Every finding on record at Holbrook Healthcare Center

Based on observation, record review, staff interview and resident review, the facility failed to provide liquids in the correct consistency to meet the resident's individual needs. This was true for three (3) of seven (7) residents that were ordered nectar and honey thickened liquids. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #7, #82, and #31. Facility Census: 107.Findings included: a) On 07/21/2024, Residents #7, #82, and #31 were observed to liquids at bedside that were not nectar or honey consistency during the investigation process. This failed practice created an immediate jeopardy situation.During the initial resident interview process, Resident #7 received thin liquids with the lunch meal in a spouted cup. The resident also had a mug with a straw on the tray table containing ice water. On 07/21/2025 at 01:10 PM, NA #12 confirmed both cups contained thin liquids. Nursing Assistant (NA) #12 stated, I think she's allowed to have some thin liquids. Resident #7's diet order stated, Dys Puree texture, Nectar Thickened Liquids consistency, Spout cups for Diet. On 07/21/25 at approximately 12:50 PM, Resident #82 was observed to have three (3) drinks on his tray table. There were two (2) two[1] handled cups with a spout containing a thickened liquid in them (beige in color), and one cup with a lid and straw containing water. When asked whether the resident was supposed to have regular water, Clinical Manager Licensed Practical Nurse (LPN) #48 stated, No, he is not supposed to have regular water and picked the cup up and took it with her to the nursing station. This occurred at approximately 01:00 PM. The resident's diet order stated, Dys Mech texture, Honey Thickened Liquids consistency, Spout cups for drinks. During an interview and observation on 07/21/25 at 1:55 PM in Resident #31's room, Nursing Assistant (NA) #3, stated, No, it does not look like it's honey thickened to me. This State Surveyor tested the chocolate milk using a plastic spoon, The liquid ran off the spoon and did not leave any residue. At the bottom of the cup was a gel-like substance. NA #3, confirmed the liquid was thin and not honey thickened consistency and stated, No, not honey. The resident's diet order stated, Dys Puree texture, honey Thickened Liquids consistency, for Diet. The Facility's Diet and Nutrition Care Manual: Guidelines for Serving Thickened Liquids stated, The SLP and food and nutrition department should work together to identify and provide appropriate fluid consistency. All individuals on thickened liquids require a physician's order for the appropriate fluid consistency. All liquids should be thickened to the proper consistency, including soups, water, oral nutritional liquid supplements, and all other beverages.The immediate jeopardy template was provided to the facility on [DATE] at 4:25 PM. The plan of correction which stated the following was provided at 6:19 PM on 07/21/25: Education to all staff was given for the three (3) residents who received liquids that were not consistent with their diet order. The nursing home administrator, regional director of clinical operations, director of nursing and regional director of nursing were all involved in this education and root cause identification. The goal was for all residents to receive liquid consistency with their diet order. On 07/21/25 all residents that were identified in the IJ were assessed for respiratory status. The incorrect liquids were removed from the resident area. All like residents were identified and an audit was completed that ensured appropriate consistency was amiable. Staff who had been and were assigned to the identified residents (#7, #82, and #31) were educated on 07/21/25. All available staff except for dining were educated by the Unit Manager, Executive Director or Designee that the facility offers each resident sufficient fluid, inducing water and other liquids consistent with the residents' needs and preferences to maintain proper hydration and health. If a staff member is not performing direct care, they are to notify a nurse or nurse aide so the liquid consistency can be verified. Any staff who were not available on this date received education prior to their next shift. All available dining staff were educated by Health Care Services Group Dietary Manager on drink consistency, tray ticket, order accuracy, and verifying trays before leaving the kitchen. All staff that were unavailable were educated prior to their next shift. Nursing staff or their designee were to monitor Resident #7, #82, and #31's vital signs and lung sounds for 72 hours with physician notification as needed. The Unit Manager or designee was to monitor residents with thickened liquids three (3) times a day for 3 days then three (3) random residents of the identified residents were to be monitored every day for five (5( days a week for two (2) weeks. Any findings from these audits were to be reported to the quality assurance (QA) committee. The IJ was abated on 07/22/25 at 2:40 PM.

Based on observation, resident interview and staff interview, the facility failed to provide a homelike dining experience for residents served in the main dining room and to ensure resident areas were clean and odor free. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident Identifiers: #90 and #5. Facility Census: 107. Findings included: a) On 07/21/2025 at 12:30 PM, during the Dining Room Observation, no tablecloths were on the tables in the main dining room and the residents were served their meals on plastic trays from the kitchen. On 07/21/2025 at 12:33 PM, Licensed Practical Nurse (LPN) confirmed the residents were eating their lunch on trays and stated, When there's tablecloths .we usually take them off. b) Resident #90 On 07/22/2025 at 10:50 AM, during the initial resident interview, Resident #90 reported they don't clean her bed pan box. The resident stated the smell comes out of her bathroom into her room at times. In the resident's bathroom, a white plastic standing box was observed containing the bedpan with a strong odor emitting from the container. When the bed pan box was opened, a bed pan was observed with a yellow and brownish substance in the bedpan and in the bottom of the plastic container. The resident stated they (housekeeping) had cleaned it about a month ago when she asked. On 07/22/2025 at 11:05 AM, LPN #25 confirmed the odor in the bathroom and stated, I will talk to them. During the initial resident interview an observation in the bathroom found a black substance around the base of the commode on 07/22/25 at 11:00 AM.

Based on observation, record review and staff interview, the facility failed to ensure food was stored in accordance with professional standards for food services. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 107. Findings included: During the Kitchen Investigation initiated on 07/21/2025 at 11:45 PM., the following items were found: a) Sausage patties - bag was not sealed and no use by date. b) Four (4) bags of hoagie buns bags - not labeled and no use by date. c) Crinkle cut fries were in a bag - not labeled. d) Baked beans in a plastic container - no used by date. On 07/21/2025 at 11:50 AM, Regional Dietary Manager #128 confirmed the items and stated, I didn't know you had to label if you know what it is. On 07/22/25 at 11:05 PM, the following items were found in the Nutrition Station 100-200: a) Two (2) bologna and cheese sandwiches - not labeled and no use by date. b) [NAME] cheeseburger - not sealed and no use by date. Items were confirmed by Regional /Director of Operations #130 on 07/22/2025 at 11:10 PM On 07/22/2025 at 01:00 PM , the following item was found in the Nutrition Pantry 300-400 Hall : a) Individual packets of Smucker's concord grape jelly - no open or use by date. The item was confirmed by Licensed Practical Nurse (LPN) #15 on 07/22/25 at 01:11 PM. On 07 22/5 at 11:35 PM, Regional Dietary Manager #129 stated food storage dates depending on the hierarchy. It is seven (7) days for leftovers or prepared food. The kitchen follows the food code with hierarchy from serve safe for labeling and dating. The Healthcare Services Group policy and procedure for Food Storage: Dry Goods stated, 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. The Healthcare Services Group policy and procedure for Food Storage: Cold Foods stated, 5. All foods will be stored, wrapped, or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

Based on record review, staff interview and record review the facility failed to ensure it had a complete and accurate medical record. This failed practice was found true for (6) six of 36 residents reviewed for medical record accuracy during the Long- Term Care Survey Process. Resident identifiers #43, #6, #7, #10, #4, and #77. Facility Census 107. Findings include: a) Resident #43 A record review on 07/23/25 at 10:31 AM, revealed a capacity form dated and signed by Family Nurse Practitioner (FNP) on 03/28/25 for Resident #43 stating that the resident has capacity. Further record review revealed a Physicians Orders for Scope of Treatment (POST) form for Resident #43 dated 03/28/25 and signed by Resident #43's Medical Power of attorney (MPOA), rather than being signed by Resident #43, who had capacity. Post form for Resident #43, was signed by the MPOA, rather than Resident #43 that has capacity. During an interview on 07/23/2025 at 10:43 AM, The Administrator confirmed that the POST form was signed by the MPOA and not by Resident #43 who has capacity. A review on 07/23/2025 at 10:45 AM, of the Policy titled Advance directive (Residents right to choose), under Policy, explanation and compliance guidelines, number 5, reads as follows: The center will periodically assess the reside3nt for decision -making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities. b) Resident #6 On 7/21/25, a chart review was initiated for Resident #6. No diet order was found on the resident's medical chart or listed on the facility's Order Listing Report. A Speech Therapy order waiting the physician's signature for an Informed Dining Consent Form changing the resident's diet to regular with regular liquids was written on 07/03/25. The physician's signature was obtained on 07/03/25. A diet order was added on 07/22/25 for a regular diet. On 07/23/25 10:47 AM, the Administrator and Corporate Director of Operations confirmed the finding and the Corporate Director of Operations stated, We will get these fixed. c) Resident #7 On 07/21/25, a chart review was initiated for Resident #7. The resident's POST (Physician Orders for Scope of Treatment) form was reviewed. The POST form was signed by Resident #7's Power of Attorney The resident was capacitated to make her own decisions on 05/28/24. The facility's policy and procedure Advance Directive (Residents Right to Choose) stated, The center will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities. On 07/23/25 10:47 AM, the Administrator and Corporate Director of Operations confirmed the finding and the Corporate Director of Operations stated, We will get these fixed. d) Resident #10 On 07/21/25, a chart review was initiated for Resident #10. A verbal consent by the resident's responsible party was given on 07/25/24. An updated POST form with the responsible party's signature was not obtained by the facility. On 07/23/25 10:47 AM, the Administrator and Corporate Director of Operations confirmed the finding and the Corporate Director of Operations stated, We will get these fixed. e) Resident #4 A chart review for this resident, documented he was receiving Eliquis Oral Tablet 5 mg, every morning and at bedtime for clot prevention. The order was dated 04/25/25. A further review of the orders, the Medication Administration Record and the Treatment Administration Record reveals there is no order for the monitoring of side effects for the anti-coagulant, nor was it being monitored. This was reviewed with the Regional Operations Coordinator on 07/23/25 at approximately 2:10 PM. She acknowledged there was no monitoring of side effects occurring. f) Resident #77 A review of the electronic health record (EHR) contains the following diagnoses for Resident #77: Unspecified Dementia, 12/21/24 Generalized Anxiety Disorder, 3/20/25 Alzheimer's, 3/20/25 Upon reviewing progress notes from the facility's medical provider dated 03/16/25, the provider records an additional diagnosis of major depressive disorder. Additionally, a progress note dated 06/10/25 by the provider, states a diagnosis of Major depressive disorder, recurrent, moderate. The electronic health record does not contain the diagnosis for major depressive disorder under the list of diagnoses. Thus, the list of diagnoses is incomplete and inaccurate. This was reviewed with the Regional Operations Coordinator on 07/23/25 at approximately 2:10 PM. She acknowledged the diagnosisof major depressive disorder should be included on resident's list of diagnoses.

