the March 2025 MRR, it was agreed the MRR was not completed for March 2025 for Resident #1. On 2/12/26 at 9:38 AM, pharmacist #3 was interviewed and stated they were off work during the first two weeks of March 2025 and agreed the MRR had not been completed for that month for Resident #1. A facility policy titled, Chart Review and Provider Notification of Irregularities with a revision date of 12/8/24, was requested and received and read in part, .1. Medication Regimen Review: A thorough evaluation of the medication regimen with the goal of promoting positive outcomes and minimizing adverse consequences associated with medications.PROCEDURE: A. The.pharmacist shall perform a monthly chart review for his/her assigned patients/residents.per policy to ensure optimal medication use and safety. No further information was provided prior to exit on 2/12/26. 2. For Resident #6 the facility staff failed to ensure a monthly medication regimen review (MRR) was completed for the month of November 2025. Resident #6's diagnosis list indicated diagnoses that included, but were not limited to, schizoaffective disorder, chronic pain syndrome, depression, pain, and history of breast cancer. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 11/18/25, assigned the resident a BIMS (brief interview for mental status) summary score of 99, indicating the resident was unable to complete the interview and was severely impaired in cognition. A review of Resident #6's MRRs did not disclose a MRR was completed for November 2025. On 2/11/26 at 12:21 PM, the pharmacy director (PD) was interviewed and agreed the MRR was not completed for November 2025 for Resident #6, as the pharmacist assigned to complete it was out of the country. This concern was discussed at the end of day meeting on 2/11/26 at 4:21 PM with the administrator and interim director of nursing. On 2/12/26 at 9:33 AM, pharmacist #2 (P#2) was interviewed and agreed the November 2025 MRR was not completed for Resident #6 due to P#2 being out of the country. A facility policy titled, Chart Review and Provider Notification of Irregularities with a revision date of 12/8/24, was requested and received and read in part, .1. Medication Regimen Review: A thorough evaluation of the medication regimen with the goal of promoting positive outcomes and minimizing adverse consequences associated with medications.PROCEDURE: A. The.pharmacist shall perform a monthly chart review for his/her assigned patients/residents.per policy to ensure optimal medication use and safety. No further information was provided prior to exit on 2/12/26. 3. For Resident #4 the facility failed to ensure monthly medication regimen reviews (MRR) were completed. Resident #4's clinical record listed diagnoses which included but not limited to schizoaffective disorder, bipolar disorder, and leukopenia caused by medication. Resident #4's most recent minimum data set with an assessment reference date of 02/10/26 coded the resident as 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 plan for Psychotropic Medication Use. Interventions for this care plan included Collaborate with pharmacist regarding dose adjustments. Resident #4's clinical record was reviewed, and surveyor could not locate monthly medication regimen reviews for the months of April 2025, June 2025, August 2025, and September 2025. Surveyor spoke with the pharmacy director on 02/11/26 at 11:30 am and informed her of the missing MRR's for Resident #4. Pharmacy director informed surveyor on 02/11/26 at 12:25 pm that she could not locate the missing MRR's and the pharmacist responsible for completing them was no longer employed by the facility. Surveyor requested and was provided with a facility policy entitled Chart Review and Provider Notification of Irregularities which read in part, 1. Medication Regimen Review: A thorough evaluation of the medication regimen with the goal of promoting positive outcomes and minimizing adverse consequences associated with medications.Procedure: A. A . (facility omitted) pharmacist shall perform a monthly chart review for his/her assigned patients/residents of . (omitted) and . (omitted) per policy to ensure optimal medication use and safety. B. The pharmacist shall document the review in the EMR (electronic medical record) using the Drug Regimen Review ad hoc form. The concern on completing monthly medication regimen reviews for Resident #4 was discussed with the administrator and interim director of nursing on 02/11/26 at 4:20 pm. No further information was provided prior to exit. 4. For Resident # 5 the facility staff failed to ensure monthly medication regimen reviews (MRR) were completed. Resident #5's clinical record listed diagnoses which included but not limited to dementia and depression. Resident #5's most recent minimum data set with an assessment reference date of 01/20/26 assigned the resident a brief interview for mental status score of 12 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Section N, medications, coded the resident as receiving antipsychotic and antidepressant medications. Resident #5's clinical record was reviewed, and surveyor could not locate any MMRs for the months of April 2025, May 2025, June 2025, July 2025, August 2025 and September 2025. Surveyor spoke with the pharmacy director on 02/11/26 at 11:30 am and informed her of the missing MRR's for Resident #5. Pharmacy director informed surveyor on 02/11/26 at 12:25 pm that she could not locate the missing MRRs and the pharmacist responsible for completing them was no longer employed by the facility. Surveyor requested and was provided with a facility policy entitled Chart Review and Provider Notification of Irregularities which read in part, 1. Medication Regimen Review: A thorough evaluation of the medication regimen with the goal of promoting positive outcomes and minimizing adverse consequences associated with medications.Procedure: A. A . (facility omitted) pharmacist shall perform a monthly chart review for his/her assigned patients/residents of . (omitted) and . (omitted) per policy to ensure optimal medication use and safety. B. The pharmacist shall document the review in the EMR (electronic medical record) using the Drug Regimen Review ad hoc form. The concern on completing monthly medication regimen reviews for Resident #5 was discussed with the administrator and interim director of nursing on 02/11/26 at 4:20 pm. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure call bell was in reach for (1) one of (14) fourteen sampled residents, Resident #21. The findings included:Resident #21's clinical record listed diagnoses which included but not limited to acquired blindness of bilateral eyes, bilateral hearing loss, agitation, and schizoaffective schizophrenia.Resident #21's most recent minimum data set with an assessment reference date of 01/27/26 coded the resident as having both long- and short-term memory problems with moderately impaired cognitive skills for daily decision making. Resident #21's comprehensive care plan was reviewed and contained a plan for At risk for falls. Interventions for this care plan include call light in reach.Surveyor observed Resident #21 on 02/10/26 at 12:50 pm. Resident #21 was seated in wheelchair beside bed. Surveyor observed Resident #21's call bell located on the floor behind the head of the bed.Surveyor observed Resident #21 on 02/11/26 at 8:45 am and 1:30 pm. Resident was lying in bed during each observation; call bell was located on floor behind head of bed.Surveyor spoke with certified nurse's aide (CNA) #1 on 02/11/26 at 1:30 pm. Surveyor asked CNA #1 where the resident's call bell should be located and CNA #1 stated, It should be right beside him.Surveyor requested and was provided with a facility policy titled Call Bell Policy which read in part, Purpose: To ensure that all residents in our Long-Term Care Skilled Nursing Facility have timely access to assistance and that call bells are responded to promptly and appropriately to maintain resident safety, dignity, and quality of care. Policy Statement: All residents shall always have access to a functioning call bell system.Procedures: Call Bell Availability: Call bells must always be within reach of all residents when they are in bed. Staff should ensure that call bells are properly positioned and functioning during every room check and interaction with residents.During an end of day meeting with the facility administrator and interim director of nursing on 02/11/26 at 4:20 pm, the issue of Resident #21's call light not being within reach was discussed. Administrator stated that it was unsure if resident was capable of using call bell, and that 30-minute checks were done throughout the day. Administrator also stated that any time resident was up in wheelchair, he was seated close to the nurse's station for observation. Surveyor informed administrator of observation of resident seated in wheelchair at his bedside.No further information was provided prior to exit.

Based on observations, resident interview, staff interview, clinical record review, and facility document review, the facility failed to provide activities of daily living care for (1) one of (14) fourteen sampled residents, Resident #5. The findings included:For Resident #5 the facility staff failed to provide nail care.Resident #5's clinical record listed diagnoses which included but not limited to cerebrovascular accident (stroke) and hemiplegia or hemiparesis.Resident #5's most recent minimum data set with an assessment reference date of 01/20/26 assigned the resident a brief interview for mental status score of 12 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Section G, functional status coded the resident as needing substantial/maximal assistance with personal hygiene.Resident #5's comprehensive care plan was reviewed and contained a plan for Self-care deficit. Interventions for this care plan include Provide appropriate level of assistance with ADL's (activities of daily living).Surveyor spoke with Resident #5 on 02/10/26 at 12:55 pm. Resident was resting in bed, watching television. Surveyor observed resident's fingernails to be long and sharp-edged. Surveyor asked resident if staff aided with trimming his fingernails and resident stated no. Surveyor asked resident if he would like to have his nails trimmed, and resident stated, Yes, they are too long and sharp and they cut me sometimes.Surveyor spoke with certified nurse's aide (CNA) #1 on 02/11/26 at 1:30 pm regarding residents' nail care. Surveyor asked CNA #1 who provides nail care for residents, and CNA #1 stated, The CNA's do. Surveyor asked CNA #1 how often nail care is provided, and CNA #1 stated, Every Wednesday.Surveyor spoke with registered nurse (RN) #2 on 02/11/26 at 1:35 pm. Surveyor asked RN #2 who provides nail care for the residents, and RN #2 stated, The nurse's and CNA's.Surveyor requested and was provided with a facility policy entitled Nail Cleaning and Cutting which read in part, A. Each resident's nails (toenails and fingernails) are inspected daily at the time the daily bath is given. It is the responsibility of the CNA bathing the resident to cut/clip and/or file the resident nails. E. Nails are to be checked twice a week and as needed, clipped/filed as necessary according to bath shift assignment, so that they grow no longer than one-eighth inch past the tips of the fingers/toes. The concern of not providing nail care for a dependent resident was discussed with the administrator and interim director of nursing during an end of day meeting on 02/11/26 at 4:20 pm. Interim director of nursing stated they would check to ensure resident's nails were trimmed. Surveyor spoke with Resident #5 on 02/12/26 at 9:15 am. Surveyor asked resident if anyone had trimmed his nails, and resident stated they had not, and raised hand to show surveyor that nails remained long. Surveyor informed administrator and interim director of nursing on 02/12/26 at 10:45 am that resident's nails remained untrimmed. During exit conference on 02/12/26 at 11:30 am, administrator informed surveyor that Resident #5's nails have been trimmed. No further information was provided prior to exit.

Based on clinical record review, staff interview, and facility document review, the facility staff failed to follow provider orders for medication administration for (1) one of (14) fourteen sampled residents, Resident #7. The findings included:For Resident #7, the facility staff failed to administer a provider ordered medications acetaminophen, chlorpromazine, divalproex, docusate, duloxetine, eucerin cream, gabapentin, menthol-zinc oxide ointment, and senna, on the evening of 1/20/26. Resident #7's diagnosis list indicated diagnoses, which included, but not limited to, pain of left/right leg, schizophrenia, bipolar disorder, constipation, depression, and soft tissue disorder. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 12/23/25, assigned the resident a brief interview for mental status (BIMS) summary score of 11 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A review of a medical provider orders disclosed the following ordered medications: .acetaminophen.650 mg (milligrams).BID (twice daily).indication: pain. with a start date of 5/21/25.chlorpromazine.200 mg.BID.indication: schizophrenia. with a start date of 4/14/25.divalproex sodium.500 mg.BID.indication: bipolar disorder. with a start date of 8/13/25.docusate.100 mg.BID.indication: constipation. with a start date of 5/21/25.duloxetine.30 mg.BID.indication: depression. with a start date of 2/26/25.eucerin calming cream.1 app (application), topical, cream, BID.indication: dry skin. with a start date of 6/16/25.gabapentin.300 mg.daily w/dinner (with dinner). with a start date of 12/12/25.menthol-zinc oxide topical.1 app, topical, ointment.Q8H (every 8 hours).indication: skin irritation. with a start date of 8/29/25.senna.17.2 mg.2 tab (2 tablets).every day at bedtime. with a start date of 10/24/25. A review of Resident #7's January 2026 MAR (medication administration record) on the evening of 1/20/26 was blank, indicating none of the above prescribed medications were administered as ordered. A review of Resident #7's comprehensive person-centered care plan included interventions in the focus areas of behavioral symptoms and bowel dysfunction, which read in part, .Administer medications as ordered. On 2/11/26 at 12:26 PM, registered nurse #2 (RN#2) was interviewed. RN#2 stated the reason the MAR read as, Not appropriate at this time on 1/20/26, was because the task had to be cleared before the medication administrations for the next shift could be entered. RN#2 agreed they were not the evening nurse on 1/20/26 and agreed the medications were not marked as given by the nurse on duty the evening before. This concern was discussed at the end of day meeting on 2/11/26 at 4:21 PM with the administrator (ADM) and interim director of nursing (IDON). On 2/11/26 at 4:38 PM, the IDON reviewed Resident #7's MAR for 1/20/26 and the IDON agreed the MAR indicated the medications on the evening of 1/20/26 were not given as ordered by the provider. On 2/12/26 at 11:33 AM, the IDON stated evidence of why Resident #7's evening medications were not administered on the evening of 1/20/26 could not be located. A facility policy titled, Administration of Medications with a revision date of 6/5/17 was requested and received and read in part, .medication administration schedule.BID = 1000 (10:00 AM), 1800 (6:00 PM).Q 8 hr = 0600 (6:00 AM), 1400 (2:00 PM), 2200 (10:00 PM).Administer all medications as ordered by physician.(MAR).c. Chart all medication omissions by initialing and then circling initials in the appropriate box and on the MAR. Record reason for omission on back of MAR and in interdisciplinary notes.Chart all medication omissions, reasons for omissions, and actions taken due to omissions.Medications withheld, omitted or refused: Medication nurses will audit MARs daily on every shift for withheld, omitted.medications and submit to nursing supervisors for corrective actions. No further information regarding this concern was presented prior to the exit on 2/12/26.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to maintain an accurate clinical record for (1) one of (14) fourteen sampled residents, Resident #1. The findings included:For Resident #1, the facility staff failed to accurately document medication regimen reviews (MRRs) for no irregularities on 2/21/25, 4/10/25, 5/15/25, 6/16/25, 7/25/25, 8/29/25, 9/18/25, 10/17/25, 11/12/25, 12/16/25, and 1/22/26. Resident #1's diagnosis list indicated diagnoses that included, but were not limited to, chronic heart failure, atrial fibrillation, mild neurocognitive disorder, anxiety, agitation, peripheral vascular disease, psychosis, and visual hallucinations. The most recent annual minimum data set (MDS) with an assessment reference date (ARD) of 11/18/25, assigned the resident a BIMS (brief interview for mental status) summary score of 13 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of Resident #1's MRRs for 2/21/25, 4/10/25, 5/15/25, 6/16/25, 7/25/25, 8/29/25, 9/18/25, 10/17/25, 11/12/25, 12/16/25, and 1/22/26 were noted to have pharmacy recommendations and the recommendations could not be located in the clinical record. On 2/11/26 at 12:23 PM, the pharmacy director was interviewed and stated there were no irregularities for the MRRs completed on 2/21/25, 4/10/25, 5/15/25, 6/16/25, 7/25/25, 8/29/25, 9/18/25, 10/17/25, 11/12/25, 12/16/25, and 1/22/26 and agreed the MRR forms were marked incorrectly and should have been marked as no irregularities for all of them. This concern was discussed at the end of day meeting on 2/11/26 at 4:21 PM, with the administrator and interim director of nursing. On 2/12/26 at 9:38 AM, pharmacist #3 (P#3) was interviewed and agreed the MRRs on 2/21/25, 4/10/25, 5/15/25, 6/16/25, 7/25/25, 8/29/25, 9/18/25, 10/17/25, 11/12/25, 12/16/25, and 1/22/26 had no irregularities. P#3 thought the last two boxes for physician review had to be marked on the forms. P#3 did not realize there was a box for no irregularities and stated they were never trained on the correct way to document on the form. A facility policy titled, Chart Review and Provider Notification of Irregularities was requested and received with a revision date of 12/8/24 which read in part, .1. Medication Regimen Review: A thorough evaluation of the medication regimen with the goal of promoting positive outcomes and minimizing adverse consequences associated with medications.PROCEDURE.C. If irregularities are not identified, the pharmacist shall mark the form as such. No further information was provided prior to exit on 2/12/26.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to offer and provide the flu and /or pneumonia vaccines to 3 Residents (Resident #1, #27, #247) in a survey sample of 5 Resident's reviewed for flu and pneumonia immunizations. The findings included: On 3/15/22, the facility staff were asked to provide any and all evidence regarding flu and pneumonia immunizations for the survey sample of 5 Residents selected for review of immunizations. On 3/16/22, the requested information was reviewed and revealed the following: 1. Resident #1 had no information submitted to indicate that the Resident had received the flu or pneumonia vaccine or had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] 2. For Resident #27, the facility submitted a progress note from a medical provider/nurse practitioner that was dated 3/22/21, and read, Legal guardian gave permission for flu immunization. No further information was provided. 3. For Resident #247, the facility submitted no information regarding flu and pneumonia immunizations. On the COVID immunization evidence there was a post-it note that read, No consent on file yet. On 3/16/22 at 3:08 PM, a group interview was conducted with Employee B, the Director of Nursing, Employee D, the Infection Preventionist and RN B, the employee health nurse. During this interview, the Infection Preventionist was informed of the above findings. Employee D stated, we ask for immunization history of Residents on admission and if nothing is on file we get consent and then ask the doctor for an order to vaccinate. Employee D responded, for Resident #1, It was no information available, there was nothing in [the] chart. For Resident #27, Employee D said, is another Resident that recently came back from the hospital. With regards to Resident #247, Employee D said, is a new admit that came in February and we don't have consent on file yet. During an end of day meeting held on 3/16/22 at 4:10 PM, the facility Administrator was made aware of the missing documentation with regards to flu and pneumonia immunizations as noted above. On 3/16/22 at 6:04 PM, additional records were submitted to the Survey team. This included, an excel spreadsheet that indicated the following: 1. Resident #1 had consent(s) on file in the chart. The flu vaccine was last given 10/15/2020. There was no documentation on record for pneumonia immunization for this Resident. 2. Resident #27 had consent(s) on file in the chart for immunizations but no documentation was on file with regards to being previously immunized or offered the flu and pneumonia vaccines. 3. Resident #247, had consent on file in the chart as of 3/16/22. There was no documentation of the Resident having previously been vaccinated for flu or pneumonia and no evidence of it being offered prior to the survey. On 3/17/22 at 9:40 AM, an interview was conducted with the Director of Nursing (DON) and Employee C, the Assistant Director of Nursing (ADON). The ADON said, We do flu vaccines annually. We get consent on admission and the pharmacist will order the flu vaccine, the doctor writes an order and then we give it to the Resident. The ADON said consent for immunizations is usually obtained within the first 48 hours of admission. The ADON confirmed that the immunizations provided are documented in the clinical record. The ADON confirmed the process is the same for the pneumonia vaccines with the exception of it is not given annually. On 3/17/22 at 10:11 AM, an interview was conducted with Employee K, the registered pharmacist. Of note, this facility has an on-site pharmacy. Employee K confirmed that they [the pharmacy] maintains a stock on hand of the flu and pneumonia vaccines that are available to be dispensed immediately for administration. Employee K, the pharmacist said, It is important to get immunized because it prevents against disease. We know our patient population is vulnerable and we want to make sure they are protected. On 3/17/22 at approximately 11:00 AM, an interview was conducted with Employee L, the pharmacy director. Employee L confirmed they have flu and pneumonia vaccines in stock and available for dispensing and administration and have had no difficulty maintaining a stock of these on-hand. A review of the facility policy titled, Influenza Vaccination, was conducted. This policy read, .All persons, upon admission to long term care programs, will be assessed for recent and past flu vaccinations. The influenza vaccine is administered to patients annually .The influenza vaccine may be given at the same time as the pneumococcal vaccine. All patients will be routinely vaccinated, except those with medical contraindication(s) to receipt of influenza vaccine, at one time, annually, before the influenza season. Those patients who are admitted during the winter months after completion of the programs vaccination program, will be offered the vaccine at the time of their admission . Review of the facility policy titled, Influenza and Pneumococcal Vaccine was conducted. This policy read, [Facility name redacted] will offer the influenza and pneumonia immunization, to each resident or the resident's representative receives education [sic] regarding the benefits and potential side effects of the immunization. The administration of influenza and pneumococcal polysaccharide vaccines, is offered to each resident between October 1 through March 31 annually, unless the immunization is medically contraindicated during this time period. The facility Administrator was made aware of the findings during an end of day meeting held on 3/17/22. No further information was submitted.