Based on family interview, staff interview, record review, and observation the facility failed to provide Activities of Daily Living (ADL) care to dependent residents. This failed practice was found true for (1) one of (8) eight residents reviewed for ADL care during the Long-Term Care Survey Process. Resident identifier: #55. Facility Census: 107. Findings include: a) Resident #55 During a phone interview on 07/22/25 at 11:40 AM, The Medical Power of Attorney (MPOA) for Resident #55 stated, Every time I come to visit his fingernails need cut. Sometimes it makes indentions in his hand. An observation on 07/23/25 at 1:43 PM, of Resident #55's right and left hand, showed that he had fingernails that were long and jagged on both hands. A record review on 07/23/2025 at 1:46 PM, revealed an ADL care plan for Resident #55 that reads as follows:Focus: (Resident #55 named) has ADL Self Care Performance deficit with further decline expected related to progressive vascular leukoencephalopathy, MS, neoplasm of parotid gland requires assistance with ADL related to hx of CVA with L side hemiparesis, dementia, depression, arthritis, weakness, hx of polycythemia vera, leukoencephalopathy, anxiety disorder, unspecified mood (affective) disorder, CAD, low back pain, hx of seizure disorder, hyperlipidemia, no longer ambulates, and unspecified lack of coordination, traumatic hemorrhage of cerebrum. ADL's fluctuate with mood Goal:(Resident #55) will maintain current level of function as long as condition will allow Interventions related to nail care read as follows: Personal hygiene: Totally Dependent of 1- 1 helper does all the effort. Resident does none of the effort. During an observation and interview on 07/23/25 at 2:01 PM, Licensed Practical Nurse (LPN) #25 confirmed that Resident #55's fingernails were long and needed to be cut. The LPN then stated, I will get them cut today.

Based upon record review, resident interview and staff interview, the facility failed to develop a personalized care plan for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD). This was found to be true for one (1) of thirty-six (36) residents reviewed during the annual survey process. Resident identifier: #4. Facility census: 107.Findings included: During an interview with Resident #4 on 07/21/25 at 12:01 PM, the resident appeared to be very withdrawn, his face void of emotion. He was sitting alone, in his wheelchair, outside of his bedroom door. After conversing with the resident for several minutes, he stated he had served two deployments with the Army in IRAQ. We talked about his care, the food, his ability to make choices, etc., and he stated everything was ok. The resident finally smiled once before we ended our conversation. A review of the resident's electronic health record (EHR), revealed he has the following diagnoses:Post-Traumatic Stress Disorder Chronic (PTSD) 04/18/25 AdmissionDepression, Unspecified 04/18/25 AdmissionHis Care Plan, dated 04/17/25, did not have any focus, goal or interventional/tasks for PTSD.Other than a record entitled, Social History Assessment WV dated 05/06/25, completed by the Director of Social Services, which stated the resident was unaware of triggers for his PTSD, there appeared to be little documentation of facility efforts to provide trauma-informed care or culturally competent care. During an interview on 07/29/25 at 11:30 AM, The Regional Clinical Coordinator, (RCC) #131, confirmed that PTSD was not care planned for Resident #4.

Based on record review and staff interview, the facility failed to provide the required notifications to a resident transfered to the hospital. This deficient practice affected one (1) of three (3) residents reviewed for the care area of hospitalization. Resident Identifier: #104. Facility Census: 107.Findings included: a) Resident #104 Review of Resident #104's medical records showed the resident was emergently transferred to the hospital on [DATE]. The resident reported emesis and shaking, stating she felt like she did when she previously had a myocardial infarction. The resident had capacity to make her own medical decisions. Further review of Resident #104's medical records did not reveal the following discharge documentation: - Written notification to the resident of the reasons for the transfer.- Notice of the facility's bed-hold policy and duration. On 07/24/2025 at 10:43 AM, Regional Clinical Coordinator #131 confirmed there was no evidence the written transfer/discharge notification and the bed hold notification had been completed and provided to Resident #104 when she was transferred to the hospital on [DATE]. No further information was provided through the completion of the survey.

Based on record review, staff interview, and family interview the facility failed to inform the Medical power of Attorney (MPOA) of appointments for Resident #55, and failed to notify the physician and responsible party of a change in condition for Resident #7. This failed practice was found true for (2) two of (2) two residents reviewed for notification of change during the Long-Term Care Survey Process. Resident identifiers #55, and #7. Facility Census 107. Findings include: a) Resident #55 During a phone interview on 07/22/25 at 11:40 AM, The MPOA, for Resident #55 stated, A couple months ago they took him (Resident #55) all the way to Morgantown for a Dermatology appointment to have a procedure done. I only found out about the appointment because the doctor’s office called me to get permission to treat him. That's about 45 minutes away. A review of the Grievance Log on 07/24/2025 at 1:03 PM, revealed that the MPOA for Resident #55 filed a grievance about not being notified of the dermatology appointment on 03/24/25. Grievance reads as follows: MPOA upset that she was not notified of (Resident #55 named) dermatology appointment today. Resolved on 03/24/25 Specific actions taken to resolve grievance included: Dermatology appointment was cancelled prior due to inclement weather. Rescheduled for 03/24/25 at 2:00 PM. MPOA was notified of appointment change. Signed by The Licensed Social Worker (LSW). A witness statement is attached to the Grievance written by Clinical Manager Licensed Practical Nurse (CMLPN) #48 that reads as follows: Resident MPOA asked about Dermatology appointment during care plans. This nurse confirmed with transports about appointment and confirmed appointment was cancelled and rescheduled. MPOA then notified by this nurse. Signed (03/24/25) Further record review, revealed a nurses note dated 01/07/25 that reads as follows: Appt. with Dr. (name) on 01/07/2025 @ 1145 one time only for dermatology for 1 Day cancelled. The social service care plan note dated 01/20/25 reads as follows: (Resident #55) Quarterly care plan is scheduled for Wednesday, January 29, 2025. (Resident #55) lacks capacity r/t dementia and is DNR with limited interventions and no feeding tube. (Resident #55) completed the PHQ-9 with a score of 2, depressed-1 and little interest-1. He has a mood state care plan in place and is prescribed anti-depressant medications. [NAME] did not have any behaviors this ARD. [NAME] has a psychosocial care plan for feelings of loneliness. [NAME]'s sister/MPOA only wants to be asked about community referrals on comprehensive assessments. (Resident #55) is expected to remain in facility long term. Further record review found no notes in the medical record to indicate that the MPOA was notified of the new dermatology appointment made for Resident #55 for 03/24/25. During an interview on 07/28/25 at 11:45 AM, LSW stated, There is not a note in his chart to say the family was notified. The State Agency SA asked, How do you typically know when families are notified of appointments? The LSW replied, There is a note in the medical record. A record review on 07/28/25 at 12:15 PM, revealed a doctor summary titled {Dermatology Consult}, confirming that Resident # 55 went to the Dermatology appointment on 03/24/25 for a Biopsy x2 of the right arm. Resident #7 Documentation for a Computed Tomography Scan (CT) completed 09/04/24 was reviewed by the state surveyor. Notification of results were not documented in the resident's electronic medical chart for physician, patient or responsible party. On 07/28/2025 at 11:45 AM, the Regional Clinical Coordinator #131 confirmed that there was no documentation for physician, resident of responsible party notification and stated, I've looked and I can't find anything. The facility's policy and procedure Notification of Changes in Condition stated under Policy, Changes may include but are not limited to accidents, incidents, transfers, changes in overall health status, significant medical changes, therapy services changes, transfer, hospitalizations, or death.

Based upon record review and staff interview, the facility failed to inform the Resident or the Resident's representative of the risks and benefits for a prescribed psychotropic medication. This was found to be true for one (1) of six (6) residents reviewed during the annual survey process. Resident identifier: #77. Facility census: 107.Findings included: a) Resident #77 A review of the electronic health record (EHR) revealed the following diagnoses for Resident #77:Unspecified Dementia - 12/21/24 Generalized Anxiety Disorder - 03/20/25Alzheimer's - 03/20/25 Upon reviewing progress notes from the facility's medical provider dated 03/16/25, an additional diagnosis of major depressive disorder was revealed. Additionally, a progress note dated 06/10/25 by the provider, stated a diagnosis of Major depressive disorder, recurrent, moderate. The electronic health record does not contain the diagnosis for major depressive disorder under the list of diagnoses. The medical provider orders for the Resident included the following anti-depressants:Sertraline HCl Tablet 25 MG Give 1 tablet by mouth one time a day for Depression, 05/07/25TraZODone HCl Tablet 50 MG Give 1 tablet by mouth at bedtime for insomnia, 05/19/25Upon review of the medical record, no Informed consent could be found for Trazodone. The surveyor asked the facility on 07/22/25 if they had this record. The facility did not provide it before exiting the survey that day. So, it was requested again the following morning on 07/23/25. According to the Regional Operations Coordinator on 07/23/2025 2:02 PM, I could not find this, or we do not have this. Therefore, the facility failed to inform the resident or the resident's representative of the risks and benefits associated with the prescription for Trazodone.

Number of residents sampled: 36Number of residents cited: 1The facility failed to ensure residents had ordered adaptive equipment.Resident #5Based on observation, resident interview, medical record review, the facility failed to ensure Resident #5 had ordered adaptive eating utensils. This failed was true for one (1) of 36 sample residents. Resident identifier: #5. Facility census: Findings included: On 07/21/25 at 9:03 and observation of Resident #5 meal tray card revealed there was to be a left angled fork, left angled spoon, plate guard and Kennedy cup. There was no left angled fork, left angled spoon on the lunch tray. When asked Resident #5 if she gets the equipment on her meal trays she stated No. I keep a set (fork and spoon) in my room and the aides wash them in my bathroom with dish washing soap. Nurse Aide (NA) #83 confirmed there was no left angled fork or spoon on the tray.

Based on observation, record review, and staff interview, the facility failed to provide tube feeding care and services within established acceptable standards of care. TThis deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of tube feeding. Resident Identifier: #2. Facility census: 107.Findings included: The facility's policy titled, Enteral General Nutrition (tube feeding) Guidelines, with no date of implementation given, gives the following procedures to be performed prior to administration of bolus tube feedings: - Validate tube placement by aspirating 12-30 cc of stomach contents using a 60 cc piston syringe. Replace stomach contents once placement is verified.- Flush the enteral feeding tube with at least 15-30 cc of water or as directed by the physician order Review of Resident #2's physician orders showed the following orders: - Enteral Feed five times a day Flush enteral tube with 30 mls [milliliters] of water before and after each bolus feed, ordered 4/27/25.- Enteral feed G-Tubes [gastroscopy tube] are checked via aspiration immediately after insertion, before each feeding and/or flush, before administering medications via tube, before performing gastric residual check and at least every 8 hours, ordered 4/19/25.- Validate tube placement; aspirate 15-30 cc of stomach contents use a 60cc catheter tipped syringe before accessing tube. Replace stomach contents once verified, if placement cannot be validated, do not use tube and contact physician, ordered 4/19/25. On 07/28/25 at 1:29 PM, Licensed Practical Nurse (LPN) #16 was observed administering a bolus tube feeding to Resident #2. LPN #16 flushed the resident's gastroscopy tube with approximately 30 cc of water using a piston syringe. LPN #16 then stated she should have checked the placement of the gastroscopy tube before flushing the tube. LPN #16 aspirated approximately 60 cc of mustard-colored fluid from Resident #2's gastroscopy tube using a piston syringe. She replaced the gastric contents. She also used the piston syringe to inject air through the tube, listening for the air with a stethoscope against the resident's stomach. After verifying the gastroscopy tube placement, LPN #16 appropriately gave Resident #2 the bolus feeding and reflushed the gastroscopy tube with water. No further information was provided though the completion of the survey process.

Based on observation and staff interview, the facility failed to ensure medications were stored properly. This was a random opportunity for discovery. Facility census: 107. Findings included: a) Hall 400 Medication Cart On 07/23/2025 at 10:10 AM, during medication cart inspection on the 400 hall, found Latanoprost with a label REFRIGERATE. The medication was unopened and had been stored in the medication cart. According to the medication insert Storage: Protect from light. Store unopened bottle(s) under refrigeration at 2 to 8 C (36 to 46 F). This was confirmed by Licensed Practical Nurse (LPN) #22.

Based on record review, observation, and staff interview, the facility failed to ensure residents did not develop preventable pressure ulcers. The facility also failed to ensure residents with pressure ulcers received assessment in accordance with professional standards of practice. This deficient practice had the potential to affect two (2) of four (4) residents reviewed for the care area of pressure ulcers. Resident Identifiers: #110. Facility census: 107. Findings included:a) Resident #110 The facility's policy and standard procedure titled, Monitoring a Wound, with no date of implementation given, stated resident skin condition would be evaluated upon return from the hospital. Review of Resident #110's medical records showed the resident had an unstagable pressure ulcer of the right gluteal fold first assessed on 03/08/25 when the resident returned from a hospital transfer. The right gluteal fold pressure ulcer became a stage IV pressure ulcer and was present through 07/07/25, when the resident was transferred to the hospital. On 07/14/25, Resident #110 returned to the facility from the hospital. The Nursing admission Evaluation completed 07/14/25 answered No to the question Any skin areas noted. A Skin and Wound Note written by the Nurse Practitioner on 07/17/25 stated, Patient being seen today for evaluation stage 3 PI of right gluteal fold which was POA [present on admission] on 03/08/2024. [NAME] readmission to facility from stay in hospital, patient noted to have DTI [deep tissue injury] of left inner thigh which was POA date of 07/14/2025. An order was written on 07/15/25 for Wound care: right gluteal fold: cleanse area with wound cleanser, pat dry. Apply skin prep around wound, then silicone dressing daily until healed, every day shift. On 07/17/25, an assessment was performed of the right gluteal fold stage III pressure ulcer. The assessment indicated this pressure ulcer had been present since 03/08/25. Also, on 07/17/25, an assessment was performed of the left thigh suspected deep tissue injury. The assessment indicated this pressure ulcer was a new pressure area first observed 07/17/25. An order was written to start 07/18/25 to Cleanse area to left inner thigh with wound cleanser, apply border dressing daily. On 07/23/2025 at 3:04 PM, Regional Clinical Coordinator #131 confirmed the pressure ulcers Resident #110 had on readmission to the facility on [DATE] were not assessed until 07/17/25.

Based on record review and staff interview, the facility failed to ensure laboratory testing was performed according to the physician orders. This deficient practice had the potential to affect one (1) of six (6) residents reviewed for the care area of unnecessary medications. Resident identifier: #10. Facility census: 107. Findings included:a) Resident #10 Review of Resident #10's physician's orders showed the following orders for laboratory testing: - Complete blood cell count with differentiation and comprehensive metabolic panel, every six (6) months in February and August, ordered 01/15/25.- Lipid panel annually, in February, ordered 01/15/25. Review of Resident #10's laboratory results did not show laboratory testing performed in February 2025. On 07/24/2025 at 12:57 PM, Regional Clinical Coordinator #131 confirmed Resident #10 did not have physician-ordered laboratory testing in February, 2025. She did have the laboratory testing on 05/22/25. No further information was provided through the completion of the survey process.

Based upon record review and staff interview, the facility failed to maintain accuracy of the Minimum Data Set (MDS) Resident Assessment and Care Screening for a diagnosis of major depressive disorder. This was found to be true for one (1) of six (6) residents reviewed during the annual survey process. Resident identifier: #77. Facility census: 107. Findings included:Resident #77's list of diagnoses, related to mental illness, included the following:Unspecified Dementia, Mild with AnxietyGeneralized Anxiety DisorderAlzheimer's DiseaseDuring a review of the medical record for the Resident, the progress notes dated 03/16/25 and 06/10/25 by Resident's medical provider, recorded the following diagnoses:Generalized anxiety disorderUnspecified dementia, mild, with anxietyMajor depressive disorder, recurrent, moderateThe Minimum Data Set (MDS) Resident Assessment was last completed on 06/17/25. Under Section I - Active Diagnoses included:Alzheimer's DiseaseNon-Alzheimer's DementiaAnxiety DisorderUnspecified Dementia, Mild, with AnxietyIn summary, the diagnosis of Major Depressive Disorder is not found in the MDS, even though it was completed after the medical provider declared this diagnosis on 03/16/25, and subsequently on 06/10/25.During an interview with the Regional Operations Coordinator on 07/23/25 at approximately 2:00 PM, she acknowledged the diagnosis of major depressive disorder should have been included in the MDS.

Based upon record review, resident interview, and staff interview, the facility failed to honor the food preferences of a resident. This was found to be true for one (1) of eleven (11) residents reviewed during the annual survey process. Resident identifier: # 45. Facility census: 107. Findings included:On 07/22/25 at 1:26 PM, during an interview with Resident #45, when asked about his food at the facility, he stated, food is not too good, too many things with vinegar in it or on it. Stated he has gotten egg salad sandwiches several times in a row, and brussel sprouts. He stated he does not like pickles or things with vinegar in them. I asked him if he had expressed this to the staff and he stated yes. A review of the resident's dietary preferences in the electronic health record (EHR), stated: Likes gravy on the side.Dislikes pickles, mayonnaise, vinegar, fish of any kind.On 07/23/25, mid-morning, the surveyor requested to review two weeks of meal tickets for this resident. The weeks selected to review were: 07/06/25 to 07/12/25, and 06/22/25 to 06/28/25.For the week of 06/22/25 to 06/28/25, the meal tickets showed resident had been served:BBQ Cheeseburger on a Bun with Pickle spear on 06/22/25Egg Salad sandwich (contains eggs, mayonnaise, pickles) on 06/23/25Fish Sandwich with Tartar Sauce (contains mayonnaise and pickles) on 06/24/25Fried fish with Tartar sauce on 06/27/25For the week of 07/06/25 - 7/12/25, meal tickets showed the resident was served:Egg Salad sandwich on 07/06/25Breaded fish on bun with tartar sauce on 07/07/25Cheeseburger on bun with pickle on 07/09/25Fried fish with Tartar sauce on 07/11/25During an interview with the Dietary Manager #106 on 7/23/2025 at approximately 3:09 PM, surveyor asked, how does the dietary department know a resident's preferences of food? Dietary Manager responded, we utilize Mealtracker. The Surveyor then requested a copy of this Resident's food preferences from Mealtracker. Approximately twenty (20) minutes later, the Dietary Manager returned with the requested Mealtracker document. Upon review of the Mealtracker document for Resident, there were no preferences marked.When the surveyor reviewed the meal tickets for the resident, and the documentation in the electronic health record (EHR) for resident's dislikes, specifically pointing out the fish, the egg salad, pickles, tartar sauce, the Dietary Manager said apparently the Mealtracker system is not crossing over from the EHR. When asked, how can you honor a resident's food preferences if you do not have them in the system? The Dietary Manager and the Regional Dietary Coordinator stated, we have found this in a few residents, we think something happened when we changed over from the Winter/Spring menus to the Summer menu.The following morning on 07/24/25, at approximately 9:30 AM, the Dietary Manager brought revised documentation showing the resident's preferences had been updated and would be honored in the future.[NAME] JR, [NAME] (45) Walker, [NAME] (51554) - RESIDENT NOTE No Notes

Based on observation and staff interview, a Nurse Aide (NA) failed to don on a gown when performing catheter care for Resident #44 who was on Enhanced Barrier Precautions. This was true for one of one sampled residents. Resident identifier: #44. Facility census: 107. Findings included: a) Resident #44 On 07/28/25 at 10:39 AM observed Resident #44 Foley catheter care provided by NA # 84. Prior to entering Resident #44's room there were signs posted that Enhanced Barrier Precautions (EBP) were required when doing direct resident care such as catheter care. EPB included donning a gown and gloves. NA #84 donned gloves and proceeded to perform catheter care. NA #84 failed to don a gown. When asked about EBP, NA #85 stated Oh no. I didn't put on a gown. NA #85 immediately donned a gown and proceeded to change the resident's brief and dispose of soiled items.