Based on staff interview and facility documentation review, the facility staff failed to conduct COVID-19 testing as required for 105 facility staff who were not up-to-date with COVID-19 vaccinations, out of a total of 205 employees. The findings included: On 3/15/22, the facility staff submitted evidence of tracking the community transmission rates. This revealed: 12/6/21-3/8/22, the community rate of transmission was noted as high. On 3/13/22, the community rate of transmission was noted as low. The facility submitted evidence that for the week of, 3/7/22-3/13/22, only 17 employees were tested for COVID-19. Review of the facility staff vaccination matrix revealed the following data: 210 total employees, 105 who are up to date with COVID immunizations, 94 who are not up to date (have not received boosters), and 11 with granted/approved exemptions. On 3/16/22 at 3:08 PM, a group interview was held with the Director of Nursing (DON), Employee C the Assistant Director of Nursing (ADON) and RN B, the employee health nurse. The ADON said that she and RN B conduct the employee testing for COVID-19. When asked about the testing conducted in March, she said, The first week of March was our last week of outbreak testing, after that we tested unvaccinated staff as CMS [Centers for Medicare and Medicaid Services] says, twice a week based on community transmissibility level. The ADON and RN B confirmed that only the staff who have been granted exemptions from COVID-19 immunizations, are considered not immunized, and are the only staff subject to routine testing. The ADON and RN B confirmed they were not aware of the new guidance issued that requires staff who are not up to date, meaning have received all recommended booster doses, to also be included in the routine testing. Review of the facility policy titled, Widespread Coronavirus 2019 Testing Plan, was conducted. This policy did not address the requirement for routine testing of staff based on community transmissibility rates. An additional document was provided to the survey team, DBHDS Human Resources Guidance titled, DBHDS COVID 19 Testing Guidance for State Facilities (Effective 01/20/2022). Review of this document also revealed it did not address the routine testing of staff based on the level of community transmission of COVID-19. Review of the CMS (Centers for Medicare and Medicaid Services) QSO-20-38-NH memo with a revision date of 3/10/2022, was conducted. This document read, .Routine testing of staff, who are not up-to-date, should be based on the extent of the virus in the community. Staff, who are up-to-date, do not have to be routinely tested .Facilities should use their community transmission level as the trigger for staff testing frequency .Level of COVID-19 Community Transmission: high (red)= minimum testing frequency of staff who are not up-to-date: twice a week .If the level of community transmission decreases to a lower level of activity, the facility should continue testing staff at the higher frequency level until the level of community transmission has remained at the lower activity level for at least two weeks before reducing testing frequency. On 3/16/22, during an end of day meeting the facility Administrator was made aware that the facility was not following the most recent CMS guidance regarding testing of staff who are not up to date with all doses of COVID-19 vaccines. No further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to develop COVID-19 vaccination policies for staff that include all of the required components, failed to track the immunization status of all facility employees, and failed to ensure 100% of facility staff were vaccinated, the facility vaccination rate was 98.1%. 1. The facility failed to develop COVID-19 policies that included the implementation of additional precautions to mitigate the transmission of COVID-19, for staff who are not fully vaccinated for COVID-19. 2. The facility failed to include 3 staff members of the vaccination tracking and were unaware of their vaccination status. 3. The facility staff failed to ensure 1 staff member had an appropriate request for a medical exemption. 4. The facility staff vaccination rate for COVID-19 was 98.1%. The findings included: 1. The facility failed to develop COVID-19 policies that included the implementation of additional precautions to mitigate the transmission of COVID-19, for staff who are not fully vaccinated for COVID-19. On 3/15/22, the facility administrator submitted a facility policy titled, COVID-19 Immunization of Employees with an effective date of 12/10/20. This policy was reviewed and it read, [Facility name redacted] or its affiliate will offer the COVID-19 immunization, to each employee, each employee receives education regarding the benefits and potential side effects of the immunization. The administration of COVID-19 vaccine is offered to each employee, unless the immunization is medically contraindicated for the employee during this time. The employee has the opportunity to refuse immunization. The facility administrator was asked to double check and ensure they didn't have a more current policy or any revisions. On 3/16/22, the facility staff provided the survey team with the staff vaccination matrix. Review of this document revealed that 11 facility employees had approved exemptions on file for COVID-19 immunization. On 3/16/22, the facility Administrator submitted additional documents that were titled, COVID-19 testing guidance, COVID-19 Screening and Testing Program, and Summary of Recommendations for management of COVID-19 during Omicron Surge. These documents were reviewed. On 3/16/22 at 3:08 PM, a group interview was conducted with the facility Director of Nursing (DON), the Infection Preventionist (Employee D) and RN B, the employee health nurse. RN B confirmed that the facility has 11 employees who have been granted exemptions from COVID-19 immunization. When asked how these employees are handled versus those employees that are fully vaccinated, RN B and Employee D confirmed there are no additional steps taken other than encourage vaccination and they are subjected to routine testing. On 3/17/22 at 9:32 AM, an interview was conducted with Employee J, the human resources representative. Employee J stated that employees who are not vaccinated are subject to testing and have to request an exemption. When asked if she had a policy that stated how to handle these items she said she would check. On 3/17/22 at 10:11 AM, an interview was conducted with Employee K, who has an approved exemption for COVID-19 immunization on file. Employee K was asked what precautions are taken since she isn't vaccinated. Employee K said, I am tested twice a week. Employee K added that, All staff have to wear masks and I know I have to be tested twice a week but other than that nothing. Employee K added that she chooses to wear an N-95 masks and double masks per her personal choice but has not been told of any additional precautions or been told she had to wear an N-95 since she isn't vaccinated. A review of the facility policies related to infection control and COVID-19 was reviewed. These policies included but were not limited to: Infection Prevention and Control Program, COVID-19 Vaccine, COVID-19 Immunization of Employees, COVID-19 Testing Guidance, and COVID-19 screening and testing program. None of the policies addressed: 1. Staff having had at least one dose of a COVID-19 vaccine before being permitted to provide any care, treatment, or other services for the facility. 2. A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19. 3. Contingency plans for staff who are not fully vaccinated for COVID-19. On 3/17/22 at 12:32 AM, Surveyor C received the following information from the facility Administrator. It read, I am following up on a conversation that you had earlier with our Human Resource Director, [name redacted]. All staff, whether COVID-19 vaccinated or unvaccinated are required to wear a surgical mask at [facility name redacted] and are required to follow the same guidelines for hygiene and infection control prevention. COVID-19 unvaccinated staff are required to get tested twice a week at [facility name redacted], as well as report exposure, symptoms, etc. in accordance with CDC recommendations. The facility administrator was made aware of the findings during an end of day meeting held on 3/17/22. No further information was provided. 2. The facility failed to include 3 staff members of the vaccination tracking and were unaware of their vaccination status. On 3/16/22, the facility staff submitted a total of three versions of the staff vaccination matrix. The third submission was confirmed to be final and complete. This matrix was compared to the as worked schedule submitted to the survey team. A total of 11 staff were noted on the as worked schedule and not on the staff vaccination matrix. On 3/16/22 an interview was conducted with RN B, the Employee Health nurse who confirmed she manages the vaccination status of employees. RN B was given all 11 employees names and stated that 10 had resigned or been terminated. She identified one who had been out of work for some time due to chronic medical issues. Time cards for the 11 employees was then requested. Review of the time cards revealed, that Other employee C had worked 3 hours the week of survey and 8 hours the week prior. Other Employee B had worked 3/8/22, 3/9/22, 3/10/22, and 3/16/22. CNA D was noted as having last worked 3/8/22, but was listed as an active employee. The other 8 employees were noted as being no longer employed by the facility. The three staff that were employed during the time of survey who were not on the staff vaccination matrix were added into the total number of employees for calculation of the employee vaccination rate. The facility Administrator and RN B were made aware that they employee vaccination matrix failed to include all staff's vaccination status that are currently working at the facility. No further information was provided. 3. The facility staff failed to ensure 1 staff member had an appropriate request for a medical exemption. On 3/16/22, the facility staff submitted a staff vaccination matrix. From this matrix a sample of 8 employees was selected, which included contracted staff. Employee G was noted as the only person having received a medical exemption for COVID-19 immunization. Employee G's documentation with regards to the exemption was requested and received. Review of Employee G's form titled, Request for Medical Accommodation in connection with COVID-19 Vaccine was conducted. This form read, Provide a brief description of your medical condition/disability and requested accommodation and the employee had written asthma. The form had a question that read, Is the condition/disability temporary or permanent? and Employee G had failed to answer this question. The bottom of the form revealed that human resources had signed off on this and noted approved and dated the form 1/27/22. On 3/17/22 at 11:25 AM, Employee J, the human resources director was interviewed. Employee J was asked if she had any supporting documentation from Employee G's medical provider regarding the request for medical exemption. Employee J said, We do not. Employee J confirmed that she was not the person that approved the exemption request and typically more information would be needed in this case. On 3/17/22, during an end of day meeting, the facility Administrator was made aware of the findings with regards to Employee G. The facility Administrator confirmed that Employee G's request for exemption was inadequate as submitted and should not have been approved as submitted. Therefore, Employee G is considered unvaccinated without an exemption. No further information was submitted. 4. The facility staff vaccination rate for COVID-19 was 98.1%. On 3/16/22, the facility staff submitted a total of three versions of the staff vaccination matrix. The third submission was confirmed to be final and complete. This matrix revealed a total of 210 employees, 11 with exemptions and 199 that were vaccinated. The staff vaccination matrix was compared to the as worked schedule submitted to the survey team. A total of 11 staff were noted on the as worked schedule and not on the staff vaccination matrix. On 3/16/22 an interview was conducted with RN B, the Employee Health nurse who confirmed she manages the vaccination status of employees. RN B was given all 11 employees names and stated that 10 had resigned or been terminated. She identified one who had been out of work for some time due to chronic medical issues. Time cards for the 11 employees was then requested. Review of the time cards revealed, that Other employee C had worked 3 hours the week of survey and 8 hours the week prior. Other Employee B had worked 3/8/22, 3/9/22, 3/10/22, and 3/16/22. CNA D was noted as having last worked 3/8/22, but was listed as an active employee. The other 8 employees were noted as being no longer employed by the facility. The three staff that were employed during the time of survey who were not on the staff vaccination matrix were added into the total number of employees for calculation of the employee vaccination rate. Review of the 8 sampled employee's vaccination records was reviewed. This review revealed, Employee G was noted as the only person having received a medical exemption for COVID-19 immunization. Employee G's documentation with regards to the exemption was requested and received. Review of Employee G's form titled, Request for Medical Accommodation in connection with COVID-19 Vaccine was conducted. This form read, Provide a brief description of your medical condition/disability and requested accommodation and the employee had written asthma. The form had a question that read, Is the condition/disability temporary or permanent? and Employee G had failed to answer this question. The bottom of the form revealed that human resources had signed off on this and noted approved and dated the form 1/27/22. On 3/17/22 at 11:25 AM, Employee J, the human resources director was interviewed. Employee J was asked if she had any supporting documentation from Employee G's medical provider regarding the request for medical exemption. Employee J said, We do not. Employee J confirmed that she was not the person that approved the exemption request and typically more information would be needed in this case. On 3/17/22, during an end of day meeting, the facility Administrator was made aware of the findings with regards to Employee G. The facility Administrator confirmed that Employee G's request for exemption was inadequate as submitted and should not have been approved as submitted. Therefore, Employee G is considered unvaccinated without an exemption. This brought the facility total to: 213 total employees, 10 with approved exemptions, 199 vaccinated; for a vaccination rate of 98.1%, which is deficient. Review of the facility line listing revealed no Resident COVID-19 cases within the past four weeks. On 3/17/22, during an end of day meeting the facility Administrator was made aware of the findings. No further information was provided.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to provide appropriate and timely notices regarding Medicare Part A services ending and failed to submit a demand bill to Medicare, for 2 Residents (Resident #39 & #25) in a survey sample of 2 Residents reviewed for beneficiary notices. 1. For Resident #39, who requested skilled care services continue and Medicare be billed to make the determination, the facility staff failed to continue skilled care services and failed to allow Medicare to make the determination. 2. For Resident #25, the facility staff failed to provide the Resident's Representative (RR) with an advanced beneficiary notice (ABN) timely and failed to issue a Notice of Medicare Non-Coverage (NOMNC). The findings included: On 3/16/22 at 6:27 PM, the facility Administrator submitted the listing of Residents discharged from skilled services without exhausting their benefit days. This list included two Residents, which were entered into the survey sample as Residents #25 and #39. Surveyor C then requested the ABN (Advance Beneficiary Notices) and NOMNC (Notice of Medicare Non-Coverage Notices) issued to each of these Residents. On 3/17/22, Surveyor C conducted a review of the items submitted. This review revealed: 1. For Resident #39, the Resident Representative (RR) requested skilled care services continue and Medicare be billed to make the determination, the facility staff failed to continue skilled care services and failed to allow Medicare to make the determination. Resident #39, the RR selected option 1 on the ABN, which was a request for a demand bill (stating they wanted to continue skilled/Medicare Part A services, have the bill submitted to Medicare for them to make the determination). Review of the clinical record revealed that Medicare Part A services ended, despite this request. On 3/17/22 at 10:50 AM, an interview was conducted with RN C, the utilization review nurse and Employee M, the health information management specialist. RN C explained that issuing the ABN and NOMNC notices is a collaborative effort between herself [RN C] and Employee M. RN C explained that Resident #39 was admitted [DATE], under Medicare part A services/skilled care. The facility staff determined she wasn't making progress and skilled services would end on 9/3/21. The notice was mailed from the facility to the RR on 8/31/21. On 9/2/21, the RR for Resident #39 signed the ABN and selected option 1, which read, I want the skilled services listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. RN C stated that she did not let the billing coordinator or other facility staff know that Resident #39's RR had selected for skilled services to continue. RN C said, We should have. The facility policy regarding ABN notices, NOMNC, or related policies was requested. The facility Administrator stated they had no policies related to this. Medicare gave the following information regarding option 1 being selected on an ABN. It read, When the beneficiary selects Option 1, the care is provided, and the SNF must submit a claim to Medicare. The SNF must notify the beneficiary when the claim is submitted. This will result in a payment decision, and if Medicare denies payment, the decision can be appealed. SNFs aren't permitted to collect money for Part A services until Medicare makes an official payment decision on the claim. Note: Beneficiaries who need an official Medicare decision (Medicare denial) for a secondary insurance claim should choose Option 1. Accessed online at: https://www.cms.gov/Medicare/Medicare-General-Information/BNI 2. For Resident #25, the facility staff failed to provide the Resident's Representative (RR) with an advanced beneficiary notice (ABN) timely and failed to issue a Notice of Medicare Non-Coverage (NOMNC). On 3/17/22, a review of the documents submitted by the facility staff for Resident #25 were reviewed. This review revealed that skilled care services were scheduled to end on 10/4/21. The notice was not mailed to the family timely for them to receive the notice and make a decision prior to services ending. The RR, didn't sign the notice until 10/5/21, and no selection was made as to if they wanted a demand bill, continue services and pay privately for them, or proceed with skilled services ending. On 3/17/22 at 10:50 AM, an interview was conducted with RN C, the utilization review nurse and Employee M. RN C confirmed that no option was selected on the ABN. RN C also confirmed that a NOMNC was not issued. When asked why these notices are issued, Employee M said, I have no idea, I have not been oriented on it yet. RN C agreed that the ABN was not issued timely and a NOMNC should have been issued for Resident #25. The facility was asked to provide their policy as it related to the ABN and NOMNC notices. The facility Administrator stated they did not have a policy. Medicare provides the following information regarding ABN notices. It read, The ABN must be reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. Accessed online at: https://www.cms.gov/Medicare/Medicare-General-Information/BNI The following information regarding NOMNC is provided by Medicare/CMS (Center for Medicare and Medicaid Services). It read, The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily .CMS requires that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent be made to a representative. Notification to the representative may be problematic because that person may not be available in person to acknowledge receipt of the required notification. Providers are required to develop procedures to use when the beneficiary/enrollee is incapable or incompetent, and the provider cannot obtain the signature of the enrollee's representative through direct personal contact. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested. The date that someone at the representative's address signs (or refuses to sign) the receipt is the date of receipt. Place a dated copy of the notice in the enrollee's medical file. When notices are returned by the post office with no indication of a refusal date, then the enrollee's liability starts on the second working day after the provider's mailing date. Accessed online at: The facility administrator and Director of Nursing were made aware of the findings during an end of day meeting held on 3/17/22. https://www.cms.gov/Medicare/Medicare-General-Information/BNI No further information was provided.