Based on record review and staff interview, the facility failed to follow principles of antibiotic stewardship. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for antibiotic use. Resident Identifier: #66. Facility Census: 107.Findings included: a) Resident #66 The facility's procedure titled, Antibiotic Stewardship Plan, with effective date 05/01/17, stated the Infection Preventionist would review culture data to support antibiotic stewardship. Review of Resident #66's medical records showed she was admitted to the facility with a surgical site infection at the site of a toe amputation. On 05/10/25, a wound culture was performed due to increased drainage at the site. The resident was also started on the antibiotic Cefalexin. The culture grew the organism Methicillin-resistant Staphylococcus aureus. The sensitivity report showed the organism was resistant to the antibiotics Clindamycin, Tetracycline, and Doxycycline, in addition to Methicillin (oxacillin). On 05/16/25, Resident #66 was also started on the antibiotic Linezolid for Methicillin-resistant Staphylococcus aureus. The prior wound culture and sensitivity showed the organism was resistant to Linezolid. On 05/19/25, Resident #66 was transferred to the hospital due to tissue necrosis at the site of the previous toe amputation. A wound culture performed at the hospital continued to show Methicillin-resistant Staphylococcus aureus, resistant to the antibiotics Clindamycin, Tetracycline, and Doxycycline, in addition to Methicillin (oxacillin). During her hospitalization, Resident #66 was started on the intravenous antibiotic Tigecycline. The wound culture and sensitivity had shown the wound was resistant to Tigecycline. The resident continued ntravenous Tigecycline upon readmission to the facility on [DATE]. She received Tigecycline through 06/22/25. She received Linezolid orally again from 06/24/25 through 06/26/26. On 06/27/25, Resident #66 was prescribed the antibiotic Doxycycline, by mouth, two (2) times a day, for five days, for surgical site infection. No documentation could be found in the medical records as to why the antibiotic was changed from Linezolid to Doxycycline that day. On 07/29/25 at 11:00 AM, Regional Clinical Coordinator confirmed Resident #66 was started on the antibiotic Doxycycline despite previous wound cultures showing the infectious organism was resistant to Doxycycline. She also stated she was not able to provide additional information as to why the antibiotic was changed from Linezolid to Doxycycline that day. No further information was provided through the completion of the survey.

Based on staff interview and record review, the facility failed to implement their written Abuse and Neglect policy as it related to reporting allegations of abuse and failed to follow procedures to investigate any such allegations. Their lack of action to investigate the abuse allegation placed Resident #1 at continued risk of staff abuse for six (6) days prior to Surveyor intervention. Review of facility records found that there were 30 other residents who had a BIMS (Brief Interview for Mental Status) score between 0-7, suggesting severe cognitive impairment. They also were at risk of staff abuse. Resident identifiers: #1, #3, #6, #10, #13, #14, #17, #26, #34, #36, #37, #38, #44, #49, #50, #53, #55, #57, #60, #66, #67, #68, #75, #87, #89, #95, #97, #99, #103, #104, #111. Facility Census: 107. Findings included: a) [NAME] Virginia Abuse, Neglect and Misappropriation Policy Review of the facility's [NAME] Virginia Abuse, Neglect and Misappropriation Policy revealed the following details: - Abuse was defined as intimidation or punishment resulting in physical harm, pain, or mental anguish. It was noted that abuse included mental abuse. - Physical Abuse was noted to include, but not be limited to, hitting slapping, pinching, biting, and kicking. - Verbal Abuse was noted to include the use of gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples given included yelling or hovering over a resident, with the intent to intimidate. - An alleged violation was defined as a situation or occurrence that was observed or reported by staff, resident, relative, visitor, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse. - Section V of the policy, titled Investigation of Incidents, noted if the individual reporting perceived an event to be abuse, neglect or misappropriation, the facility must report the event. - Section III of the policy, titled Prevention, directed that an employee who was alleged or accused of being a party to abuse would immediately be removed from the area(s) of resident care, interviewed by facility leadership for a written statement and not left alone. -Section VII, titled Reporting of Incidents and Facility Response, indicated: 1. All alleged violations will be reported to the Administrator immediately 2. The Administrator / Designee will report appropriate incidents to OHFLAC (Office of Health Facility Licensure and Certification), APS (Adult Protective Services), the Regional Ombudsman, and other local authorities, including but not limited to local law enforcement (if appropriate), as required by State law. 3. If the event that caused the allegation involves abuse, the self-report must be made immediately, but not later than two (2) hours after the allegation is made. 4. The results of the facility's investigation must be reported to the Administrator / Designee, OHFLAC, APS, Regional Ombudsman, and other officials as required by State law, within five working days of the incident. b) Staff Interview with CNA #22 During a telephone interview on 12/26/23 at 6:30 PM, CNA #22 stated other CNAs working the evening shift will purposefully provoke Resident #1 until he becomes agitated, screams, and demonstrates behaviors then staff giggle about it. They will get in his face and shake his chair, pull his hat off his head, taunt him by holding it out of reach, or poke him repeatedly on the cheek until he screams out. They say he will sleep better after such outbursts. CNA #22 stated she reported this to LPN #30, on 12/20/23 at approximately 1:00 AM, and was told probably not much that would be done about it. CNA #22 stated she then sent a text message, at approximately 1:30 AM, to the DON and expressed concern by texting, He's (Resident #1) is screaming because they had him agitated intentionally. CNA #22 reported she never received any response from the DON. CNA #22 reported being very upset regarding the fact that such treatment was happening in the building and went on to say as a severely cognitively impaired resident, having someone in your face shaking your chair, pulling your hat off your head and taunting you by holding it out of reach, and poking you repeatedly on your cheek until you screamed out, would be very upsetting and confusing. A subsequent record review revealed Resident #1 is a resident with severely impaired cognition. He has been diagnosed with Alzheimer's Disease and Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Insomnia. Resident #1 has a BIMS score of 01, suggesting severe cognitive impairment. c) Staff Interview with CNA #118 During a telephone interview on 12/27/23 at 9:37 AM, CNA #118 stated she had personally observed other CNAs working the evening shift purposefully provoke Resident #1 until he becomes agitated, screams, and demonstrates behaviors. She went on to say, It angers me. They think it's funny. It's not. Then when he does have combative behaviors the same staff act upset with him. It's not right. CNA #118 relayed she has not reported any of her concerns for fear of retaliation. She said, It's common knowledge amongst CNAs that if you say something, you might as well be prepared to leave your job. CNA #118 also reported that she has witnessed CNA #24 has placed Resident #1 in the nook by the shower room and then blocked the chair so Resident #1 could not be mobile throughout the building. Allegedly, CNA #24 has stated, He gets on my nerves. I'm tired of his wandering. d) Review of the Facility Reportable Log Review of the facility's reportable log, completed on 12/27/23 at 9:55 AM, revealed the allegation of abuse had not been reported to appropriate state agencies. e) Review of Residents' Brief Interview for Mental Status (BIMS) Scores Resident #3's Quarterly Minimum Data Set (MDS), dated [DATE], reflected resident had a BIMS score of 03 suggesting severe cognitive impairment. Resident #6's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 07 suggesting severe cognitive impairment. Resident #10's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 05 suggesting severe cognitive impairment. Resident #13's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 07 suggesting severe cognitive impairment. Resident #14's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 06 suggesting severe cognitive impairment. Resident #17's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 99 suggesting severe cognitive impairment. Resident #26's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 04 suggesting severe cognitive impairment. Resident #34's Annual MDS, dated [DATE], reflected resident had a BIMS score of 06 suggesting severe cognitive impairment. Resident #36's Admission MDS, dated [DATE], reflected resident had a BIMS score of 05 suggesting severe cognitive impairment. Resident #37's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 05 suggesting severe cognitive impairment. Resident #38's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 04 suggesting severe cognitive impairment. Resident #44's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 04 suggesting severe cognitive impairment. Resident #49's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 04 suggesting severe cognitive impairment. Resident #50's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 07 suggesting severe cognitive impairment. Resident #53's Annual MDS, dated [DATE], reflected resident had a BIMS score of 05 suggesting severe cognitive impairment. Resident #55's Medicare - 5 Day MDS, dated [DATE], reflected resident had a BIMS score of 99 suggesting severe cognitive impairment. Resident #57's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 07 suggesting severe cognitive impairment. Resident #60's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 03 suggesting severe cognitive impairment. Resident #66's Annual MDS, dated [DATE], reflected resident had a BIMS score of 07 suggesting severe cognitive impairment. Resident #67's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 03 suggesting severe cognitive impairment. Resident #68's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 03 suggesting severe cognitive impairment. Resident #75's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 04 suggesting severe cognitive impairment. Resident #87's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 03 suggesting severe cognitive impairment. Resident #89's Admission MDS, dated [DATE], reflected resident had a BIMS score of 05 suggesting severe cognitive impairment. Resident #95's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 03 suggesting severe cognitive impairment. Resident #97's Significant Change MDS, dated [DATE], reflected resident had a BIMS score of 04 suggesting severe cognitive impairment. Resident #99's Annual MDS, dated [DATE], reflected resident had a BIMS score of 05 suggesting severe cognitive impairment. Resident #103's Annual MDS, dated [DATE], reflected resident had a BIMS score of 07 suggesting severe cognitive impairment. Resident #104's Annual MDS, dated [DATE], reflected resident had a BIMS score of 03 suggesting severe cognitive impairment. Resident #111's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 03 suggesting severe cognitive impairment. f) Interview with the Director of Nursing (DON) and Administrator During an interview on 12/27/23 at 10:17 AM, the DON reported she would need to check her messages to determine if she had ever been notified of possible abuse/mistreatment of Resident #1 on the evening shift. On 12/27/23 at 11:16 AM, the DON confirmed she did receive a text from CNA #22 on 12/20/23 at 1:47 AM. She states when she had read the text, she had not interpreted CNA #22's statement to be an allegation of abuse. The DON confirmed this issue had never been reported and had never been investigated. Both the DON and the Administrator acknowledged that the facility had never reported the allegation of abuse to appropriate state agencies, nor was it addressed in any fashion within the building to prevent further abuse from happening. The facility was notified of the IJ (Immediate Jeopardy) at 3:00 PM on 12/27/23. The facility submitted their initial abatement plan of correction (POC) at 4:36 PM on 12/27/23. The State Office requested revision and the POC was approved at 5:39 PM on 12/27/23. After observation, staff interview, review of facility documentation, and record review determining the implementation of the POC, the IJ was abated at 6:30 PM on 12/27/23. The IJ started on 12/27/23 at 3:00 PM and ended on 12/27/23 at 6:30 PM. The facility's approved abatement POC consisted of the following: 1. Resident #1 being assessed by NP (Nurse Practitioner) for any psychosocial effects from incident. CNA #24 was immediately removed from the schedule upon notification on 12/27/23 and suspended pending investigation. This incident was immediately reported on 12/27/23 at 1:11 pm to OHFLAC (Office of Health Facility Licensure and Certification), APS (Adult Protective Services), Ombudsman and Nurse Aide Registry by the DON (Director of Nursing). 2. All alert residents were interviewed by Social Worker on 12/27/23 to identify other concerns and no other issues were identified. 3. All Staff was immediately re-educated on reporting allegations of abuse, including perceived threats of involuntary seclusion, immediately to OHFLAC, Nurse Aide Registry, APS, and Ombudsman or other licensing board as warranted with posttest for validation of understanding. All staff in facility at this time were also re-educated on immediate reporting of abuse allegations and the definition of abuse and involuntary seclusion and staff not available at this time will be re-educated prior to start of next scheduled shift including post-test to validate understanding. Staff will be reassured that any and all reports will remain confidential and ensure understanding of timely reporting to supervisor. The DON will review all texts timely that are received from staff, follow up with a phone call to staff related to incident, and subsequently follow all reporting guidelines if the allegation rises to that level. 4. Administrator/designee will round with all residents daily for two weeks, then three times a week for two weeks then per month for three months to identify residents with concerns of abuse and any allegations will be reported immediately to OHFLAC, Ombudsman, APS, Nurse Aide registry and other licensing board as warranted. All allegations of abuse and neglect will be reviewed at the facilities QAPI (Quality Assurance and Performance Improvement) meeting each month.