Based on facility documentation and clinical record review and in the course of a complaint investigation, the facility staff failed to follow standards of quality for one resident (#2) in a survey sample of 5 Residents. Resident #2 was not served the correct meal tray which had food specifically prepared to meet his medical needs. The findings included: Resident #2 a [AGE] year old man was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's most recent MDS (minimum data set) with ARD (assessment reference date) of 7/25/19 coded as an annual assessment, codes the Resident as having a (Brief Interview of Mental Status) BIMS score of 0, indicating the Resident is unwilling or unable to complete. The Resident was coded as (#4) Total dependence requiring (#3) 2+ person physical assistance for toileting. Bathing, dressing and transfers. For ambulation via wheel chair and for eating he is coded as (#3) Extensive Assistance and requiring (#2) 1 person physical assistance. On 10/15/19 during clinical record review it was discovered that on 10/4/19 the Resident had received a meal tray with a regular diet when he has orders for chopped diet with thickened liquids. The resident subsequently choked and had to have the [MEDICATION NAME] maneuver performed on him. Excerpts from the FRI (facility reported incident) read: Results of the investigation showed that the resident received a regular diet that staff cut up into pieces, instead of the chopped diet that was ordered. The facility kitchen sent the correct diet for that meal, but the staff assisting the resident with that meal admitted to mistakenly giving the resident a regular diet tray instead. On 10/16/19 at approximately 10:00 AM the DON provided a copy of a document titled Clinical Procedure 152-A Resident / Patient dining. Excerpts from the document state: IV- 1. Dining Each resident/patient will have an individualized meal card. a) Staff making sure they are following the instructions on the resident's meal card b) Ensuring residents are given the correct diet c) Double checking the meal tickets against the meal cards prior to serving the residents and not modifying any diet. 2. All staff will follow the Five Rights of meal service assistance: *Right Resident *Right Diet *Right Consistency including not modifying food texture *Right Level of Supervision or Assistance *Right Equipment to Include Adaptive Equipment and Dentures. The employee received an Employee Counseling Report that read: Reason for conference: On 10/4/19, you inadvertently gave a patient the incorrect tray. This lack of oversight is potentially detrimental to the patient's wellbeing, as in addition to choking, consuming the incorrect meal consistency can be fatal to the patient. Corrective actions to be taken by employee: When offering nutrition to patients please review meal card to ensure the correct diet consistency and precautions are being followed. Additionally double check the meal tickets against the meal card before offering the meal to the patient. If there are any concerns, please report to the nurse and or speech therapist for follow up. Employee Comments: I not double checking I mistakenly gave the wrong tray which resulted in the incident which I very sorry for (sic). I've been re-in serviced and am aware of protocol. On 10/16/19 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on staff interview, facility documentation and clinical record review and in the course of a complaint investigation, the facility staff failed to ensure the Residents are free from accident and hazarads for 1 Resident (#2) was free from accident hazards. Findings included: For Resident #2 the facility staff accidentally gave the Resident the wrong tray which resulted in a choking incident requiring the [MEDICATION NAME] maneuver. Resident #2 a [AGE] year old man was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's most recent MDS (minimum data set) with ARD (assessment reference date) of 7/25/19 coded as an annual assessment, codes the Resident as having a (Brief Interview of Mental Status) BIMS score of 0, indicating the Resident is unwilling or unable to complete. The Resident was coded as (#4) Total dependence requiring (#3) 2+ person physical assistance for toileting. Bathing, dressing and transfers. For ambulation via wheel chair and for eating he is coded as (#3) Extensive Assistance and requiring (#2) 1 person physical assistance. On 10/15/19 during clinical record review it was discovered that on 10/4/19 the Resident had received a meal tray with a regular diet when he has orders for chopped diet with thickened liquids. The resident subsequently choked and had to have the [MEDICATION NAME] maneuver performed on him. Excerpts from the FRI (facility reported incident) read: Results of the investigation showed that the resident received a regular diet that staff cut up into pieces, instead of the chopped diet that was ordered. The facility kitchen sent the correct diet for that meal, but the staff assisting the resident with that meal admitted to mistakenly giving the resident a regular diet tray instead. On 10/15/19 at approximately 4:00 PM an interview was conducted with employee G (Dietary Manager) who stated that in the kitchen they have a double check system for the meal trays. The tickets are on the tray the food gets placed on the tray according to the tickets and We have kitchen supervisors who do nothing but check the trays as they come off the line to see that the meal is correct. When asked about the chopped diet he stated that in a chopped diet the food is cut 1/2 X 1/2 cubes, the ground diet is 1/4 X 1/4 cubes. On 10/16/19 at approximately 3:00 PM in an interview with employee F (Speech Language Pathologist) she stated that she was on the floor the day of the incident and remembers the Resident got an alternate tray instead of his chopped diet try by accident. She further elaborated that when she found out what was going on she looked at the tray and I realized the problem right away because I was feeding someone with a chopped diet and it was chopped beef patty with gravy and (Resident #2) had a grilled chicken sandwich cut up on his tray. Employee F stated that a chopped diet from the kitchen is cut up to specific size pieces. With the staff cutting the food there was no way to tell what size the pieces were. She also stated that the kitchen tends to send food that is moister or has gravy or sauce to keep it from drying out. The chicken sandwich was grilled chicken on a bun with lettuce and tomato. On 10/16/19 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observation and staff interview the facility staff failed to transport linen in a manner to prevent the spread of infection in one of two dining areas. In one of two dining areas during meal service the facility staff failed to distribute clothing protectors in a manner to prevent the spread of infection. The findings included: On 3/27/19 from 11:11am until 11:21am, during observation of meal service on the third floor, CNA F (certified nursing assistant) , CNA G, and LPN D (licensed practical nurse) were holding clothing protectors against their body, which was touching their clothing, while they were distributing the clothing protectors to residents. On 03/28/19 at 11:15 AM, during an interview with RN A, when asked how should staff transport linens, she replied staff would wash their hands, obtain linen for what they need, and carry it holding it not against their clothing or anything like that. On 3/28/19 at 2:26pm during a meeting with the Administrator and DON when asked what their expectations regarding linen transport, the DON replied, hold it in their hands, not touching their body. The Administrator and DON were made aware of staff's failure to transport linen in a manner to prevent the spread of infection during end of day meeting on 3/28/19 at 2:26pm. No further information was provided.

Based on observations, staff interviews, clinical record reviews, and facility documentation, the facility staff failed to ensure professional practice standards for medication administration for 4 residents (Resident #38, Resident #2, Resident 11 # , Resident #13 ) in a sample size of 21. 1. For Resident #38, the facility staff failed to administer medications via gastrostomy tube according to professional practice standards. 2. For Resident # 2, the facility staff failed to document the administration of medications as ordered by the physician 3. For Resident #11 the facility staff failed to follow physicians order and administered [MEDICATION NAME] twice in one day when it was ordered daily at 6:30 AM. 4. For Resident #13, the facility staff failed to obtain weights as ordered by the physician The findings include: 1. For Resident #38, the facility staff failed to administer medications via gastrostomy tube according to professional practice standards. Resident #38, a [AGE] year old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #38's most recent Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 02/25/2019 and was coded as a quarterly assessment. Resident #24 was not coded for a Brief Interview of Mental Status (BIMS). Cognitive skills for daily decision-making were coded as severely impaired. Functional status for bed mobility, transfers, eating (tube feedings), dressing, and personal hygiene were all coded as total dependence on staff. On 03/27/2019 at 9:40 AM, LPN C was observed at medication cart preparing to administer medications to Resident #38. Medications LPN C prepared to administer included but not limited to [MEDICATION NAME] 30 mg (delayed-release orally disintegrating tablet) and Senna 8.6 mg tablet. LPN C opened each unit dose package and placed the whole (not crushed) [MEDICATION NAME] tablet in a medicine cup and place the whole (not crushed) Senna tablet in a separate medicine cup. She placed them on a tray with the other medications to be administered, covered the tray with a cloth, and carried the tray to Resident #38's bedside. LPN C introduced herself to Resident #38 and stated, I'm going to give you your medicines now. At that time, this surveyor asked LPN C to return to the medication cart in hall. When asked about the Senna, LPN C looked at the Medication Administration Record [REDACTED]. The administration time listed on the MAR indicated [REDACTED]. LPN C then picked up the tray of medications and started to re-enter Resident #38's room. At that time, this surveyor then asked LPN C how the [MEDICATION NAME] is to be given. LPN C stated, I should crush it first. LPN C returned to the medication cart, placed the [MEDICATION NAME] tablet in a plastic bag, crushed the tablet, and placed the powder in a medicine cup. LPN C now had 5 medications on the tray and a cup of water. At the bedside, LPN C checked for gastric residual volume with a 60 ml syringe and then flushed with water in between each medication. LPN C would draw up a medication in the 60 ml syringe with a large air bolus between the medication and the syringe plunger. LPN C would then attach the syringe to the gastrostomy tube and plunge the medication as well as the large air bolus into Resident #38's stomach. LPN C repeated that process two more times. LPN C reconstituted the [MEDICATION NAME] with water at the bedside, removed the plunger from the syringe, attached the syringe to the gastrostomy tube, and poured the reconstituted [MEDICATION NAME] into the syringe and it immediately drained into the gastrostomy tube. She poured water into the syringe to flush the medication and then repeated that process for the last medication. When LPN C was asked about administering medications through a gastrostomy tube, she stated, I should've put them all in by gravity. When asked if she was aware of the amount of air she injected into Resident #38's stomach, she stated she didn't know. When this surveyor told her it was approximately 150 ml of air, she stated, That's too much air. On 03/27/2019 at approximately 12:05 PM, the DON was asked what references are utilized for professional practice standards and she stated, CMS (Centers for Medicare and Medicaid Services), CDC (Centers for Disease Control and Prevention), AMA (American Medical Association). She also provided a list of resources for nurses: Lippincott - Nursing Practice; Meg Gulanick, Judith Meyer: Nursing Care; Donita D'Amico,[NAME] Barbarito: Health and Physical Assessment in Nursing; Mosby (YEAR) Drug book. On 03/27/2019 at approximately 5:45 PM, the DON was asked about the expectation of nurses when administering medications through a gastrostomy tube, she stated, It shouldn't have air in it. She also stated that when air is added, that can develop more problems. In the Seventh Edition of Lippincott Nursing Procedures under the section entitled Tube Feedings and the sub-heading For gastric feeding it stated, If you're using a bulb or catheter-tip syringe, remove the bulb or plunger and attach the syringe to the pinched-off feeding tube to prevent excess air from entering the patient's stomach, causing distention. .fill the syringe with formula and release the feeding tube to allow formula to flow through it. The height at which you hold the syringe will determine the flow rate. When the syringe is three-quarters empty, pour more formula into it. To prevent air from entering the tube and the patient's stomach, never allow the system to empty completely. The facility staff provided their facility policy entitled, Gastrostomy Tube Feedings. Section II Part D documented, Water for flushing the gastrostomy tube after feeding and/or medication administration. Thirty to sixty ml of water is used for flushing via gravity, unless otherwise ordered by physician. On 03/28/2019 at approximately 5:45 PM, the Administrator and DON were notified of findings and they offered no further documentation or information. 2. For Resident # 2, the facility staff failed to document the administration of medications as ordered by the physician. Resident # 2, an [AGE] year old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The most recent Minimum Data Set assessment was a Quarterly assessment with an assessment reference date (ARD) of 3/12/19. Resident # 2 was coded as having severe cognitive impairment. Resident # 2 was coded as requiring total assistance of one staff person for Activities of Daily Living except she required total assistance of two staff persons for bathing and transfers. Resident # 2 was coded as always incontinent of bowel and bladder. On 3/27/2019, review of the clinical record was conducted. Review of (MONTH) 2019 Medication Administration Record [REDACTED] [MEDICATION NAME] 0.83% inhalers solution inhale one vial via nebulizer every 12 hours 3/9/2019 at 10:00 PM [MEDICATION NAME] 0.5 milligrams per 2 milliliters suspension inhale one vial via nebulizer every 12 hours 3/8/2019 at 10 AM [MEDICATION NAME] 250 milligrams per 5 milliliters take 900 milligrams (18 milliliters) via [DEVICE] (gastrostomy tube) on 3/11/2019 at 8:00 AM, 3/19/2019 at 2:00 PM Amox/Clav 250-62.5 milligrams per 5 milliliters take 10 milliliters via [DEVICE] every 12 hours for 7 days- 3/27/19 at 12 noon Review of the (MONTH) 2019 Medication Administration Record [REDACTED] [MEDICATION NAME] 0.83% inhalers solution inhale one vial via nebulizer every 12 hours 2/15/19 at 10 AM [MEDICATION NAME] 0.5 milligrams per 2 milliliters suspension inhale one vial via nebulizer every 12 hours 2/15/19 at 10 AM [MEDICATION NAME] 5 milligrams (1/2 tab) take a half tab every 12 hours via [DEVICE] 2/15/19 at 10 AM [MEDICATION NAME] Kids Packets mix one packet in water, juice, or non-[MEDICATION NAME] beverage and take via [DEVICE] twice daily 2/15/19 at 10 AM [MEDICATION NAME] 250 milligrams per 5 milliliters take 900 milligrams (18 milliliters) via [DEVICE] (gastrostomy tube) 2/15/19 at 8 AM [MEDICATION NAME] 300 milligrams per 5 milliliters take 300 milligrams (5 milliliters) 2/15/19 at 8 AM [MEDICATION NAME] 0.2 % eye drops place one drop in each eye once daily for the eye 2/15/19 at 10 AM [MEDICATION NAME] 200 milligrams take one tablet via [DEVICE] twice daily 2/15/19 at 8 AM, 2/23/19 at 8 PM, 2/24/19 at 8 PM [MEDICATION NAME] 10 milligrams per milliliters solution take 150 milligrams (15 milliliters) via [DEVICE] twice daily 2/15/19 at 8 AM, 2/24/19 at 8 PM Senna 8.6 milligrams tablet twice a day via G tube 2/15/19 at 10 AM On 3/27/19 at approximately 12:05 PM, the Director of Nursing presented a written note with a list of resources for professional standard including Lippincott - Nursing Practice. On 3/27/2019 at 3:05 PM, an interview was conducted with the Assistant Director of Nursing who stated nurses should document medications at the time of administration. The Director of Nursing and Administrator cited Lippincott as its Nursing professional guidance used by the facility. Fundamentals of Nursing, by Lippincott, stated The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Guidance is given from Lippincott Solutions, Safe Medication Administration Practices, General 10/02/2015. Document all medications administered in the patient's MAR indicated [REDACTED]. If a medication wasn't administered, document the reason why, any interventions taken, practitioner notification, and the patient's response to interventions. Additional Guidance from Lippincott's Nursing Center.com (www.nursingcenter.com) Rights of Medication Administration 1. Right patient Check the name on the order and the patient. Use 2 identifiers. Ask patient to identify himself/herself. When available, use technology (for example, bar-code system). 2. Right medication Check the medication label. Check the order. 3. Right dose Check the order. Confirm appropriateness of the dose using a current drug reference. If necessary, calculate the dose and have another nurse calculate the dose as well. 4. Right route Again, check the order and appropriateness of the route ordered. Confirm that the patient can take or receive the medication by the ordered route. 5. Right time Check the frequency of the ordered medication. Double-check that you are giving the ordered dose at the correct time. Confirm when the last dose was given. 6. Right documentation Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug. 7. Right reason Confirm the rationale for the ordered medication. What is the patient's history? Why is he/she taking this medication? Revisit the reasons for long-term medication use. 8. Right response Make sure that the drug led to the desired effect. If an antihypertensive was given, has his/her blood pressure improved? Does the patient verbalize improvement in depression while on an antidepressant? Be sure to document your monitoring of the patient and any other nursing interventions that are applicable. Reference: Nursing2012 Drug Handbook. (2012). Lippincott[NAME] & Wilkins: Philadelphia, Pennsylvania. www.nursingcenter.com Accessed online 3/29/2019. On 3/27/2019 during the end of day debriefing, the facility Administrator and Director of Nursing were informed of the findings of missing documentation of medications. The Administrator stated the Director of Nursing had identified the issue of missing documentation of medication administration in (MONTH) 2019 and had done a plan of correction to address the problem. The Administrator was informed that the issue had not been resolved since there was evidence of continued missing documentation of medication administration since the problem was identified. The Director of Nursing stated she would continue to educate the nursing staff on the importance of documentation of medication administration at the time of administration. No further information was provided. 3. For Resident #11 the facility staff failed to follow physicians order and administered [MEDICATION NAME] twice in one day when it was ordered daily at 6:30 AM. Resident # 11 a [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/28/19 during clinical record review it was noted on the Physicians Order Sheet that the Resident #11 several orders for pain medications as follows: 1. [MEDICATION NAME] Soln (Tylenol solution) 650 MG /20 ML (Milliliters) Take 20 ML via [DEVICE] Every 12 Hours (at 1000 and 2200) (10 AM and 10 PM) as directed. 2. [MEDICATION NAME] Soln - Every 6 hours as needed for pain or temp 100.5 or above. Max of 4000 MG/day 3. [MEDICATION NAME] (Narcotic pain medicine) 25 MCG/HR (Micrograms per Hour) apply one patch every 72 hours. Remove old patch alternate sites.*External Use* 4. [MEDICATION NAME] HCL (Narcotic pain medicine) 50 MG -Take 1 tablet Via [DEVICE] at 6:30 AM Upon further review it was discovered that the Resident was given two doses of [MEDICATION NAME] 50 MG on 3/27/19. The Narcotic Control sheet documented Resident # 11 being given [MEDICATION NAME] 50 MG as ordered at 6:30 AM by LPN E the night shift nurse (11 PM-7:30 AM shift). A second entry in the Narcotic Control sheet on 3/27/19 shows LPN C (Day Shift 7 AM-3:30 PM) also gave the Resident a 50 MG dose of [MEDICATION NAME] however no time of administration was entered on the narcotic sheet. According to the Physician Interdisciplinary Notes the Nurse Practitioner 3/27/19 1450 (2:50 PM) - Noted that Resident received extra dose of [MEDICATION NAME] this AM. Pt sleepy but awakens to stimulation / voice T-97.8 (temperature) P-104 (Pulse)-R-18 (Respirations) O2 Sat. 94% on room air (Oxygen Saturation) B/P 107/72 (Blood Pressure) Monitor vital signs q shift (every shift) with O2 Sat monitoring. According to the DON the Professional Guidance used for nursing is Lippincott. According to Lippincott the eight rights of medication administration are: 1. Right patient- Check the name on the order and the patient. Use 2 identifiers. Ask patient to identify himself/herself. When available, use technology (for example, bar-code system). 2. Right medication-Check the medication label. Check the order. 3. Right dose-Check the order. Confirm appropriateness of the dose using a current drug reference. If necessary, calculate the dose and have another nurse calculate the dose as well. 4. Right route- Again, check the order and appropriateness of the route ordered. Confirm that the patient can take or receive the medication by the ordered route. 5. Right time-Check the frequency of the ordered medication. Double-check that you are giving the ordered dose at the correct time. Confirm when the last dose was given. 6. Right documentation-Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug. 7. Right reason- Confirm the rationale for the ordered medication. What is the patient's history? Why is he/she taking this medication? Revisit the reasons for long-term medication use. 8. Right response-Make sure that the drug led to the desired effect. If an antihypertensive was given, has his/her blood pressure improved? Does the patient verbalize improvement in depression while on an antidepressant? Be sure to document your monitoring of the patient and any other nursing interventions that are applicable. Reference: Nursing2012 Drug Handbook. (2012). Lippincott[NAME] & Wilkins: Philadelphia, Pennsylvania. On 3/28/19 at 3:30 PM an interview was conducted with the DON who stated she was aware that the dayshift nurse had given the extra dose of [MEDICATION NAME] and that they did contact the physician and written a medication variance. DON also stated she would give LPN C additional in-service training on medication administration. On 3/28/19 the Administrator was made aware during the end of day conference and no additional information was provided 4. For Resident #13, the facility staff failed to obtain weights as ordered by the physician. Resident #13, was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #13's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 1/4/19 was coded as a quarterly assessment. Resident #13 was coded as daily decision making being severely impaired. The resident was also coded as being totally dependent, requiring the assistance of two staff persons, for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. Review of physician orders [REDACTED]. START 3-5-19 STOP 4-1-19. These orders were also signed on 3/6/19 by an RN that indicated she had read and checked the orders on 3/6/19. On 3/28/19 during record review, which included review of nursing notes and weight flow sheets; the weights had not been obtained 6 days weekly, as ordered. Weights were documented as having only been obtained on 3/5/19, 3/6/19, 3/14/19, 3/20/19, and 3/27/19. The facility staff failed to obtain weights on 14 occasions as ordered. During an interview with the DON (Director of Nursing) on 3/28/19 she reviewed Resident #13's clinical record and acknowledged that weights had not been obtained as ordered. The Administrator and DON were informed of the failure of staff to obtain weights as ordered on [DATE] at approximately 3pm. No further information was provided.

Based on staff interview, clinical record review and facility documentation the facility staff failed to ensure 2 Residents (Residents #35, and #46) were free from unnecessary [MEDICAL CONDITION] drugs in a survey sample of 21 Residents. 1. For Resident # 35, the facility staff used [MEDICATION NAME] PRN (as needed) for more than 14 days without a [DIAGNOSES REDACTED]. 2. For Resident # 46 the facility staff only attempted 1 gradual dose reduction since start of [MEDICATION NAME] 150 MG on 11/16/17 and no GDR for the other 3 [MEDICAL CONDITION] medications. The findings include: 1. For Resident # 35, the facility staff used [MEDICATION NAME] PRN (as needed) for more than 14 days without a [DIAGNOSES REDACTED]. Resident #35 a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/25/19 at 3:00 PM a clinical record review was conducted and it was found that Resident # 35 was on several [MEDICAL CONDITION] medications including: [MEDICATION NAME] (Trade name- [MEDICATION NAME]- an Anti-Anxiety) 2 MG every 8 hours PRN for agitation and yelling On 3/28/18 the DON was asked what the [MEDICATION NAME] order read as indication for use. DON read from the Physicians order [MEDICATION NAME] 2 mg. take 1 tablet via [DEVICE] every 8 hours as needed for Agitation/Yelling. When asked if agitation or yelling are [DIAGNOSES REDACTED]. When asked about having the [MEDICATION NAME] as a PRN order for more than 14 days the DON stated she was unaware that they could only get the medication PRN for 14 days. The Administrator was made aware of this issue during the end of day meeting on 3/28/19, no further information was provided. 2. For Resident # 46 the facility staff to only attempted 1 gradual dose reduction since [MEDICATION NAME] (Anti-Psychotic) began on 11/16/17 and no GDR for [MEDICATION NAME], and [MEDICATION NAME]. Resident #46 a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/25/19 at 3:00 PM a clinical record review was conducted and it was found that Resident #46 was on several [MEDICAL CONDITION] medications including: 1. [MEDICATION NAME] (Trade name -[MEDICATION NAME] an Anti-Psychotic) 50 MG take 3 tablets (to equal 150 mg) via [DEVICE] every 8 hours. 2. [MEDICATION NAME] (Trade name [MEDICATION NAME] - an Anti-Depressant) 75 MG 1 tab. via [DEVICE] in morning and evening 3. [MEDICATION NAME] (Trade name- [MEDICATION NAME]- an Anti-Anxiety) 2 MG take 1 tab. three times daily at 0700 1300 and 2000 (7am, 1PM and 8PM) 4. [MEDICATION NAME] (Trade name [MEDICATION NAME] -an Anti-Anxiety) 1 MG take 1 tab. three times daily at 0700 1300, and 2000 (7AM, 1PM, and 8PM) 5. [MEDICATION NAME] (Trade name [MEDICATION NAME] an Anti-Depressant) 7.5 MG 1 tab. via [DEVICE] at Bedtime as needed for [MEDICAL CONDITION]. On 3/28/19 this surveyor requested GDR (Gradual Dose Reduction) for the [MEDICAL CONDITION] that Resident #46 was receiving. Administrator submitted a document titled Gradual Dose Reduction Guidance to Provider. The document stated: [MEDICAL CONDITION] mediation initiated (enter date): 11/16/17 GDR Attempt: 1st Attempt List [MEDICAL CONDITION] medication in review: [MEDICATION NAME] 150 MG every 8 hours. Guidance: Per CMS regulations a gradual dose reduction is recommended in the medication listed above. If a dose reduction is clinically appropriate consider reducing the 10 mg bedtime dose. Per American Psychiatric Association (APA) guidelines, a gradual reduction by 10% per month over a 6 to 24 months is preferred in order to avoid withdrawal and minimize the risk of relapse. (The document has the pharmacist Signature and date signed 11/9/18) Prescriber Response required (check box) (Box checked) Read but do not wish to implement Comments: (Doctor's name redacted) Consultation (recert.) Present medication will be continued for a while. Thanks for your suggestion. Physician Signature: (Redacted) Date: 11/13/18 On 3/28/19 the Administrator was asked if there were any further GDR's for any of the other meds or another attempt for the [MEDICATION NAME]. She stated No we have looked in both charts this is the only one we have. The Administrator was made aware of this issue during the end of day meeting on 3/28/19, no further information was provided.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to complete a SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice) for 3 Residents (Resident #300, Resident #301, Resident #23) in a survey sample of 21 Residents. 1. For Resident #300, the facility staff failed to provide a SNF ABN notice prior to skilled care services, paid by Medicare, ended. Resident #300 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services. 2. For Resident #301, the facility staff failed to provide a SNF ABN notice prior to skilled care services, paid by Medicare, ended. Resident #301 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services. 3. For resident #23, the facility staff failed to provide a SNF ABN notice prior to skilled care services, paid by Medicare, ended. Resident #23 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services. The findings included: 1. For Resident #300, the facility staff failed to provide a SNF ABN notice prior to skilled care services, paid by Medicare, ended. Resident #300 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services. Resident #300, was admitted to the facility on [DATE], with a readmission date of [DATE]. Resident #300's [DIAGNOSES REDACTED]. Resident #300's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/13/19 was coded as an Admission Assessment. Resident #300 was coded as his cognitive skills for daily decision making being severely impaired. The resident was also coded as being totally dependent upon two staff members for bed mobility, transfers, dressing, toileting and bathing. The resident was coded as being totally dependent upon one staff person for eating and personal hygiene. Resident #300 was discharged from a Medicare covered Part A stay on 3/22/19, he remained in the facility. Facility record review of Medicare discharge notices on 3/27/19, revealed the facility mailed a NOMNC (notice of medicare non-coverage) and letter dated 3/18/19 to Resident #300's family member stating that his Medicare covered Part A stay would end on 3/22/19. A copy of the certified mail receipt was attached. The Administrator was asked on 3/27/19 if any other documentation was available regarding the Medicare discharge notices. No further information was provided. On 03/27/19 at 04:03 PM during an interview with Employee I, Utilization Review Coordinator, she stated she is the responsible person for sending the notices and when asked about the notices sent, she stated, This is all that I send. We don't have any other form. The facility staff provided Resident #300 with the NOMNC, which provides notice of the right to an appeal and expedited review of service termination. The facility staff failed to provide Resident #300 with the second required notice, a SNF ABN, which allows the resident an option to continue to receive services, be notified of the expected cost, and have Medicare make the coverage determination once a bill is submitted to Medicare. The Administrator and DON, were informed on 3/27/19 at 4:44pm of the failure of staff to provide Resident #300 with a SNF ABN notice prior to skilled care services ending, which would have allowed Resident #300 or his representative, to make a decision about continuation of services and have Medicare make the coverage determination. No further information was provided. 2. For Resident #301, the facility staff failed to provide a SNF ABN notice prior to skilled care services, paid by Medicare, ended. Resident #301 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services. Resident #301 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #301's most recent MDS (Minimum Data Set) (an assessment tool) with an ARD (assessment reference date) of 11/19/18, was coded as a 14 day assessment. Resident #301 was coded as having a BIMS (Brief Interview for Mental Status) score of 11, indicating moderately impaired cognition. The resident was coded as requiring limited assistance of one staff member for activities of daily living except bathing, which the resident required extensive assistance. Resident #301 was discharged from a Medicare covered Part A stay, and from the facility on 11/19/18. Facility record review of Medicare discharge notices on 3/27/19, revealed the facility mailed a NOMNC (notice of medicare non-coverage) and letter dated 11/13/18 to Resident #301's family member stating that her Medicare covered Part A stay would end on 11/19/18. A copy of the certified mail receipt was attached and a signed return receipt card. The Administrator was asked on 3/27/19 if any other documentation was available regarding the Medicare discharge notices. No further information was provided. On 03/27/19 at 04:03 PM during an interview with Employee I, Utilization Review Coordinator, she stated she is the responsible person for sending the notices and when asked about the notices sent, she stated, This is all that I send. We don't have any other form. The facility staff provided Resident #301 with the NOMNC, which provides notice of the right to an appeal and expedited review of service termination. The facility staff failed to provide Resident #301 with the second required notice, a SNF ABN, which allows the resident an option to continue to receive services, be notified of the expected cost, and have Medicare make the coverage determination once a bill is submitted to Medicare. The Administrator and DON, were informed on 3/27/19 at 4:44pm of the failure of staff to provide Resident #301 with a SNF ABN notice prior to skilled care services ending, which would have allowed Resident #301 or her representative, to make a decision about continuation of services and have Medicare make the coverage determination. No further information was provided. 3. For Resident #23, the facility staff failed to provide a SNF ABN notice prior to skilled care services, paid by Medicare, ended. Resident #23 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services. Resident #23, a [AGE] year old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #23's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 1/21/19, was coded as the resident having severe cognitive impairment for daily decision making. The resident was coded as being totally dependent upon two staff persons for bed mobility, transfers, toilet use and bathing. Resident #23 was discharged from a Medicare covered Part A stay on 1/25/19. Facility record review of Medicare discharge notices on 3/27/19, revealed the facility mailed a NOMNC (notice of medicare non-coverage) and letter dated 1/15/19 to Resident #23's family member stating that her Medicare covered Part A stay would end on 1/25/19. A copy of the certified mail being returned to sender as being undeliverable as addressed, was attached. The Administrator was asked on 3/27/19 if any other documentation was available regarding the Medicare discharge notices. No further information was provided. On 03/27/19 at 04:03 PM during an interview with Employee I, Utilization Review Coordinator, she stated she is the responsible person for sending the notices and when asked about the notices sent, she stated, This is all that I send. We don't have any other form. The facility staff provided Resident #23 with the NOMNC, which provides notice of the right to an appeal and expedited review of service termination. The facility staff failed to provide Resident #23 with the second required notice, a SNF ABN, which allows the resident an option to continue to receive services, be notified of the expected cost, and have Medicare make the coverage determination once a bill is submitted to Medicare. The Administrator and DON, were informed on 3/27/19 at 4:44pm of the failure of staff to provide Resident #23 with a SNF ABN notice prior to skilled care services ending, which would have allowed Resident #23 or her representative, to make a decision about continuation of services and have Medicare make the coverage determination. No further information was provided.