Based on record review and staff interview, the facility failed to complete a thorough investigation of a staff member's allegation of resident abuse, maintain documentation that alleged violation was thoroughly investigated, and report the results to Adult Protective Services and the State Survey Agency, within five (5) working days of the incident in accordance with State law. The facility's failure to complete a thorough investigation of a staff member's allegation of resident abuse left residents who were deemed to be severely cognitively impaired at risk of further abuse. In addition, the facility failed to ensure the victim was protected from further abuse which put the residents at risk for additional serious harm and or death. Findings included: a) Staff Interview with CNA #22 During a telephone interview on 12/26/23 at 6:30 PM, CNA #22 stated other CNAs working the evening shift will purposefully provoke Resident #1 until he becomes agitated, screams, and demonstrates behaviors then staff giggle about it. They will get in his face and shake his chair, pull his hat off his head, taunt him by holding it out of reach, or poke him repeatedly on the cheek until he screams out. They say he will sleep better after such outbursts. CNA #22 stated she reported this to LPN #30, on 12/20/23 at approximately 1:00 AM, and was told probably not much that would be done about it. CNA #22 stated she then sent a text message, at approximately 1:30 AM, to the DON and expressed concern by texting, He's (Resident #1) is screaming because they had him agitated intentionally. CNA #22 reported she never received any response from the DON. CNA #22 reported being very upset regarding the fact that such treatment was happening in the building and went on to say as a severely cognitively impaired resident, having someone in your face shaking your chair, pulling your hat off your head and taunting you by holding it out of reach, and poking you repeatedly on your cheek until you screamed out, would be very upsetting and confusing. A subsequent record review revealed Resident #1 is a resident with severely impaired cognition. He has been diagnosed with Alzheimer's Disease and Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Insomnia. Resident #1 has a BIMS score of 01, suggesting severe cognitive impairment. b) Review of the Facility Reportable Log Review of the facility's reportable log, completed on 12/27/23 at 9:55 AM, revealed the allegation of abuse had not been reported to appropriate state agencies. c) Interview with the Director of Nursing (DON) and Administrator During an interview on 12/27/23 at 10:17 AM, the DON reported she would need to check her messages to determine if she had ever been notified of possible abuse/mistreatment of Resident #1 on the evening shift. On 12/27/23 at 11:16 AM, the DON confirmed she did receive a text from CNA #22 on 12/20/23 at 1:47 AM. She states when she had read the text, she had not interpreted CNA #22's statement to be an allegation of abuse. The DON confirmed this issue had never been reported and had never been investigated. Both the DON and the Administrator acknowledged that the facility had never reported the allegation of abuse to appropriate state agencies, nor was it addressed in any fashion within the building to prevent further abuse from happening. The facility was notified of the IJ (Immediate Jeopardy) at 3:00 PM on 12/27/23. The facility submitted their initial abatement plan of correction (POC) at 4:36 PM on 12/27/23. The State Office requested revision and the POC was approved at 5:39 PM on 12/27/23. After observation, staff interview, review of facility documentation, and record review determining the implementation of the POC, the IJ was abated at 6:30 PM on 12/27/23. The IJ started on 12/27/23 at 3:00 PM and ended on 12/27/23 at 6:30 PM. The facility's approved abatement POC consisted of the following: 1. Resident #1 being assessed by NP (Nurse Practitioner) for any psychosocial effects from incident. CNA #24 was immediately removed from the schedule upon notification on 12/27/23 and suspended pending investigation. This incident was immediately reported on 12/27/23 at 1:11 pm to OHFLAC (Office of Health Facility Licensure and Certification), APS (Adult Protective Services), Ombudsman and Nurse Aide Registry by the DON (Director of Nursing). 2. All alert residents were interviewed by Social Worker on 12/27/23 to identify other concerns and no other issues were identified. 3. All Staff was immediately re-educated on reporting allegations of abuse, including perceived threats of involuntary seclusion, immediately to OHFLAC, Nurse Aide Registry, APS, and Ombudsman or other licensing board as warranted with posttest for validation of understanding. All staff in facility at this time were also re-educated on immediate reporting of abuse allegations and the definition of abuse and involuntary seclusion and staff not available at this time will be re-educated prior to start of next scheduled shift including post-test to validate understanding. Staff will be reassured that any and all reports will remain confidential and ensure understanding of timely reporting to supervisor. The DON will review all texts timely that are received from staff, follow up with a phone call to staff related to incident, and subsequently follow all reporting guidelines if the allegation rises to that level. 4. Administrator/designee will round with all residents daily for two weeks, then three times a week for two weeks then per month for three months to identify residents with concerns of abuse and any allegations will be reported immediately to OHFLAC, Ombudsman, APS, Nurse Aide registry and other licensing board as warranted. All allegations of abuse and neglect will be reviewed at the facilities QAPI (Quality Assurance and Performance Improvement) meeting each month.