Based on staff interview, clinical record review, and facility documentation the facility staff failed to implement their abuse and neglect policy. 1. For Resident #35 the facility staff failed to implement abuse and neglect policy for an injury of unknown origin. 2. For Resident #45, the facility staff failed to implement their policy and procedure of abuse for a fracture of unknown origin. The findings include: 1. For Resident #35 the facility staff failed to implement abuse and neglect policy for an injury of unknown origin. Note: This deficiency is the result of an investigation conducted in relation to (Facility Related Incident) FRI send to the Office of Licensure and Certification on 11/3/2017. The FRI indicated that Resident #25 had X-Rays that showed a possible fracture of knee as a result of an injury of unknown origin. Resident #35 a [AGE] year old woman was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/26/19 at 2:00 PM requested investigation for FRI that was sent to OLC. Administrator explained that previous employee responsible for investigations was no longer at facility and that she would try to find the investigation. On 3/27/19 a clinical record review was conducted and it was found that Resident #35 had complained of pain and showed signs of pain such as facial grimaces since 10/24/17. Her attending physician ordered X-Rays on (MONTH) 2, (YEAR). According to documents provided by the facility Administrator the results were of the X-Rays were received by Radiology Dept. at the facility and date stamped on Nov. 2, (YEAR), however MD was not notified by Radiology until Nov. 3, (YEAR) thus creating a delay in notification to the Office of Licensure and Certification and a delay in treatment. A review of the Abuse and neglect policy provided by the facility page 3 Paragraph E states: E. All allegations of abuse/neglect and incidents of unknown origin (IUO) are reported to the Virginia Department of Health (VDH) in accordance with Centers of Medicare and Medicaid Services (CMS) conditions of Participation as follows: 1. Abuse / Neglect allegations will be reported within 2 hours of discovery. 2. Incident of unknown origin resulted in a serious injury to a patient/resident will be reported within two (2) hours of discovery. 3. Incidents of unknown origin resulting in no apparent injury or minor injury will be reported no later than two (2) hours of discovery. 4. A copy of the report that is faxed to VDH will be emailed to CNE Facility Director, Medical Director, Clinical Director and Risk Manager. The program would not be complete without a procedure for investigating allegations of abuse and neglect that do occasionally occur. Specially trained personnel, who while responding to an allegation, report directly to the Office of Investigations Management at DBHDS, investigate these allegations. The facility Director will maintain the products of these investigations. In an interview with the Administrator she stated that the Radiology dept. at the facility failed to notify the doctor of the results on the day it was received [DATE], (YEAR). She further stated that the facility launched an investigation and notified the VDH as soon as they had the results of the X-Rays. The Administrator and the Medical Director were made aware of the findings on 3/28/19 during the end of day meeting no further information was provided. 2. For Resident #45, the facility staff failed to implement their policy and procedure of abuse for a fracture of unknown origin. Resident #45, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #45's most recent MDS (Minimum Data Set) (an assessment tool) with an ARD (assessment reference date) of 12/5/18 was coded as a quarterly assessment. Resident #45 was coded as having severe cognitive impairment. The resident was also coded as requiring limited assistance of two staff members for transfers, and being totally dependent on staff for dressing, toileting and bathing. Resident #45 required supervision of one staff member for eating. During clinical record review on 3/27/19 and 3/28/19, of the nursing notes, physician progress notes [REDACTED]. Nursing notes read on 8/28/19 resident was observed sitting up in w/c (wheel chair) @ (at) nursing station. Observed rubbing hard headphones against left shoulder area. Small purple bruise noted on left shoulder. Nursing notes dated 9/1/18 read, noted to have 2 new parallel areas of bruising to left shoulder and left anterior chest. Fading bruising remains to top of left shoulder and anterior left chest skin intact. Nursing notes dated 9/5/18 read bruise to l (left) shoulder spreading down to L (left) breast. Nursing notes dated 9/6/18 read, bruising of left shoulder, chest, & lower side remains. Seems to be protective guarding of moving left arm. On 9/7/18 x-ray results revealed a non-displaced acute fracture of distal clavicle. On 3/27/19 at 9am, the Administrator was requested to provide investigation information for Resident #45's injury. A blue folder was provided. The folder contained the following 10 documents. 1. Investigator's summary dated 9/12/18 2. FRI (Facility reported incident) report which was submitted to the office of licensure 3. A facility event report dated 8/28/18 4. Interdisciplinary notes dated 8/27/18-9/9/18 5. Physician interdisciplinary notes dated 8/8/18- 9/10/14 6. Physician orders dated 9/5/18-9/10/18 7. X-ray reports dated 9/7/18 8. Fax confirmation of APS (Adult Protective Services) notification of injury 9. A Letter dated 9/13/18 addressed to Resident #45's guardian with a certified mail receipt and signed return receipt card which notified her an investigation was being performed 10. A letter dated 9/14/18 addressed to Resident #45's guardian which read, based on the preponderance of evidence, the case was found to be unsubstantiated for neglect and the case is now closed. The facility Administrator was asked again on 3/27/19 at 4:44pm and the morning of 3/28/19 to provide any additional investigation information regarding Resident #45. On 03/28/19 at 10:59 AM the Administrator said there is nothing else. On 3/28/19 at 1:19pm a telephone call was made to Employee H, the investigator, and she stated I looked through the chart at the documentation related to the issue. When asked if she interviewed any nursing staff, CNA staff, other residents, or radiology personal; she stated, no ma'am. The resident was unable to be protected from further abuse, as the Administrator and the Director of Nursing stated no staff had been interviewed during the investigation of abuse and neglect for Resident #45. Review of the facility Policy and Procedure titled: Patient Abuse, Neglect, & Injuries of Unknown Origin; Prevention & Investigation of with a revision date of 3/4/19 states, the purpose of the policy is To provide guidance to staff concerning the prevention of patient/resident abuse and/or neglect, and to establish uniform procedures for the reporting and investigation of allegations of patient/resident abuse, neglect, or injuries of an unknown origin. The policy reads: All unexplained fractures are reportable as alleged abuse/neglect. (facility name) has zero tolerance for acts of abuse or neglect. Therefore, whenever an allegation of abuse or neglect is made, (Facility name) shall take immediate steps to protect the safety & welfare of patients/residents who may be victims of the alleged abuse or neglect, conduct a thorough investigation and take any action necessary to prevent future occurrences of abuse or neglect. The facility staff failed to implement their abuse policy in regard to investigating allegations of alleged abuse. The facility Administrator and Director of Nursing were made aware of these findings on 3/28/19 at 2:16pm. No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review the facility staff failed to submit a 5 day follow up report to the State Agency for two residents (Resident #2 and #24) in a survey sample of 21 residents. 1. For Resident #2, the facility did not report the results of the investigation of an injury of unknown origin to the State Agency. Resident # 2 was found with a large raised area on the right side of her forehead on 9/29/18. 2. For Resident #24, the facility staff failed to report investigation results of an injury of unknown origin to the state agency. Resident #24 was found with bruising to her third and fifth fingers on her right hand. The findings included: 1. For Resident #2, the facility did not report the results of the investigation of an injury of unknown origin to the State Agency. Resident # 2 was found with a large raised area on the right side of her forehead on 9/29/18. Resident # 2, an [AGE] year old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The most recent Minimum Data Set assessment was a Quarterly assessment with an assessment reference date (ARD) of 3/12/19. Resident # 2 was coded as having severe cognitive impairment. Resident # 2 was coded as requiring total assistance of one staff person for Activities of Daily Living except she required total assistance of two staff persons for bathing and transfers. Resident # 2 was coded as always incontinent of bowel and bladder. Review of the clinical record was conducted on 3/27/2019. Review of the Interdisciplinary notes (nurses notes) revealed documentation of: 9/29/2018 at 8:00 AM .0540 (5:40 AM) noted up in chair, has large raised area on right side of forehead (sic), no bleeding, sm (small) amt (amount) of bruising center of area, ice pack applied, helped some, swelling decreased some, chg (charge) nurse aware, doctor notified. will see pt (patient) on rounds. 9/29/2018 at 1400 (2:00 PM) Patient was up in wheelchair at start of dayshift. Patient noted with a 7 cm (centimeter) x 7 cm raised intact area of swelling and bruising to right forehead .Pt seen by Dr. _____(Employee G) on morning rounds. No new orders received. Review of the Physicians Interdisciplinary Notes revealed documentation on 9/29/2018 11:02 AM- c/c (complaint/ concern): right forehead bump-wound swelling and bruised. No neurological deficit, well localized bump with intact skin. Diagnosis: [REDACTED]. (May be related to bang herself.) Prescription: (1) close observation (2) incident report (3) called left message on answering machine for family 10/1/2018 at 1400 (2:00 PM) c/c: forehead bruise-fading but spread to right temple/face bump decrease Diagnosis: [REDACTED]. Rx (prescription) observation On 3/27/2019 at 9:18 AM, an interview was conducted with doctor (Employee F) who stated she was Resident # 2's doctor and was told of the injury of unknown origin when she returned to work. Employee F stated another doctor (Employee G) was on call that day. Employee F was informed the surveyor would complete the interview with her after interviewing Employee G. On 3/27/2019 at 9:24 AM, an interview was conducted with the doctor (Employee G) who was on call on 9/29/2018 when the injury of unknown origin was discovered. Employee G stated he was informed of the injury and assessed Resident # 2 when he made rounds. Employee G stated he discovered swelling and a bruise. Employee G stated the lump was a good size and appeared to be hit by something probably in the morning hours. Employee G stated the injury was unwitnessed, an ice pack was applied along with close observation. Employee G stated due to Resident # 2's history of low platelets disease (ITP) any banging or any injuries would cause lots of bruising. On 3/27/2019 at 9:29 AM, a subsequent interview was conducted with Resident # 2's primary doctor (Employee F) who stated Resident # 2 had involuntary movements of her head and that it was possible that she hit her head on the side rails. Employee F stated it was more likely possible that Resident # 2 sustained the injury of unknown origin during a transfer with the hoyer lift. Employee F stated the lump and bruise were indicative of a strong impact to the right side of her forehead. Employee F stated the facility staff have now begun to cradle Resident # 2's head during transfers to prevent her from bumping her head. On 3/27/2019 at 10:20 AM, an interview was conducted with the Director of Nursing (DON) who stated she had been informed by the nursing supervisor on the day the injury of unknown origin was discovered. The DON stated the investigation showed the injury probably happened during the transfer with the hoyer lift. The DON stated the nursing staff on all three shifts were educated on transfer training. Six pages of sign in sheets of training on Transfer Training were presented. Review of the Training Signature Record revealed that training was conducted on various dates and shifts and included Certified Nursing Assistant, Licensed Practical Nurses and Registered Nurses. Review of the facility's investigation report revealed no documentation of the summary of the investigation of the injury of unknown origin being reported to the State Agency. There was an email written on 9/29/2018 by the Director of Nursing to the former risk manager informing him of the injury of unknown origin for Resident # 2. The email stated We have a VDH reportable on IUO for ___(Resident # 2) and would like to report it to you. Please follow up with me on Monday. Report put in ____box. Further review of the facility documentation of the investigation revealed a document that the Administrator stated was the final report submitted to her by the former Risk Manager. The document stated: Aide related to RN (Registered Nurse) that they observed an about 8 cm (centimeter) 'bump' on resident's right forehead. Area assessed; skin intact, swelling viable and skin reddish in color Action Taken: ice pack wrapped in washcloth applied. AR(Authorized Representative)/Family, MD (Medical Doctor), Nurse and Supervisor notified; resident seen by Nurse at time of discovery (0600)(6:00 AM) and MD (1000)(10:00 AM) No new orders at the time of notification. Incident reported to VDH/CMS (Virginia Department of Health/Center for Medicare and Medicaid Services) as IUO (Injury of Unknown Origin); FD (Facility Director) and Advocate notified per report. Investigation initiated Sept. 29, (YEAR) per report. The report also stated: Patient/Resident unable to respond to interview questions due to intellectual disability. Over the course of the investigation, Resident's aides at the time of discover were interviewed. Both were unable to state how injury occurred but speculated that resident's behavior of moving head from side to side may have contributed to injury, possibly during a transfer using the Hoyer lift. The unit Manager and resident's nurse and aide were interviewed on Oct. 2, (YEAR), both noted a possible cause of injury the resident's uncontrolled head movements, trashing (sic) from side to side. The nurse manager also remarked on the resident's ITP (Idiopathic [MEDICAL CONDITION] Purpura), which allows for easy bruising and extreme bleeding . There is no discernible pattern of occurrence of this incident to the resident or others on her unit. There is no evidence to support or abuse or neglect as a cause of the incident. The type and location of the injury is as previously reported. Resident care is properly addressed in her treatment plan. RM (Risk Management) Assessment: The reported facts and circumstances DO NOT meet the definition of suspicious injury. However, based on the review summarized above, this incident remains unresolved as to cause of injury. While injury is suspected to be accidental in nature, related to the resident's uncontrolled head movement, the actual cause of the injury was unwitnessed and remained unexplained. On 3/27/2019 at 10:36 AM, an interview was conducted with the Administrator and Director of Nursing regarding the process regarding any injuries of unknown origin. The Administrator stated the facility investigates all injuries of unknown origin and completes a summary report within five days. The Administrator stated there had been recent changes in Risk Management personnel and there was difficulty finding documentation of the summary of the investigation of Resident # 2's injury of unknown origin being sent to the State Agency. The Director of Nurses stated the facility's expectation was: the nurse would assess the resident for injuries, start neurological checks, notify the medical doctor, and responsible party. The nurse would start the investigation, notify the Director of Nursing, Administrator. The investigation would include interviewing resident if possible, interviewing staff, inspect to make sure the equipment is operating properly, putting appropriate interventions in place, and update care plans. The Administrator and DON stated the facility would report an injury to the State Agency and a summary of the investigation should be reported within 5 days to the State Agency. Review of the facility abuse policy Patient Abuse, Neglect, & Injuries of Unknown Origin: Prevention, Investigation of: Effective date 3/10/2006, Revised Date: 3/4/2019 revealed C. Injuries of Unknown or Unexplained Origin (IUO) are an indicator that patient/resident abuse/neglect has occurred. A patient/resident injury is considered to be a possible IUO if: 1. The injury's cause can not be reasonably determined. 2. When an incident report is received coding the report event as Unexplained, 3. When an incident report is received without a marked event category. Incident of unknown origin resulting in serious injury to a patient/resident must be reported to the Facility Director and Physician immediately, but no later than two (2) hours of discovery. All incident of unknown origin will be reported to VDH/CMS as follows: * Incident of unknown origin resulting in serious injury to a patient/resident will be reported within two (2) hours of discovery *Incidents of unknown origin resulting in no apparent injury or minor injury will be reported no later than two (2) hours of discovery All unknown patient/resident events must be explained if at all possible by: 1 The supervisor initially receiving the report, 2. The Risk Manager during the initial review of the report, 3. The interdisciplinary treatment team after discussion at daily meetings. 4. By Physician or Nurse in the ID notes. All IUOs will be reported to: 1. The Facility Director 2. The Facility Advocate 3. The patent/resident's Authorized Representative (AR) 4. The Virginia Department of Health (VDH) Any investigation that leads to an allegation of patient/resident abuse/neglect must be reported to the Facility Director immediately. Investigation of the IUO must be completed within five (5) business days of the incident. Results must be reported to the Facility Director and the Virginia Department of Health (VDH) within five (5) business days. On 3/28/19 at 2:00 PM, the Administrator and DON were again informed of the findings. The Administrator stated she did not find any documentation of the final summary being submitted to the State Agency of an injury of unknown origin for Resident # 2. No further information was provided. 2. For Resident #24, the facility staff failed to report investigation results of an injury of unknown origin to the state agency. Resident #24 was found with bruising to her third and fifth fingers on her right hand. Resident #24, an [AGE] year old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #24's most recent Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 01/21/2019 and was coded as a quarterly assessment. Resident #24 was not coded for a Brief Interview of Mental Status (BIMS). Cognitive skills for daily decision-making were coded as severely impaired. Functional status for bed mobility, transfers, eating (tube feedings), dressing, and personal hygiene were all coded as total dependence on staff. On 10/26/2018 at 11:47 AM, a facility-reported incident (FRI) was transmitted to the state agency in reference to Resident #24 and an injury of unknown origin. Under the section entitled 'Description of Incident', it was documented, Around 0900 on 10-26-18, staff reported patient had discoloration to right 3rd and 5th fingers. Fifth right knuckle slightly swollen and purple in color. No break in skin. Under the section entitled 'Facility Action Taken', it was documented, NP (nurse practitioner) in to assess patient. xray (sic) right hand (3rd-5th fingers) ordered. Ice to right hand 15 minutes every 4 hours x 24 hours. On 03/28/2019 at 10:00 AM, the Administrator stated that Employee H (employed by an outside agency) was the investigator for Resident #24's injury of unknown origin. A copy of the investigation documentation and a copy of facility investigation protocol was requested. On 03/28/2019 at 12:35 PM, the Administrator provided 2 pages of an email conversation between Employee C (clinical director) and Employee H (investigator). An email dated 10/29/18 at 1:52 PM documented, Hi (Employee H): Ecchymosis - causes breaking of the capillaries. She had taken Vitamin C to help with this but it was discontinued at some point. It's now been ordered again. Here are some samples of how we write it. The one labeled IUO is how I write it. The other is how (name) wrote it. Either way is fine please let me know if you have any questions. Thanks, (Employee C). An email dated 10/30/18 at 10:28 AM documented, Good morning (Employee C) I am currently working on the report for (Resident #24) and have a couple questions .what is (MD name)'s title? Is he/she active in (Resident #24)'s treatment? How did he/she learn about (Resident #24)'s injury? In other words, I'm trying to figure out how he ended up telling us about the ecchymosis .Any info you can share would be helpful. (Employee H). An email dated 10/30/18 at 11:05 AM documented, Hi (Employee H), (MD name) is the Medical Director. So she's not on his direct caseload, but he oversees the care of all the pts (patients) and makes recommendations as needed. He's been here for years and is very familiar with her case. Hope that helps, (Employee C). On 03/28/2019 at 12:45 PM, the Administrator provided all the documentation associated with the investigation which was seven pages. Included in the packet of papers: 1. Facsimile transmittal sheet dated 10/26/18 that was sent to the state agency on the day of incident 2. Facility Reported Incident Form dated 10/26/18 that was sent to state agency on the day of incident 3. A copy of the nurse's note dated 10/26/18 at 12:00 PM 4. A copy of the NP progress note dated 10/26/18 at 10:15 AM 5. A Facility Event Report dated 10/26/18 6. Handwritten notes by Employee H dated 10/26/18. 