Based on policy review, record review, and staff interview, the facility failed to protect a resident's right to be free from abuse that resulted in mental anguish for Resident #1. This was a random opportunity for a discovery made during a complaint investigation. Resident identifier: #1. Facility census: 107. Using the reasonable person concept, the facility's failure to protect a resident's right to be free from abuse resulted in mental anguish for Resident #1 and had the potential to cause serious harm and or death. This was true for Resident #1. Facility Census: 107. Findings included: a) [NAME] Virginia Abuse, Neglect and Misappropriation Policy Review of the facility's [NAME] Virginia Abuse, Neglect and Misappropriation Policy revealed the following details: - Abuse was defined as intimidation or punishment resulting in physical harm, pain, or mental anguish. It was noted that abuse included mental abuse. - Physical Abuse was noted to include, but not be limited to, hitting slapping, pinching, biting, and kicking. - Verbal Abuse was noted to include the use of gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples given included yelling or hovering over a resident, with the intent to intimidate. - An alleged violation was defined as a situation or occurrence that was observed or reported by staff, resident, relative, visitor, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse. - Section V of the policy, titled Investigation of Incidents, noted if the individual reporting perceived an event to be abuse, neglect or misappropriation, the facility must report the event. - Section III of the policy, titled Prevention, directed that an employee who was alleged or accused of being a party to abuse would immediately be removed from the area(s) of resident care, interviewed by facility leadership for a written statement and not left alone. -Section VII, titled Reporting of Incidents and Facility Response, indicated: 1. All alleged violations will be reported to the Administrator immediately 2. The Administrator / Designee will report appropriate incidents to OHFLAC (Office of Health Facility Licensure and Certification), APS (Adult Protective Services), the Regional Ombudsman, and other local authorities, including but not limited to local law enforcement (if appropriate), as required by State law. 3. If the event that caused the allegation involves abuse, the self-report must be made immediately, but not later than two (2) hours after the allegation is made. 4. The results of the facility's investigation must be reported to the Administrator / Designee, OHFLAC, APS, Regional Ombudsman, and other officials as required by State law, within five working days of the incident. b) Staff Interview with CNA #22 During a telephone interview on 12/26/23 at 6:30 PM, CNA #22 stated other CNAs working the evening shift will purposefully provoke Resident #1 until he becomes agitated, screams, and demonstrates behaviors then staff giggle about it. They will get in his face and shake his chair, pull his hat off his head, taunt him by holding it out of reach, or poke him repeatedly on the cheek until he screams out. They say he will sleep better after such outbursts. CNA #22 stated she reported this to LPN #30, on 12/20/23 at approximately 1:00 AM, and was told probably not much that would be done about it. CNA #22 stated she then sent a text message, at approximately 1:30 AM, to the DON and expressed concern by texting, He's (Resident #1) is screaming because they had him agitated intentionally. CNA #22 reported she never received any response from the DON. CNA #22 reported being very upset regarding the fact that such treatment was happening in the building and went on to say as a severely cognitively impaired resident, having someone in your face shaking your chair, pulling your hat off your head and taunting you by holding it out of reach, and poking you repeatedly on your cheek until you screamed out, would be very upsetting and confusing. A subsequent record review revealed Resident #1 is a resident with severely impaired cognition. He has been diagnosed with Alzheimer's Disease and Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Insomnia. Resident #1 has a BIMS score of 01, suggesting severe cognitive impairment. c) Staff Interview with CNA #118 During a telephone interview on 12/27/23 at 9:37 AM, CNA #118 stated she had personally observed other CNAs working the evening shift purposefully provoke Resident #1 until he becomes agitated, screams, and demonstrates behaviors. She went on to say, It angers me. They think it's funny. It's not. Then when he does have combative behaviors the same staff act upset with him. It's not right. CNA #118 relayed she has not reported any of her concerns for fear of retaliation. She said, It's common knowledge amongst CNAs that if you say something, you might as well be prepared to leave your job. CNA #118 also reported that she has witnessed CNA #24 has placed Resident #1 in the nook by the shower room and then blocked the chair so Resident #1 could not be mobile throughout the building. Allegedly, CNA #24 has stated, He gets on my nerves. I'm tired of his wandering. d) Review of the Facility Reportables Log Review of the facility's reportable log, completed on 12/27/23 at 9:55 AM, revealed the allegation of abuse had not been reported to appropriate state agencies. e) Interview with the Director of Nursing (DON) and Administrator During an interview on 12/27/23 at 10:17 AM, the DON reported she would need to check her messages to determine if she had ever been notified of possible abuse/mistreatment of Resident #1 on the evening shift. On 12/27/23 at 11:16 AM, the DON confirmed she did receive a text from CNA #22 on 12/20/23 at 1:47 AM. She states when she had read the text, she had not interpreted CNA #22's statement to be an allegation of abuse. The DON confirmed this issue had never been reported and had never been investigated. Both the DON and the Administrator acknowledged that the facility had never reported the allegations of abuse to appropriate state agencies, nor was it addressed in any fashion within the building to prevent further abuse from happening. The facility was notified of the IJ (Immediate Jeopardy) at 3:00 PM on 12/27/23. The facility submitted their initial abatement plan of correction (POC) at 4:36 PM on 12/27/23. The State Office requested revision and the POC was approved at 5:39 PM on 12/27/23. After observation, staff interview, review of facility documentation, and record review determining the implementation of the POC, the IJ was abated at 6:30 PM on 12/27/23. The IJ started on 12/27/23 at 3:00 PM and ended on 12/27/23 at 6:30 PM. The facility's approved abatement POC consisted of the following: 1. Resident #1 being assessed by NP (Nurse Practitioner) for any psychosocial effects from incident. CNA #24 was immediately removed from the schedule upon notification on 12/27/23 and suspended pending investigation. This incident was immediately reported on 12/27/23 at 1:11 pm to OHFLAC (Office of Health Facility Licensure and Certification), APS (Adult Protective Services), Ombudsman and Nurse Aide Registry by the DON (Director of Nursing). 2. All alert residents were interviewed by Social Worker on 12/27/23 to identify other concerns and no other issues were identified. 3. All Staff was immediately re-educated on reporting allegations of abuse, including perceived threats of involuntary seclusion, immediately to OHFLAC, Nurse Aide Registry, APS, and Ombudsman or other licensing board as warranted with posttest for validation of understanding. All staff in facility at this time were also re-educated on immediate reporting of abuse allegations and the definition of abuse and involuntary seclusion and staff not available at this time will be re-educated prior to start of next scheduled shift including post-test to validate understanding. Staff will be reassured that any and all reports will remain confidential and ensure understanding of timely reporting to supervisor. The DON will review all texts timely that are received from staff, follow up with a phone call to staff related to incident, and subsequently follow all reporting guidelines if the allegation rises to that level. 4. Administrator/designee will round with all residents daily for two weeks, then three times a week for two weeks then per month for three months to identify residents with concerns of abuse and any allegations will be reported immediately to OHFLAC, Ombudsman, APS, Nurse Aide registry and other licensing board as warranted. All allegations of abuse and neglect will be reviewed at the facilities QAPI (Quality Assurance and Performance Improvement) meeting each month.

Based on medical record review, staff interview, hospital record review, policy review, and resident interview, the facility failed to ensure all residents were free from neglect. The facility's failure to notify the physician and/or nursing supervisor of changes in a resident's condition and take appropriate, timely action resulted in actual harm for one (1) of three (3) residents reviewed for wound management. A nurse assessed a resident had purulent, foul smelling drainage and severe weeping from stasis ulcers of the lower extremities. This caused the resident embarrassment to attend out of room activities around other residents, resulting in psychological harm to the resident. The weeping and loss of fluid added to the resident's development of dehydration, electrolyte imbalance, and change in mental status. This resulted in actual harm to the resident, necessitating a transfer to the hospital three (3) days after a nurse's assessment. The resident required hospitalization to treat the [DIAGNOSES REDACTED]. Upon transfer to the hospital, hospital physician(s) also assessed the resident to have maggots in her left leg wound. Resident identifier: #1. Facility census: 86. Findings include: a) Resident #1 The medical record was reviewed on 07/23/19 and 07/24/19. This resident had a [DIAGNOSES REDACTED]. On 05/31/19 the physician ordered [MEDICATION NAME] (a diuretic) for [MEDICAL CONDITION], ten (10) milligrams (mg) daily each Monday, Wednesday and Friday, and five (5) mg. daily every Sunday, Tuesday, Thursday, and Saturday. She received these medications daily up to and including her admitted to the hospital on [DATE]. On 06/28/19 the physician ordered both [MEDICATION NAME] (an antibiotic) 150 mg. three (3) times daily, and Keflex (an antibiotic) 500 mg. four (4) days daily, through 07/05/19 for venous stasis ulcer treatment. A late entry nurse progress on 07/10/19 by former registered nurse #100 (RN #100), referenced a nursing assessment for 07/06/19 at 5 PM. RN #100 assessed that this resident had {typed as written}a large amount of purulent drainage from all wound beds. Slough to each individual wound bed was also noted; along with a foul aroma that penetrated through the dressings on her BLE (bilateral lower extremities). Large amounts of seepage visually noted through the bandages and on the floor were (where) the resident rest her feet. BLE also appear to be red and swollen and very tender to touch. Resident stated that she was embarrassed to attend church or any activities because her legs leave large amounts of liquid puddles wherever she goes. The progress note lacked evidence of physician or nursing supervisor notification of the resident's condition. Nurse progress notes for all shifts on 07/07/09 and 07/08/09 were silent related to the condition of the resident's bilateral lower extremities, or the condition of the dressings to the stasis ulcers. A nurse progress note dated 07/09/19 at 2:34 PM conveyed that at 8:00 AM the residents legs were weeping and had a foul odor. In a nurse progress note dated 07/09/19 at 2:37 PM, licensed nurse #10 (LPN #10) conveyed that upon entering the resident's room, the resident was noted to be pale and complained of feeling shaky. Her speech was slurred. LPN #10 stated {typed as written} BLE in Unna boots per orders with four odor noted. Socks noted to be moderately wet from knees down. Resident also noted to have abnormal labs of BUN (blood urea nitrogen), creatinine. Received order to send to ER per (name of doctor). The resident left the facility at 12:33 PM with emergency medical services. The (name of hospital) initial history and physical (H&P) on 07/09/19 stated the chief complaint was presentation with altered mental status. In the physical examination section of the H&P, maggots were noted in the wound bed. Other assessments included venous stasis [MEDICAL CONDITION] of both lower extremities, bilateral lower extremity [MEDICAL CONDITION] and [MEDICAL CONDITION], and acute kidney injury. The (name of hospital) primary discharge [DIAGNOSES REDACTED]. Per the discharge summary, she was placed on medicated wraps and her wounds improved greatly and her [MEDICAL CONDITION] resolved as well. The hospital recommended that she stop taking [MEDICATION NAME]. On 07/24/19 at 1:45 PM and again at 3:00 PM interviews were conducted with the director of nursing (DON). She said the nurse who dressed the wounds on 07/06/19 was a contracted registered nurse (RN #100) who has since been let go by the facility. She said RN #100 did not notify the evening shift supervisor who was working on another hall, nor did she notify the nurse on call (DON) or the physician of her assessment, nor did she convey it on the 24-hour report. The DON said had she done so, they most likely would have sent the resident to the emergency roiagnom on [DATE]. It was discussed that this substantiated neglect, as changes occurred to the residents legs and excessive drainage (puddles) on 07/06/19, but nothing was done until 07/09/19. She agreed that the medical record was silent on 07/07/19 and 07/08/19 on all shifts related to the condition of the dressings on her legs as to whether they were dry and intact, or weeping, or odorous. She said she realized that, and since their investigation staff have been more diligent about assessing and documenting the dressings on her legs. She said she could provide no evidence as to the condition of the resident's bilateral lower extremities or the dressings prior to the day shift on 07/09/19. Upon inquiry, the DON said the basic metabolic panel (BMP) which was done on 07/09/19 was performed due to a standing order after a change in medication or dosage ([MEDICATION NAME]) was done approximately six (6) weeks prior. She said medical records kept a tickler file and automatically ordered a BMP six (6) weeks later which coincidentally came due on 07/09/19. The DON said that on 07/10/19 the hospital notified them by telephone that they were reporting neglect to state officials, and relayed that the resident presented with maggots in her leg wound(s). The DON said she began her own investigation into the matter in part by obtaining witness statements from nurses who provided care for the resident in the days leading up to the hospitalization on [DATE]. It was only then that she discovered that RN #100 had assessed a change in condition on 07/06/19 but failed to follow through. She said that on 07/10/19 she asked RN #100 for a witness statement, but instead RN #100 wrote a late entry nurse progress note for 07/06/19. An interview was conducted with LPN #10 on 07/24/19 at 2:15 PM. She said this resident was ordered dressing changes to the bilateral lower extremities every three (3) days in early July. She changed the leg dressings on 07/03/09. She said the wounds when she saw them on 07/03/19, in comparison with the late entry note for the 07/06/19 dressing change, was a lot different. She said on 07/03/19 there was no odor and there were no puddles of fluid. She said the resident had non-[MEDICAL CONDITION] of the BLE, and the skin surrounding the stasis ulcers was intact. She said there was only a moderate amount of clear drainage when she removed the old dressings. She said the 07/06/19 assessment of the wounds would have amounted to a change in condition for this resident. On 07/24/19 at 4:00 PM an interview was conducted with the resident. She said she has had weeping from stasis ulcers in the past but never as bad as before she went into the hospital on [DATE]. She said she was embarrassed to go to church services or leave her room for any activities because she left puddles of water around her feet wherever she sat. She said this made her feel dirty and she did not want people to see her that way. She related that the (name of physician) at the (name of hospital) got down on their knees and took pictures of her stasis ulcer wounds when she entered the hospital. She whispered that the wound on the left leg contained maggots. An interview was conducted with the administrator on 07/24/19 at 4:30 PM. She said she was not even sure there were any maggots as the hospital did not show her any pictures of them. It was discussed that the problem was not just the maggots, but also a nurse knew of changes in a resident's condition three (3) days prior to the hospital transfer and did not tell anyone else about it. It was discussed that the loss of fluids may have contributed to her dehydration and the hospital [DIAGNOSES REDACTED]. Had the nurse acted timely, it may have prevented the resident from worsening to the point discovered three (3) days later. She acknowledged understanding but had no further evidence at this time to provide to the contrary. On 07/25/19 at 10:30 AM the DON provided a notification policy which stated that is is the policy of this facility to immediately identify a potential change of condition, assess and, when indicated, notify the physician regarding unusual circumstances involving residents. Conditions that may signal a change in condition may include observed physical changes. The supervising nurse, if not a RN, will inform the nurse manager/RN on call of the findings. If the supervising nurse is an RN, the unusual circumstances will be reported to the administrator and nurse manager and handled accordingly. The physician is to be notified of all circumstances that pertain to the resident's care or that have the potential for harm, creating an unsafe condition.