7. Typewritten report by Employee H dated 10/26/18 The Facility Event Report was a document with many boxes to select as relevant. The event date was 10/26/18. The event time was 9:50 AM. Unexplained was selected for Type of Event. Bedroom was select for Location. Bruise was selected for Type of Injury. Under the section Describe Event, it was documented, Staff reported patient had discoloration to right 3rd and 5th fingers. Fifth right digit knuckle slightly swollen and purple in color. No break in skin. Under the section Treatment/Interventions, it was documented, NP in to assess patient. New order to x-ray right hand/3rd-5th fingers discoloration to right 3-5th fingers. Ice to right hand 15 min every 4 hours x 24 hours. Nurse was notified on 10/26/18 at 9:55 AM. MD/NP notified 10/26/18 at 10:00 AM. Supervisor was notified 10/26/18 at 11:00 AM. The form was signed by the RN (registered nurse) completing the form. The copy of the handwritten notes by Employee H (investigator) was a lined paper that documented: 10/26/18 (Resident #24's last name) IUO (injury of unknown origin) No known injury/accident-nothing documented (name) - Mdirector Pt has ecchymosis - has had long time Vitamin C for symptoms. quit taking new order. On 03/28/2019 at 1:15 PM, a telephone interview with Employee H was conducted. Employee H verified that the notes listed above were her handwritten notes of the investigation. When asked about her investigation process, she stated that Resident #24 was not able to speak so she reviewed Resident #24's chart. When asked if she spoke with any of the staff or interviewed anyone in the course of her investigation, she stated, No. The typewritten report by Employee H was dated 10/26/2018. Under the section Description of Incident it was documented, Incident of Unknown Origin: Resident was found with bruising to her right hand at approximately 0950 hours in the morning of Friday, 10/26/2018. Interdisciplinary notes from 10-26-18 written by (name) RN stated there was discoloration to right 3rd and 5th fingers with 5th right digit knuckle noted to be slightly swollen and purple in color. There was no break in skin, no active bleeding, no wincing or facial grimacing when palpating the fingers. At approximately 1015 hours, FNP (family nurse practitioner) (name) assessed (Resident #24) and an x-ray of her right hand (3rd and 5th fingers) was ordered. an order for [REDACTED]. Under the section Facility Action Taken it was documented, Facility and Clinical Director were notified on Friday 10/26/2018 and an IUO (injury of unknown origin) investigation was initiated. (State and federal agencies) notified. Reviewed interdisciplinary notes and spoke with nursing staff and (MD name), facility medical director. As the medical director, (name) oversees the patients at (facility) and is very familiar with (Resident #24). He stated the area appeared to be a result of ecchymosis. A condition (Resident #24) has had for quite some time and has taken vitamin C for in the past to aide (sic) with symptoms. A new order for vitamin C has been made. (Resident #24) has no documented symptoms of pain or distress from the injury. After further investigation, there are no new findings in this case. In summary, the state agency received initial facility-report incident documentation on 10/26/2018 pertaining to Resident #24 and her injury of unknown origin. The facility did not report follow-up investigation results pertaining to Resident #24 and her injury of unknown origin. On 03/28/2019 at approximately 3:45 PM, the Administrator and the DON were notified of findings and they offered no further documentation of information.

Based on staff interviews, clinical record review, and facility documentation, the facility staff failed to thoroughly investigate an injury of unknown origin for 2 residents (Resident #24, Resident #45) out of a sample size of 21 residents. The findings included: 1. For Resident #24, the facility staff failed to fully investigate an injury of unknown origin to ensure Resident #24 was not a victim of abuse. Resident #24 was found with bruising to her third and fifth fingers on her right hand. 2. For Resident #45, the facility staff failed to conduct an investigation for a fracture of unknown origin. The findings include: Resident #24, an [AGE] year old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #24's most recent Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 01/21/2019 and was coded as a quarterly assessment. Resident #24 was not coded for a Brief Interview of Mental Status (BIMS). Cognitive skills for daily decision-making were coded as severely impaired. Functional status for bed mobility, transfers, eating (tube feedings), dressing, and personal hygiene were all coded as total dependence on staff. On 10/26/2018 at 11:47 AM, a facility-reported incident (FRI) was transmitted to the state agency in reference to Resident #24 and an injury of unknown origin. Under the section entitled 'Description of Incident', it was documented, Around 0900 on 10-26-18, staff reported patient had discoloration to right 3rd and 5th fingers. Fifth right knuckle slightly swollen and purple in color. No break in skin. Under the section entitled 'Facility Action Taken', it was documented, NP (nurse practitioner) in to assess patient. xray (sic) right hand (3rd-5th fingers) ordered. Ice to right hand 15 minutes every 4 hours x 24 hours. An NP progress note dated 10/26/18 at 10:15 AM documented, Reported purplish discoloration on Rt (right) 3rd and 5th finger/knuckle area. No reported/known injury. Palm roll was off. Appears slightly swollen. X-ray will be ordered. Ice to area, monitor. Physician's orders dated 10/26/18 at 10:15 AM documented, X-ray right hand (3rd-5th fingers) - discoloration to rt (right) 3-5th fingers. Ice to Rt hand 15 min every 4 hours x 24 hours. A nurse's note dated 10/26/18 at 12:00 PM documented, Alert and responsive. Respirations even and unlabored. Staff reported patient had discoloration to write 3rd and 5th fingers. 5th right digit knuckle slightly swollen and purple in color. No breaks in skin. No active bleeding noted. No wincing or facial grimacing when palpating fingers. Fingers to right hand slightly contracted. Palm roll in place. 1000 VS (10:00 AM vital signs) 97.9 (temperature), 99 (pulse), 17 (respirations), 113 / 67 (blood pressure) O2 sat (oxygen saturation) 95% RA (room air). NP in to assess patient. New order to x-ray right hand 3rd through 5th fingers, discoloration to write three through five fingers. Ice to right hand 15 minutes Q (every) 4 hours x 24 hours. A radiographic report dated 10/26/2018 at 8:01 PM documented, Impression: 1. no definite radiographic evidence of acute fracture or dislocation. If there are persistent symptoms, follow-up x-ray may be obtained as clinically warranted. 2. Old fracture first metacarpal healed with mild deformity. 3. Specifically, 3rd through 5th digits intact. 4. Moderate osteopenia or [MEDICAL CONDITION] is demonstrated. 5. Mild degree of [MEDICAL CONDITION]. A nurse's note dated 10/27/18 at 6:00 AM documented, Ice to right hand x 2(every 4 hours) Knuckle next to thumb (index finger) slightly swollen and red to purple in color resp (respirations) even and unlabored skin warm and dry to touch Alert and responsive HOB (elevated) tolerating tube feeding In no acute distress A physician's order dated 10/29/18 at 9:45 AM documented, Vit C 500 mg po (by mouth) daily (via G tube) (gastrostomy tube) daily x 30 days. A physician's progress note dated 10/29/18 at 9:46 a.m. documented, S (subjective). Bruise noted on right hand last Friday [DATE], (YEAR). X-ray of the hand - no fracture 0 (objective).Reddish discoloration noted over right hand, (illegible) 5th and 4th metacarpals and between 4th and 3rd metacarpals. The areas have prominent and engorged veins and capillaries with loose skin. (illegible) discoloration looks like ecchymosis from spontaneous rupture of various capillaries. A (assessment). Ecchymosis, right hand P (plan). Will add Vit C (vitamin C) to drug regimen. A physician's progress note dated 10/29/18 at 10 a.m. documented, bruise on right hand/ not knuckle. On 03/28/2019, the DON explained that medication orders are renewed every 30 days and are considered active on the date the physician signs the order. Physician's medication orders signed on 09/25/2018, 10/23/2018, and 11/19/2018 documented, Multivitamin/Mineral LIQU (liquid) Take 15 ml (milliliters) daily via [DEVICE] (gastrostomy tube). A copy of the physician's order when the multivitamin was first initiated was requested. A copy of the multivitamin package insert was also requested. The facility staff provided a copy of a physician's order dated 03/25/2010 at 3:00 PM which documented, MVI (multivitamin) with mineral supplement 15 ml (milliliters) GT (gastrostomy tube) x 30d (days). Start first dose 03/26/2010. The facility staff also provided a copy of the Supplement Facts for the multivitamin that Resident #24 has been receiving since 2010. Included on the list of vitamins in the multivitamin was Vitamin C 60mg, 150% of the recommended daily value. The Medication Administration Record [REDACTED]. MVI was administered daily as ordered during that date range. Vitamin C was also administered daily from 10/29/18 through 11/22/18. On 03/28/2019 at 10:00 AM, the Administrator stated that Employee H (employed by an outside agency) was the investigator for Resident #24's injury of unknown origin. A copy of the investigation documentation and a copy of facility investigation protocol was requested. On 03/28/2019 at 12:35 PM, the Administrator provided 2 pages of an email conversation between Employee J (clinical director) and Employee H (investigator). An email dated 10/29/18 at 1:52 PM documented, Hi (Employee H): Ecchymosis - causes breaking of the capillaries. She had taken Vitamin C to help with this but it was discontinued at some point. It's now been ordered again. Here are some samples of how we write it. The one labeled IUO is how I write it. The other is how (name) wrote it. Either way is fine please let me know if you have any questions. Thanks, (Employee J). An email dated 10/30/18 at 10:28 AM documented, Good morning (Employee J) I am currently working on the report for (Resident #24) and have a couple questions .what is (MD name)'s title? Is he/she active in (Resident #24)'s treatment? How did he/she learn about (Resident #24)'s injury? In other words, I'm trying to figure out how he ended up telling us about the ecchymosis .Any info you can share would be helpful. (Employee H). An email dated 10/30/18 at 11:05 AM documented, Hi (Employee H), (MD name) is the Medical Director. So she's not on his direct caseload, but he oversees the care of all the pts (patients) and makes recommendations as needed. He's been here for years and is very familiar with her case. Hope that helps, (Employee J). On 03/28/2019 at 12:45 PM, the Administrator provided all the documentation associated with the investigation which was seven pages. Included in the packet of papers: 1. Facsimile transmittal sheet dated 10/26/18 that was sent to the state agency on the day of incident 2. Facility Reported Incident Form dated 10/26/18 that was sent to state agency on the day of incident 3. A copy of the nurse's note dated 10/26/18 at 12:00 PM 4. A copy of the NP progress note dated 10/26/18 at 10:15 AM 5. A Facility Event Report dated 10/26/18 6. Handwritten notes by Employee H dated 10/26/18. 7. Typewritten report by Employee H dated 10/26/18 The Facility Event Report was a document with many boxes to select as relevant. The event date was 10/26/18. The event time was 9:50 AM. Unexplained was selected for Type of Event. Bedroom was select for Location. Bruise was selected for Type of Injury. Under the section Describe Event, it was documented, Staff reported patient had discoloration to right 3rd and 5th fingers. Fifth right digit knuckle slightly swollen and purple in color. No break in skin. Under the section Treatment/Interventions, it was documented, NP in to assess patient. New order to x-ray right hand/3rd-5th fingers discoloration to right 3-5th fingers. Ice to right hand 15 min every 4 hours x 24 hours. Nurse was notified on 10/26/18 at 9:55 AM. MD/NP notified 10/26/18 at 10:00 AM. Supervisor was notified 10/26/18 at 11:00 AM. The form was signed by the RN (registered nurse) completing the form. The copy of the handwritten notes by Employee H (investigator) was a lined paper that documented: 10/26/18 (Resident #24's last name) IUO (injury of unknown origin) No known injury/accident-nothing documented (name) - Mdirector Pt has ecchymosis - has had long time Vitamin C for symptoms. quit taking new order. On 03/28/2019 at 1:15 PM, a telephone interview with Employee H was conducted. Employee H verified that the notes listed above were her handwritten notes of the investigation. When asked about her investigation process, she stated that Resident #24 was not able to speak so she reviewed Resident #24's chart. When asked if she spoke with any of the staff or interviewed anyone in the course of her investigation, she stated, No. The typewritten report by Employee H was dated 10/26/2018. Under the section Description of Incident it was documented, Incident of Unknown Origin: Resident was found with bruising to her right hand at approximately 0950 hours in the morning of Friday, 10/26/2018. Interdisciplinary notes from 10-26-18 written by (name) RN stated there was discoloration to right 3rd and 5th fingers with 5th right digit knuckle noted to be slightly swollen and purple in color. There was no break in skin, no active bleeding, no wincing or facial grimacing when palpating the fingers. At approximately 1015 hours, FNP (family nurse practitioner) (name) assessed (Resident #24) and an x-ray of her right hand (3rd and 5th fingers) was ordered. an order for [REDACTED]. Under the section Facility Action Taken it was documented, Facility and Clinical Director were notified on Friday 10/26/2018 and an IUO (injury of unknown origin) investigation was initiated. (State and federal agencies) notified. Reviewed interdisciplinary notes and spoke with nursing staff and (MD name), facility medical director. As the medical director, (name) oversees the patients at (facility) and is very familiar with (Resident #24). He stated the area appeared to be a result of ecchymosis. A condition (Resident #24) has had for quite some time and has taken vitamin C for in the past to aide (sic) with symptoms. A new order for vitamin C has been made. (Resident #24) has no documented symptoms of pain or distress from the injury. After further investigation, there are no new findings in this case. In summary, Resident #24 is completely dependent on staff for mobility and ADL care. An injury of unknown origin was identified on 10/26/18 but there is conflicting information in the clinical record documentation pertaining to the description and location of the injury (right hand versus 3rd and 5th fingers versus index finger). The practitioner ordered Vitamin C although Resident #24 had been receiving 150% of the daily recommended value of Vitamin C daily since 2010. The investigation did not include interviews with staff, potential witnesses, or practitioner to ensure Resident #24 was not a victim of abuse. The typewritten report by the investigator was dated 4 days prior to the email written by the investigator that stated, I am currently working on the report for (Resident #24) . On 03/28/2019 at approximately 3:45 PM, the Administrator and the DON were notified of findings and they offered no further documentation of information. 2. For Resident #45, the facility staff failed to conduct an investigation for a fracture of unknown origin. Resident #45, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #45's most recent MDS (Minimum Data Set) (an assessment tool) with an ARD (assessment reference date) of 12/5/18 was coded as a quarterly assessment. Resident #45 was coded as having severe cognitive impairment. The resident was also coded as requiring limited assistance of two staff members for transfers, and being totally dependent on staff for dressing, toileting and bathing. Resident #45 required supervision of one staff member for eating. During clinical record review on 3/27/19 and 3/28/19, of the nursing notes, physician progress notes [REDACTED]. Nursing notes read on 8/28/19 resident was observed sitting up in w/c (wheel chair) @ (at) nursing station. Observed rubbing hard headphones against left shoulder area. Small purple bruise noted on left shoulder. Nursing notes dated 9/1/18 read, noted to have 2 new parallel areas of bruising to left shoulder and left anterior chest. Fading bruising remains to top of left shoulder and anterior left chest skin intact. Nursing notes dated 9/5/18 read bruise to l (left) shoulder spreading down to L (left) breast. Nursing notes dated 9/6/18 read, bruising of left shoulder, chest, & lower side remains. Seems to be protective guarding of moving left arm. On 9/7/18 x-ray results revealed a non-displaced acute fracture of distal clavicle. On 3/27/19 at 9am, the Administrator was requested to provide investigation information for Resident #45's injury. A blue folder was provided. The folder contained the following 10 documents. 1. Investigator's summary dated 9/12/18 2. FRI (Facility reported incident) report which was submitted to the office of licensure 3. A facility event report dated 8/28/18 4. Interdisciplinary notes dated 8/27/18-9/9/18 5. Physician interdisciplinary notes dated 8/8/18- 9/10/14 6. Physician orders dated 9/5/18-9/10/18 7. X-ray reports dated 9/7/18 8. Fax confirmation of APS (Adult Protective Services) notification of injury 9. A Letter dated 9/13/18 addressed to Resident #45's guardian with a certified mail receipt and signed return receipt card which notified her an investigation was being performed 10. A letter dated 9/14/18 addressed to Resident #45's guardian which read, based on the preponderance of evidence, the case was found to be unsubstantiated for neglect and the case is now closed. The facility Administrator was asked again on 3/27/19 at 4:44pm and the morning of 3/28/19 to provide any additional investigation information regarding Resident #45. On 03/28/19 at 10:59 AM the Administrator said there is nothing else. On 3/28/19 at 1:19pm a telephone call was made to Employee H, the investigator, and she stated I looked through the chart at the documentation related to the issue. When asked if she interviewed any nursing staff, CNA staff, other residents, or radiology personal; she stated, no ma'am. The resident was unable to be protected from further abuse, as the Administrator and the Director of Nursing stated no staff had been interviewed during the investigation of abuse and neglect for Resident #45. Review of the facility Policy and Procedure titled: Patient Abuse, Neglect, & Injuries of Unknown Origin; Prevention & Investigation of with a revision date of 3/4/19 states, the purpose of the policy is To provide guidance to staff concerning the prevention of patient/resident abuse and/or neglect, and to establish uniform procedures for the reporting and investigation of allegations of patient/resident abuse, neglect, or injuries of an unknown origin. The policy reads: All unexplained fractures are reportable as alleged abuse/neglect. (facility name) has zero tolerance for acts of abuse or neglect. Therefore, whenever an allegation of abuse or neglect is made, (Facility name) shall take immediate steps to protect the safety & welfare of patients/residents who may be victims of the alleged abuse or neglect, conduct a thorough investigation and take any action necessary to prevent future occurrences of abuse or neglect. The facility had no formal investigation of the fracture of unknown source, which was an allegation of abuse. The facility didn't have statements from any staff members involved in the care of the individual when the injury was identified. The facility staff failed to provide any protection of Resident #45 during the investigation, and failed to take any measures to prevent reoccurrence. The facility Administrator and Director of Nursing were made aware of these findings on 3/28/19 at 2:16pm. No additional information was provided.

Based upon facility documentation review and clinical record review, the facility staff failed to review and revise a careplan for one Resident (Resident #13) in a survey in survey sample of 21 Residents. For Resident #13, the facility staff failed to review and revise the careplan to include the correct viscosity of thickened liquids and the use of a restraint to the right hand. The findings included: Resident #13, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #13's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 1/4/19 was coded as a quarterly assessment. Resident #13 was coded as daily decision making being severely impaired. The resident was also coded as being totally dependent, requiring the assistance of two staff persons, for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. Review of physician orders [REDACTED]. an order written [REDACTED]. Typed physician orders, signed by the provider on 3/6/19 read, lunch-pureed diet honey thickened liquids starting 3/5/19 through 3/11/19. A physician's orders [REDACTED]. Physician order [REDACTED]. Review of the careplan, with a team date of 1/9/19 read, (resident name) receives Nectar liquids or soda per orders and during recreational parties. An undated, handwritten entry on the careplan reads, (resident's name) diet is pureed with Nectar fluids when eating p.o (by mouth). A Physician order [REDACTED]. Review of the careplan with a team date of 1/9/19 had a line through the typewritten text of mitten to right hand. A handwritten entry, dated 2/26/19 was written on the careplan which read, trial reduction of (resident's name) rt. (right) hand mitten x 7d (days), if self injury occurs, resume rt hand mitten 2/26-3/5/19. Another handwritten entry dated 3/8/19 read, rt hand mitten d/c'd (discontinued). Review of the facility document, Careplan Clinical Procedure with a review date of 7/15/18 read, the comprehensive care plans are changed or revised by the RN to reflect change in conditions and new problems identified by the physician. The Administrator and DON were informed of the failure of staff to review and revise the careplan for Resident #13 thickened liquids and right hand mitten, on 3/28/19 at approximately 3pm. No further information was provided.

Based on staff interview, clinical record review and facility documentation the facility staff failed to ensure freedom from unnecessary drugs for 1 Resident (Resident #11) in a survey sample of 21 Residents. For Resident # 11 the facility staff administered [MEDICATION NAME] (narcotic pain medicine) 50 MG (Milligrams) twice on 3/27/19 when the order was for [MEDICATION NAME] 50 MG once daily at 6:30 AM. The findings included; Resident # 11 a [AGE] year old man, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/27/19 during clinical record review it was noted on the Physicians Order Sheet that the Resident #11 had several orders for pain medication as follows: 1. [MEDICATION NAME] Soln (Tylenol solution) 650 MG /20 ML (Milliliters) Take 20 ML via [DEVICE] Every 12 Hours (at 1000 and 2200) (10 AM and 10 PM) as directed. 2. [MEDICATION NAME] Soln - Every 6 hours as needed for pain or temp 100.5 or above. Max of 4000 MG/day 3. [MEDICATION NAME] 25 MCG/HR (Micrograms per Hour) apply one patch every 72 hours. Remove old patch alternate sites.*External Use* 4. [MEDICATION NAME] HCL 50 MG -Take 1 tablet Via [DEVICE] at 6:30 AM Upon further review it was discovered that the Resident was given two doses of [MEDICATION NAME] on 3/27/19. On the Narcotic Control sheet (Nurses sign off sheet) Resident # 11 was given [MEDICATION NAME] 50 MG as ordered at 6:30 AM by LPN D the night shift nurse (11 PM-7:30 AM shift on 3/27/19 According to the Narcotic Control sheet on 3/27/19 the day shift nurse LPN C (Day Shift 7 AM-3:30 PM) also gave the Resident another 50 MG dose of [MEDICATION NAME] however no time was entered on the narcotic sheet. According to the Physician Interdisciplinary Notes the Nurse Practitioner wrote on 3/27/19 at 2:50 PM, Noted that Resident received extra dose of [MEDICATION NAME] this AM. Pt sleepy but awakens to stimulation / voice T-97.8 (temperature) P-104 (Pulse)-R-18 (Respirations) O2 Sat. 94% on room air (Oxygen Saturation) B/P 107/72 (Blood Pressure) Monitor vital signs q shift (every shift) with O2 Sat monitoring. On 3/28/19 at 3:30 PM, an interview was conducted with the DON who stated she was aware that the dayshift nurse had given the extra dose of [MEDICATION NAME] and that they did contact the physician and written a medication variance. DON also stated she would give LPN C additional in-service training on medication administration. On 3/28/19 the Administrator was made aware during the end of day conference and no additional information was provided.

Based on observation, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to prevent the development of pressure ulcers for 1 of 3 residents in the survey sample, Resident #1. Resident #1 entered the facility without pressure ulcers to his feet; the resident developed pressure ulcers with necrotic (dead) tissue that required surgical debridement on the fourth and fifth toe of each foot. Hospital Operative Report for Resident #1 dated 03/01/2015 documented, "Operation-Excisional debridement of the decubitus ulcer underneath the fifth metatarsal (digit) to include skin and subcutaneous tissue, over an area measuring 4 cm2 (centimeters square) on the right foot and 4 cm2 on the left foot. Removal of nail plate left fifth toe." Hospital Record for Resident #1 dated 03/04/2015 documented, "Final Diagnoses: [REDACTED]." The findings included: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 02/23/2015 coded Resident #1 with Cognitive Skills Daily Decision Making: Severely impaired-never/rarely made decisions. In addition, the MDS coded Resident #1 as total dependence in terms of bed mobility, transfer, dressing, eating, toilet use and personal hygiene. Resident #1 was coded as being always incontinent in terms of bladder. Resident #1's MDS with an Assessment Reference Date of 02/23/2015 Section M Skin Conditions-coded Resident #1 with 0 total number of venous and arterial ulcers. The resident was not coded for pressure ulcers on his feet. Nursing Admission Assessment for Resident #1 dated 02/11/2015 documented, "Height: 6'7" (6 feet 7 inches=79 inches)." physician's orders [REDACTED]." Braden Scale for Predicting Pressure Sore Risk for Resident #1 dated 02/11/2015 documented, "Total Score 12 (High Risk)." Braden Scale for Predicting Pressure Sore Risk for Resident #1 dated 02/11/2015 documented, "ELEVATE HOB (Head of Bed) NO MORE THAN 30E (30 degrees)." Interdisciplinary Individualized Care Plan for Resident #1 titled "PRESSURE AT RISK (15-18)" dated 02/11/2015 documented, "Assess patient using the Braden Scale for Pressure Ulcer Potential Upon admission, weekly for the first four weeks, and any significant change. Reassess quarterly.......Keep patient's skin clean and dry." Interdisciplinary Individualized Care Plan for Resident #1 titled "SELF CARE IMPAIRMENTS IN PERSONAL HYGIENE AND ELIMINATION (INCONTINENT)" dated 02/11/2015 documented, "Clip finger and toe nails weekly. Refer problem nails to podiatry as ordered......Observe skin condition daily and report abnormalities promptly." Interdisciplinary Individualized Care Plan for Resident #1 titled "FEEDING PROBLEM/DEHYDRATION" dated 02/11/2015 documented, "Inspect skin surfaces, especially pressure point, Q (every) shift and report any breakdown." Resident #1's MDS with an Assessment Reference Date of 02/23/2015 Section M Skin Conditions-coded Resident #1 with 0 total number of venous and arterial ulcers. Interdisciplinary Notes for Resident #1 dated 03/01/2015 documented, "During am (morning) ADL's (Activities of Daily Livings) The CNAs (Certified Nurse Aids) report bleeding to R (right) feet. During the nurse assessment toes 5th digit bilit (bilateral) feet amputated and necrosis tissue noted with moderated amt (amount) of bright blood noted to socks and sheet. Open area note between R foot 3rd & 4th digit. L (left) foot 4th digit blue area noted. Bilit feet dry skin noted, +4 [MEDICAL CONDITION] noted to L foot." Interdisciplinary Notes for Resident #1 dated 03/01/2015 documented, "(Physician) notified @ (at) 0915 (9:15 a.m.) of pt (patient) condition. Order receive to transfer pt to (Hospital) ER (emergency room ). Supervisor notified. Pt (Responsible Party) notified but no answer message left to call (Facility)." Hospital Emergency Documentation for Resident #1 dated 03/01/2015 documented, "XR (x-ray) foot Left-There is previous amputation of the second toe......No radiographic evidence for osteo[DIAGNOSES REDACTED] (bone infection)." Hospital Emergency Documentation for Resident #1 dated 03/01/2015 documented, "XR foot Right-There is previous amputation of the second toe......No radiographic evidence for osteo[DIAGNOSES REDACTED]." Hospital Operative Report for Resident #1 dated 03/01/2015 documented, "Preoperative Diagnosis-decubitus ulcer underneath the fifth metatarsal bilaterally (both 5th toes), onycholysis (detachment of the nail from the nail bed) left fifth toe nail." Hospital Operative Report for Resident #1 dated 03/01/2015 documented, "Operation-Excisional debridement of the decubitus ulcer underneath the fifth metatarsal to include skin and subcutaneous tissue, over an area measuring 4 cm2 (centimeters square) on the right foot and 4 cm2 on the left foot. Removal of nail plate left fifth toe." Hospital Record for Resident #1 dated 03/04/2015 documented, "Final Diagnoses: [REDACTED]." Debridement is a process of removing dead tissue. Interdisciplinary Individualized Care Plan for Resident #1 titled "SKIN INTEGRITY IMPAIRED" dated 03/05/2015 documented, "Bed cradle and long bed to reduce pressure from sheets and foot board." An internal facility e-mail dated 03/06/2015 was given to surveyor. It documented "On (Resident #1)'s foot, the most plausible explanation that the patient developed necrotic or gangrenous foot that needed debridement but not amputation, is the combination of pressure like the foot or feet were pressing against the foot board or the socks were a little tight, and the subsequent development of infection." Facility Allegation Report Form for Resident #1 dated 03/17/2015 documented, "......Pressure of the resident's feet against the foot board of his bed; (Resident #1) is a tall man and even when positioned in bed correctly, with his legs extended his feet touched the foot board of the bed." Facility Allegation Report Form for Resident #1 dated 03/17/2015 documented, "Photographs taken prior to (Resident #1)'s transfer to (Hospital) for evaluation and eventual surgical debridement reveal feet and nails of which appear unkempt, a weeping blister to the top of one toe, a dark discoloration to the outside of the ball of each foot, and what appears to be very dry, scaly skin on the top of both feet." Facility Allegation Report Form for Resident #1 dated 03/17/2015 documented, "On interview, (Nurse Practitioner) stated that the necrosis to (Resident #1)'s feet would have taken at least 48 hours to develop to the extent requiring his transfer to (Hospital) for surgical debridement. There is no documentation in the nursing notes that Aides/LPN (Licensed Practical Nurse) reported any changes to the skin condition of (Resident #1)'s feet prior to his transfer for surgery." Facility Allegation Report Form for Resident #1 dated 03/17/2015 documented, "Conclusion- Allegation: That clinical care staff failed to provide necessary monitoring and/or treatments to (Resident #1)'s feet, resulting in wounds to both feet requiring the surgical debridement of necrotic tissue; an allegation stemming from an investigated but unresolved incident of unknown origin and brought on the resident's behalf by the Facility Director. Finding: SUBSTANTIATED. On investigation, the preponderance of the evidence does not eliminate concerns that clinical care staff failed to provide monitoring and/or treatments to (Resident #1)'s feet. While several clinical factors, the resident's medical condition and foot infection being paramount, were considered, the possibility remains that had the resident's condition been monitored more closely that the surgical debridement of necrotic tissue may not have been necessary. To this, the several errors and omissions in the clinical record lend credence. Therefore, I find this allegation of neglect to be substantiated against the Nursing & Medical Departments of (Facility)." On 03/31/2015 at 3:15 p.m., Resident #1 was observed lying in bed. Resident #1's feet were hanging off of the bed. Although foot board was not present at this time, bed/mattress appeared to be too small/too short for Resident #1. On 03/31/2015 at 3:30 p.m., an interview was conducted with Quality Assurance (QA)Director. QA Director stated the following: -Resident #1 did not have any pressure ulcers on admission. -Staff failed to properly assess/monitor Resident #1's condition. -Inaccurate documentation: Resident #1's second toes were amputated; not the fifth as documented in nurse's notes. -Braden Scale was not done weekly for the first four weeks as recommended. -No concerns/abnormalities regarding Resident #1's feet were reported. -Inaccurate care plan: Care Plan for Pressure Sore should be based on the Braden Scale (10-12) for High Risk not (15-18) At Risk. -There's photographic evidence showing Resident #1's feet were unkempt. Staff should consult with podiatrist; but did not. -QA Director recommended to put Resident #1 on a long bed with extender on 03/04/2015. -Resident #1's condition did not happen overnight. -Resident #1 should not be in the condition he was in. -According to QA Director, Resident #1 was neglected. On 03/31/2015 at 4:00 p.m., an interview was conducted with MDS Coordinator. MDS Coordinator stated she did not assess Resident #1. According to MDS Coordinator, "I rely on nursing assessment for my MDS." On 04/02/2015 at 11:30 a.m., an interview was conducted with Certified Nurse Aid-C (CNA-C). CNA-C discovered Resident #1's wound noted above. According to CNA-C, there was "dry blood" on Resident #1's bed sheet. On 04/02/2015 at 12:05 p.m., an interview was conducted with CNA-A. CNA-A stated she noticed Resident #1's feet were pressing against the foot board ever since he first arrived. According to CNA-A, she reported this concern, but "nothing was done." On 04/02/2015 at 3:00 p.m., an interview was conducted with Administrator. Administrator stated she expected staff to accurately assess/monitor/report changes in condition in a timely manner. On 04/02/2015 at 5:30 p.m., an interview was conducted with CNA-B. CNA-B stated she noticed Resident #1's feet were pressing against the foot board ever since he first arrived. According to CNA-B, Resident #1's HOB was always at 45 degrees; not less than 30 degrees as recommended. CNA-B also stated she always used Suave lotion on Resident #1's legs/feet; not [MEDICATION NAME] cream as prescribed. On 04/02/2015 at 5:45 p.m., an interview was conducted with CNA-D. CNA-D stated Resident #1's HOB was always greater than 30 degrees; not less than 30 degrees as recommended. CNA-D also stated she always used Suave lotion on Resident #1's legs/feet; not [MEDICATION NAME] cream as prescribed. On 04/03/2015 at 10:15 a.m., Resident #1 was lying in bed. Resident #1's feet were observed to be hanging off of the bed. On 04/03/2015 at 10:30 a.m., an interview was conducted with Central Supplies Coordinator. Central Supplies Coordinator stated Resident #1's bed was too small for him. On 04/03/2015 at 11:00 a.m., Electrician measured Resident #1's bed/mattress. Length of bed: 80 inches. Length of mattress: 78.25 inches (Resident #1 was 79 inches tall). On 04/03/2015 at 2:00 p.m., an interview was conducted with QA (Quality Assurance)Director. QA Director suspected that Resident #1's feet were pressing against the foot board for a period of time. Resident #1 had wounds to both feet requiring surgical debridement of necrotic tissue. QA Director stated Resident #1's foot board was removed on 03/01/2015. According to QA Director, Resident #1 should have a new bed with bed extender by now, but did not. On 04/03/2015 at 3:55 p.m. an interview was conducted with Administrator. Administrator stated Resident #1 would have a "long bed" by the end of day. Facility Policy/Procedure titled "Nail Cleaning and Cutting" dated 08/15/2013 sated , "Abnormal characteristics of the nails (streaking, discoloration, thickness, etc. (et cetera)) are reported to the charge nurse or nurse assigned to the resident and physician and documented in the resident's medical record." Facility Policy/Procedure titled "Patient Abuse, Neglect, & Injuries of Unknown Origin; Prevention & Investigation of" dated 06/25/2014 stated, "Neglect: The failure by an individual, program or facility...to provide nourishment, treatment, care goods, or services necessary to health, safety or welfare of a patient. Patients admitted to (Facility) will receive the highest quality medical treatment possible in an environment reasonably safe from physical and/or emotional harm." Facility Policy/Procedure titled "Turning, Positioning and Skin Care" dated 03/05/2015 stated, "Remove all clothing, mittens socks when turning and observe skin condition. Report any skin changes (reddening, bruising, tears, dry, skin) to nurse document on flow sheet." Facility Policy/Procedure titled "Risk Assessment" dated 03/19/2015 stated, "The total score for the assessment period will indicate the level of risk as follows: Moderate Risk (13-14) High Risk (10-12) Very High Risk (9 or below)." Facility Policy/Procedure titled "Pressure Ulcer Prevention, Assessment And Monitoring" dated 03/24/2015 stated, "Residents admitted without a pressure ulcer should not develop pressure ulcer unless clinically unavoidable." Facility Policy/Procedure titled "Administration and Documentation of Treatments" dated 03/27/2015 stated, "Treatments shall be administered to the right resident by the assigned licensed nurse on each shift according to the physician's orders [REDACTED]. According to "www.nursingceu.com <http://www.nursingceu.com> "The compression of soft tissue interferes with the tissue blood supply, leading to vascular insufficiency, tissue anoxia, and cell death. Pressure ulcers usually occur over bony prominence such as the sacrum, ischium, heel, and trochanter, where there is less tissue to compress. Pressure ulcers can develop within 24 hours of the initial pressure but take as long as 5 days to present themselves." The Administrator was made aware of these findings on 04/03/2015 at 5:00 p.m., no further information provided. Complaint Deficiency