Based on medical record review, staff interview, hospital record review, policy review, and resident interview, the facility failed to notify the physician in a significant change in a resident's physical and psychosocial condition. The facility's failure to notify the physician and/or nursing supervisor of changes in a resident's condition and take appropriate, timely action resulted in actual harm for one (1) of three (3) residents reviewed for wound management. A nurse assessed a resident had purulent, foul smelling drainage and severe weeping from stasis ulcers of the lower extremities. Purulent drainage is liquid or discharge that oozes from a wound that has a milky look and texture. This caused the resident embarrassment to attend out of room activities around other residents, resulting in psychosocial harm to the resident. The weeping and loss of fluid added to the resident's development of dehydration, electrolyte imbalance, and change in mental status. This resulted in actual harm to the resident, necessitating a transfer to the hospital three (3) days after a nurse's assessment. The resident required hospitalization to treat the [DIAGNOSES REDACTED]. Upon transfer to the hospital, hospital physician(s) also assessed the resident to have maggots in her left leg stasis ulcer wound. Resident identifier: #1. Facility census: 86. Findings included: a) Resident #1 The medical record was reviewed on 07/23/19 and 07/24/19. This resident had a [DIAGNOSES REDACTED]. [MEDICAL CONDITION] is a condition where the leg veins fail to return blood back toward the heart normally and a shallow wound (also known as venous ulcer, varicose ulcer or stasis ulcer) develops on the lower leg. On 05/31/19 the physician ordered [MEDICATION NAME] for [MEDICAL CONDITION], ten (10) milligrams (mg) daily each Monday, Wednesday and Friday, and five (5) mg. daily every Sunday, Tuesday, Thursday, and Saturday. She received these medications daily up to and including her admitted to the hospital on [DATE]. [MEDICATION NAME] (or [MEDICATION NAME]) is a diuretic used to reduce extra fluid in the body ([MEDICAL CONDITION]). On 06/28/19 the physician ordered both [MEDICATION NAME] (an antibiotic) 150 mg. three (3) times daily, and Keflex (an antibiotic) 500 mg. four (4) days daily, through 07/05/19 for venous stasis ulcer treatment. A late entry nurse progress on 07/10/19 by former registered nurse #100 (RN #100), referenced a nursing assessment for 07/06/19 at 5 PM. RN #100 assessed that this resident had {typed as written}a large amount of purulent drainage from all wound beds. Slough to each individual wound bed was also noted; along with a foul aroma that penetrated through the dressings on her BLE (bilateral lower extremities). Large amounts of seepage visually noted through the bandages and on the floor were (where) the resident rest her feet. BLE also appear to be red and swollen and very tender to touch. Resident stated that she was embarrassed to attend church or any activities because her legs leave large amounts of liquid puddles wherever she goes. The progress note lacked evidence of physician or nursing supervisor notification of the resident's condition. Nurse progress notes for all shifts on 07/07/09 and 07/08/09 were silent related to the condition of the resident's bilateral lower extremities, or of the condition of the dressings to the stasis ulcers. A nurse progress note dated 07/09/19 at 2:34 PM conveyed that at 8:00 AM the residents legs were weeping and had a foul odor. In a nurse progress note dated 07/09/19 at 2:37 PM, licensed nurse #10 (LPN #10) conveyed that upon entering the resident's room, the resident was noted to be pale and complained of feeling shaky. Her speech was slurred. LPN #10 stated {typed as written} BLE in Unna boots per orders with foul odor noted. Socks noted to be moderately wet from knees down. Resident also noted to have abnormal labs of BUN (blood urea nitrogen), creatinine. Received order to send to ER per (name of doctor). The resident left the facility at 12:33 PM with emergency medical services. The (name of hospital) initial history and physical (H&P) on 07/09/19 stated the chief complaint was presentation with altered mental status. In the physical examination section of the H&P, maggots were noted in the wound bed. Other assessments included venous stasis [MEDICAL CONDITION] of both lower extremities, bilateral lower extremity [MEDICAL CONDITION] and [MEDICAL CONDITION], and acute kidney injury. The (name of hospital) primary discharge [DIAGNOSES REDACTED]. Per the discharge summary, she was placed on medicated wraps and her wounds improved greatly and her [MEDICAL CONDITION] resolved as well. The hospital recommended that she stop taking [MEDICATION NAME]. On 07/24/19 at 1:45 PM and again at 3:00 PM interviews were conducted with the director of nursing (DON). She said the nurse who dressed the wounds on 07/06/19 was a contracted registered nurse (RN #100) who has since been let go by the facility. She said RN #100 did not notify the evening shift supervisor who was working on another hall, nor did she notify the nurse on call (DON) or the physician of her assessment, nor did she convey it on the 24-hour report. The DON said had she done so, they most likely would have sent the resident to the emergency roiagnom on [DATE]. It was discussed that this substantiated neglect, as changes occurred to the residents legs and excessive drainage (puddles) on 07/06/19, but nothing was done until 07/09/19. She agreed that the medical record was silent on 07/07/19 and 07/08/19 on all shifts related to the condition of the dressings on her legs as to whether they were dry and intact, or weeping, or odorous. She said she realized that, and since their investigation staff have been more diligent about assessing and documenting the dressings on her legs. She said she could provide no evidence as to the condition of the resident's bilateral lower extremities or the condition of the dressings prior to the day shift on 07/09/19. Upon inquiry, the DON said the basic metabolic panel (BMP) which was done on 07/09/19 was performed due to a standing order after a change in medication or dosage ([MEDICATION NAME]) was done approximately six (6) weeks prior. She said medical records kept a tickler file and automatically ordered a BMP six (6) weeks later which coincidentally came due on 07/09/19. The DON said that on 07/10/19 the hospital notified them by telephone that they were reporting neglect to state officials, and relayed that the resident presented with maggots in her leg wound(s). The DON said she began her own investigation into the matter in part by obtaining witness statements from nurses who provided care for the resident in the days leading up to the hospitalization on [DATE]. It was only then that she discovered that RN #100 had assessed a change in condition on 07/06/19 but failed to follow through. She said that on 07/10/19 she asked RN #100 for a witness statement, but instead RN #100 wrote a late entry nurse progress note for 07/06/19. An interview was conducted with LPN #10 on 07/24/19 at 2:15 PM. She said this resident was ordered dressing changes to the bilateral lower extremities every three (3) days in early July. She changed the leg dressings on 07/03/09. She said the wounds when she saw them on 07/03/19, in comparison with the late entry note for the 07/06/19 dressing change, was a lot different. She said on 07/03/19 there was no odor and there were no puddles of fluid. She said the resident had non-[MEDICAL CONDITION] of the BLE, and the skin surrounding the stasis ulcers was intact. She said there was only a moderate amount of clear drainage when she removed the old dressings. She said the 07/06/19 assessment of the wounds would have amounted to a change in condition for this resident. On 07/24/19 at 4:00 PM an interview was conducted with the resident. She said she has had weeping from stasis ulcers in the past but never as bad as before she went into the hospital on [DATE]. She said she was embarrassed to go to church services or leave her room for any activities because she left puddles of water around her feet wherever she sat. She said this made her feel dirty and she did not want people to see her that way. She related that the (name of physician) at the (name of hospital) got down on their knees and took pictures of her wounds when she entered the hospital. She whispered that the wound on the left leg contained maggots. An interview was conducted with the administrator on 07/24/19 at 4:30 PM. She said she was not even sure there were any maggots as the hospital did not show her any pictures of them. It was discussed that the problem was not just the maggots, but also a nurse knew of changes in a resident's condition three (3) days prior to the hospital transfer and did not tell anyone else about it. It was discussed that the loss of fluids may have contributed to her dehydration and the hospital [DIAGNOSES REDACTED]. Had the nurse acted timely, it may have prevented the resident from worsening to the point discovered three (3) days later. She acknowledged understanding but had no further evidence at this time to provide to the contrary. On 07/25/19 at 10:30 AM the DON provided a notification policy which stated that is the policy of this facility to immediately identify a potential change of condition, assess and, when indicated, notify the physician regarding unusual circumstances involving residents. Conditions that may signal a change in condition may include observed physical changes. The supervising nurse, if not a RN, will inform the nurse manager/RN on call of the findings. If the supervising nurse is an RN, the unusual circumstances will be reported to the administrator and nurse manager and handled accordingly. The physician is to be notified of all circumstances that pertain to the resident's care or that have the potential for harm, creating an unsafe condition. The failure to report a change in condition resulted psychosocial harm for Resident #1. For Resident #1, psychosocial harm manifested in feelings of embarrassment, shame, feeling dirty, and as a result Resident #1 did not want others to see her. Furthermore, Resident #1 did not leave her room for activities and did not attend church services (07/06/19) as a result of the psychosocial harm. Resident #1 was so embarrassed by her condition 15 days after her hospitalization , she whispered to this surveyor about the maggots that were found in her wound. She was socially withdrawn from former social patterns. The psychosocial harm was also verified through the late entry progress note on 07/10/19 for the 07/06/19 nursing assessment. In addition to the psychosocial harm, Resident #1 experience actual physical harm when her change of condition was not reported. Resident #1 was hospitalized and diagnosed with [REDACTED]. The DON verified in an interview on 07/24/19 the change of condition assessed on 07/06/19 in a late nursing note (on 07/10/19) would have likely resulted in the resident being transferred to the hospital on [DATE]. This was three (3) days prior to the hospitalization and acute renal injury.