Based on observation, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to implement the facility's policy and procedure to prevent neglect for one of 3 residents, Resident #1, in the survey sample. The facility failed to provide the appropriate services, failed to follow the physician orders [REDACTED].#1. Resident #1 entered the facility without pressure ulcers to his feet; the resident developed pressure ulcers with necrotic (dead) tissue that required surgical debridement on the fourth and fifth toe of each foot. Hospital Operative Report for Resident #1 dated 03/01/2015 documented, "Operation-Excisional debridement of the decubitus ulcer underneath the fifth metatarsal (digit) to include skin and subcutaneous tissue, over an area measuring 4 cm2 (centimeters square) on the right foot and 4 cm2 on the left foot. Removal of nail plate left fifth toe." Hospital Record for Resident #1 dated 03/04/2015 documented, "Final Diagnoses: [REDACTED]." The findings included: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 02/23/2015 coded Resident #1 with Cognitive Skills Daily Decision Making: Severely impaired-never/rarely made decisions. In addition, the MDS coded Resident #1 as total dependence in terms of bed mobility, transfer, dressing, eating, toilet use and personal hygiene. Resident #1 was coded as being always incontinent in terms of bladder. Resident #1's MDS with an Assessment Reference Date of 02/23/2015 Section M Skin Conditions-coded Resident #1 with 0 total number of venous and arterial ulcers. No pressure sores were coded for his feet. Nursing Admission Assessment for Resident #1 dated 02/11/2015 documented, "Height: 6'7" (6 feet 7 inches=79 inches)." physician's orders [REDACTED]." Braden Scale for Predicting Pressure Sore Risk for Resident #1 dated 02/11/2015 documented, "Total Score 12 (High Risk)." Braden Scale for Predicting Pressure Sore Risk for Resident #1 dated 02/11/2015 documented, "ELEVATE HOB (Head of Bed) NO MORE THAN 30E (30 degrees)." Interdisciplinary Individualized Care Plan for Resident #1 titled "PRESSURE AT RISK (15-18)" dated 02/11/2015 documented, "Assess patient using the Braden Scale for Pressure Ulcer Potential Upon admission, weekly for the first four weeks, and any significant change. Reassess quarterly.......Keep patient's skin clean and dry." Interdisciplinary Individualized Care Plan for Resident #1 titled "SELF CARE IMPAIRMENTS IN PERSONAL HYGIENE AND ELIMINATION (INCONTINENT)" dated 02/11/2015 documented, "Clip finger and toe nails weekly. Refer problem nails to podiatry as ordered......Observe skin condition daily and report abnormalities promptly." Interdisciplinary Individualized Care Plan for Resident #1 titled "FEEDING PROBLEM/DEHYDRATION" dated 02/11/2015 documented, "Inspect skin surfaces, especially pressure point, Q (every) shift and report any breakdown." Resident #1's MDS with an Assessment Reference Date of 02/23/2015 Section M Skin Conditions-coded Resident #1 with 0 total number of venous and arterial ulcers. Interdisciplinary Notes for Resident #1 dated 03/01/2015 documented, "During am (morning) ADL's (Activities of Daily Livings) The CNAs (Certified Nurse Aids) report bleeding to R (right) feet. During the nurse assessment toes 5th digit bilit (bilateral) feet amputated and necrosis tissue noted with moderated amt (amount) of bright blood noted to socks and sheet. Open area note between R foot 3rd & 4th digit. L (left) foot 4th digit blue area noted. Bilit feet dry skin noted, +4 [MEDICAL CONDITION] noted to L foot." Interdisciplinary Notes for Resident #1 dated 03/01/2015 documented, "(Physician) notified @ (at) 0915 (9:15 a.m.) of pt (patient) condition. Order receive to transfer pt to (Hospital) ER (emergency room ). Supervisor notified. Pt (Responsible Party) notified but no answer message left to call (Facility)." Hospital Emergency Documentation for Resident #1 dated 03/01/2015 documented, "XR (x-ray) foot Left-There is previous amputation of the second toe......No radiographic evidence for osteo[DIAGNOSES REDACTED] (bone infection)." Hospital Emergency Documentation for Resident #1 dated 03/01/2015 documented, "XR foot Right-There is previous amputation of the second toe......No radiographic evidence for osteo[DIAGNOSES REDACTED]." Hospital Operative Report for Resident #1 dated 03/01/2015 documented, "Preoperative Diagnosis-decubitus ulcer underneath the fifth metatarsal bilaterally (both 5th toes), onycholysis (detachment of the nail from the nail bed) left fifth toe nail." Hospital Operative Report for Resident #1 dated 03/01/2015 documented, "Operation-Excisional debridement of the decubitus ulcer underneath the fifth metatarsal to include skin and subcutaneous tissue, over an area measuring 4 cm2 (centimeters square) on the right foot and 4 cm2 on the left foot. Removal of nail plate left fifth toe." Hospital Record for Resident #1 dated 03/04/2015 documented, "Final Diagnoses: [REDACTED]." Debridement is a process of removing dead tissue. Interdisciplinary Individualized Care Plan for Resident #1 titled "SKIN INTEGRITY IMPAIRED" dated 03/05/2015 documented, "Bed cradle and long bed to reduce pressure from sheets and foot board." An internal facility e-mail dated 03/06/2015 was given to surveyor. It documented "On (Resident #1)'s foot, the most plausible explanation that the patient developed necrotic or gangrenous foot that needed debridement but not amputation, is the combination of pressure like the foot or feet were pressing against the foot board or the socks were a little tight, and the subsequent development of infection." Facility Allegation Report Form for Resident #1 dated 03/17/2015 documented, "......Pressure of the resident's feet against the foot board of his bed; (Resident #1) is a tall man and even when positioned in bed correctly, with his legs extended his feet touched the foot board of the bed." Facility Allegation Report Form for Resident #1 dated 03/17/2015 documented, "Photographs taken prior to (Resident #1)'s transfer to (Hospital) for evaluation and eventual surgical debridement reveal feet and nails of which appear unkempt, a weeping blister to the top of one toe, a dark discoloration to the outside of the ball of each foot, and what appears to be very dry, scaly skin on the top of both feet." Facility Allegation Report Form for Resident #1 dated 03/17/2015 documented, "On interview, (Nurse Practitioner) stated that the necrosis to (Resident #1)'s feet would have taken at least 48 hours to develop to the extent requiring his transfer to (Hospital) for surgical debridement. There is no documentation in the nursing notes that Aides/LPN (Licensed Practical Nurse) reported any changes to the skin condition of (Resident #1)'s feet prior to his transfer for surgery." Facility Allegation Report Form for Resident #1 dated 03/17/2015 documented, "Conclusion- Allegation: That clinical care staff failed to provide necessary monitoring and/or treatments to (Resident #1)'s feet, resulting in wounds to both feet requiring the surgical debridement of necrotic tissue; an allegation stemming from an investigated but unresolved incident of unknown origin and brought on the resident's behalf by the Facility Director. Finding: SUBSTANTIATED. On investigation, the preponderance of the evidence does not eliminate concerns that clinical care staff failed to provide monitoring and/or treatments to (Resident #1)'s feet. While several clinical factors, the resident's medical condition and foot infection being paramount, were considered, the possibility remains that had the resident's condition been monitored more closely that the surgical debridement of necrotic tissue may not have been necessary. To this, the several errors and omissions in the clinical record lend credence. Therefore, I find this allegation of neglect to be substantiated against the Nursing & Medical Departments of (Facility)." On 03/31/2015 at 3:15 p.m., Resident #1 was observed lying in bed. Resident #1's feet were hanging off of the bed. Although foot board was not present at this time, bed/mattress appeared to be too small/too short for Resident #1. On 03/31/2015 at 3:30 p.m., an interview was conducted with Quality Assurance (QA)Director. QA Director stated the following: -Resident #1 did not have any pressure ulcers on admission. -Staff failed to properly assess/monitor Resident #1's condition. -Inaccurate documentation: Resident #1's second toes were amputated; not the fifth as documented in nurse's notes. -Braden Scale was not done weekly for the first four weeks as recommended. -No concerns/abnormalities regarding Resident #1's feet were reported. -Inaccurate care plan: Care Plan for Pressure Sore should be based on the Braden Scale (10-12) for High Risk not (15-18) At Risk. -There's photographic evidence showing Resident #1's feet were unkempt. Staff should consult with podiatrist; but did not. -QA Director recommended to put Resident #1 on a long bed with extender on 03/04/2015. -Resident #1's condition did not happen overnight. -Resident #1 should not be in the condition he was in. -According to QA Director, Resident #1 was neglected. On 03/31/2015 at 4:00 p.m., an interview was conducted with MDS Coordinator. MDS Coordinator stated she did not assess Resident #1. According to MDS Coordinator, "I rely on nursing assessment for my MDS." On 04/02/2015 at 11:30 a.m., an interview was conducted with Certified Nurse Aid-C (CNA-C). CNA-C discovered Resident #1's wound noted above. According to CNA-C, there was "dry blood" on Resident #1's bed sheet. On 04/02/2015 at 12:05 p.m., an interview was conducted with CNA-A. CNA-A stated she noticed Resident #1's feet were pressing against the foot board ever since he first arrived. According to CNA-A, she reported this concern, but "nothing was done." On 04/02/2015 at 3:00 p.m., an interview was conducted with Administrator. Administrator stated she expected staff to accurately assess/monitor/report changes in condition in a timely manner. On 04/02/2015 at 5:30 p.m., an interview was conducted with CNA-B. CNA-B stated she noticed Resident #1's feet were pressing against the foot board ever since he first arrived. According to CNA-B, Resident #1's HOB was always at 45 degrees; not less than 30 degrees as recommended. CNA-B also stated she always used Suave lotion on Resident #1's legs/feet; not [MEDICATION NAME] cream as prescribed. On 04/02/2015 at 5:45 p.m., an interview was conducted with CNA-D. CNA-D stated Resident #1's HOB was always greater than 30 degrees; not less than 30 degrees as recommended. CNA-D also stated she always used Suave lotion on Resident #1's legs/feet; not [MEDICATION NAME] cream as prescribed. On 04/03/2015 at 10:15 a.m., Resident #1 was lying in bed. Resident #1's feet were observed to be hanging off of the bed. On 04/03/2015 at 10:30 a.m., an interview was conducted with Central Supplies Coordinator. Central Supplies Coordinator stated Resident #1's bed was too small for him. On 04/03/2015 at 11:00 a.m., Electrician measured Resident #1's bed/mattress. Length of bed: 80 inches. Length of mattress: 78.25 inches (Resident #1 was 79 inches tall). On 04/03/2015 at 2:00 p.m., an interview was conducted with QA (Quality Assurance)Director. QA Director suspected that Resident #1's feet were pressing against the foot board for a period of time. Resident #1 had wounds to both feet requiring surgical debridement of necrotic tissue. QA Director stated Resident #1's foot board was removed on 03/01/2015. According to QA Director, Resident #1 should have a new bed with bed extender by now, but did not. On 04/03/2015 at 3:55 p.m. an interview was conducted with Administrator. Administrator stated Resident #1 would have a "long bed" by the end of day. Facility Policy/Procedure titled "Nail Cleaning and Cutting" dated 08/15/2013 sated , "Abnormal characteristics of the nails (streaking, discoloration, thickness, etc. (et cetera)) are reported to the charge nurse or nurse assigned to the resident and physician and documented in the resident's medical record." Facility Policy/Procedure titled "Patient Abuse, Neglect, & Injuries of Unknown Origin; Prevention & Investigation of" dated 06/25/2014 stated, "Neglect: The failure by an individual, program or facility...to provide nourishment, treatment, care goods, or services necessary to health, safety or welfare of a patient. Patients admitted to (Facility) will receive the highest quality medical treatment possible in an environment reasonably safe from physical and/or emotional harm." Facility Policy/Procedure titled "Turning, Positioning and Skin Care" dated 03/05/2015 stated, "Remove all clothing, mittens socks when turning and observe skin condition. Report any skin changes (reddening, bruising, tears, dry, skin) to nurse document on flow sheet." Facility Policy/Procedure titled "Risk Assessment" dated 03/19/2015 stated, "The total score for the assessment period will indicate the level of risk as follows: Moderate Risk (13-14) High Risk (10-12) Very High Risk (9 or below)." Facility Policy/Procedure titled "Pressure Ulcer Prevention, Assessment And Monitoring" dated 03/24/2015 stated, "Residents admitted without a pressure ulcer should not develop pressure ulcer unless clinically unavoidable." Facility Policy/Procedure titled "Administration and Documentation of Treatments" dated 03/27/2015 stated, "Treatments shall be administered to the right resident by the assigned licensed nurse on each shift according to the physician's orders [REDACTED]. According to "www.nursingceu.com <http://www.nursingceu.com> "The compression of soft tissue interferes with the tissue blood supply, leading to vascular insufficiency, tissue anoxia, and cell death. Pressure ulcers usually occur over bony prominence such as the sacrum, ischium, heel, and trochanter, where there is less tissue to compress. Pressure ulcers can develop within 24 hours of the initial pressure but take as long as 5 days to present themselves." The Administrator was made aware of these findings on 04/03/2015 at 5:00 p.m., no further information provided. Complaint Deficiency