Based on medical record review and staff interview, the facility failed to follow physician's orders for Resident #1 as related to bowel protocol for the absence of bowel movements/constipation. This was evident for one (1) of six (6) residents reviewed. Resident #1's had no bowel movement in seventy-two (72) hours. This caused actual harm to the resident who later that day developed abdominal pain, nausea, and vomiting at approximately eighty-four (84) hours since the last bowel movement, but who still received no treatment or offer of treatment for [REDACTED]. At approximately ninety-six (96) hours after the last bowel movement, the nurse did offer milk of magnesia to which the resident refused at that time. Approximately two (2) hours later the resident was transferred to the hospital. The resident remained hospitalized for [REDACTED]. The hospital's [DIAGNOSES REDACTED]. The resident was then discharged from the hospital back into the nursing home and referred to hospice services. The resident expired at the nursing home the following day. Resident identifier: #1. Facility census: 87. Findings included: a) Resident #1 The medical record was reviewed on [DATE]. Per the facility's vitals report, the resident's last bowel movement occurred on [DATE] at 10:37 AM. The standing orders for this resident, as signed by the physician, directed that if the resident had no bowel movement (BM) in seventy-two (72) hours, to administer milk of magnesia (MOM) thirty (30) cubic centimeters (cc's). This could have been offered by nursing on the morning of [DATE], but it was not offered. The physician's standing order further directed that for no BM in the next 24 hours following the MOM, to give a [MEDICATION NAME] suppository per rectum. If the resident still had no BM within twelve (12) hours, the order directed to notify the physician. The standing orders also included that a nurse may perform a rectal check PRN (as needed). Review of the medical record found no evidence that a nurse performed a rectal check on [DATE] or on [DATE]. Review of a nurse progress note dated [DATE] at 10:31 PM, revealed that the resident complained of stomach pain during this shift. Later in the shift, the resident vomited once. A nurse progress note dated [DATE] at 11:44 PM relayed that the resident requested and received PRN (as needed) [MEDICATION NAME] for vomiting twice. A nurse progress note dated [DATE] at 1:01 AM relayed that the [MEDICATION NAME] was not effective. The resident then requested a [MEDICATION NAME] rectal suppository to treat the nausea. An hour later the nurse assessed its effectiveness. The next nurse progress note was entered at 11:30 AM on [DATE] which stated she was lethargic, would open her eyes on command but would not respond otherwise. The bowel sounds were hyperactive in all four (4) quadrants. Routine labs were obtained this morning, and the creatinine was elevated. The nurse stated She is to be sent to the ER (emergency room ) for evaluation and treatment of [REDACTED]. A nurse progress note dated [DATE] at 3:47 PM relayed that at 11:30 AM they received an order from the nurse practitioner to send her to the hospital ER for evaluation and treatment related to elevated creatinine level. The resident left the facility at 12:15 PM. A nurse progress note dated [DATE] at 11:21 PM addressed that at 3:10 PM on [DATE] the facility received a phone call from a hospital nurse who stated the resident was admitted with a possible bowel obstruction. A nurse progress note dated [DATE] at 3:33 PM conveyed at at 10:05 AM on [DATE] the resident sat in a cardiac chair at the beside. The nurse stated she offered the resident PRN MOM several times per BM protocol, and the resident refused the MOM at that time. The nurse explained that when she laid back down in bed she would need a [MEDICATION NAME] suppository, and the resident voiced understanding. Review of the Medication Administration Record [REDACTED]. Review of the [DATE] hospital Admission History and Physical found in the history and present illness (HPI) section, that this resident was brought to the hospital due to increased weakness and abdominal distention. She stated she started having abdominal pain last night. The computed tomography (CT) scan revealed large bowel obstruction with focal narrowing of the proximal sigmoid colon, sigmoid volvulus is not excluded, bladder distention. The radiologist recommended a surgical consultation, and a water soluble enema which may be helpful for further evaluation. The Physical Examination section of the hospital's admission H&P assessed that her abdomen was distended, bowel sounds not appreciated, and the patient denies pain with palpation at the time of the exam. She was lethargic. at the time of the exam, but alert and oriented and able to move all extremities. The hospital's Discharge Summary, dated [DATE], noted the reason for admission was large bowel obstruction. The discharge [DIAGNOSES REDACTED]. The principle problem during the hospitalization was Paralytic ileus of large intestine. Review of the hospital's general summary titled Reason for hospitalization and Hospital Course revealed this resident came to the hospital due to increased weakness and abdominal distention. She was noted to have acute [MEDICAL CONDITION] with an elevated creatinine and a normal blood count. The initial CT scan demonstrated colonic ileus versus obstruction and surgical consultation obtained with recommendations to monitor as she was not a surgical candidate. Another CT scan of the abdomen showed no improvement and possible worsening. It further stated that she has only had some liquid stools, increased anorexia, bloating and not responding to medication for constipation. Hospice was discussed as it appeared she was entering the early stages of dying with decreased bowel function preceded by the [MEDICAL CONDITION]. Per a nurse progress note dated [DATE], the resident returned to the facility at 3:58 PM and had persistent diarrhea. At 6:00 PM on [DATE] a hospice nurse arrived at the facility and admitted the resident to the Hospice for paralytic ileus. On [DATE] at 5:30 PM the resident had ceased to breathe and had no heart beat. She was pronounced deceased at 5:30 AM. An interview was conducted with the director of nursing (DON) on [DATE] at 12 PM. She provided a copy of the standing orders for constipation with this resident's name and medical record number, which was signed and dated by the physician. She also provided a copy of the Vital Report for this resident, and a copy of the resident's Medication Administration Record [REDACTED]. She agreed there was no evidence that nursing offered the resident a dose of milk of magnesia 72 hours after the last BM as their standing orders directed. She agreed the bowel protocol was not initiated until [DATE] at 10:05 AM, which was one (1) day delayed, and which occurred only two (2) hours before she was sent out to the hospital with a large bowel obstruction. At 2:00 PM on [DATE] the DON provided a copy of the hospital's admission history and physical, hospital CT scan reports, laboratory reports, and the hospital discharge summary related to the resident's most recent hospitalization . An interview was conducted with the administrator on [DATE] at 3:30 PM. She acknowledge her understanding and has been in consult with the DON about the issues identified with not following the physician's orders in offering bowel protocol to a resident who went three (3) days/72 hours without having a BM, and the resident's hospitalization for a large bowel obstruction. She provided no further evidence prior to exit.

Based on record review, staff interview, review of facility policy, physician interview, and nurse practitioner interview, the facility failed to provide the necessary care and services to maintain and/or attain the highest practicable physical well-being of each resident. This was true for five (5) of seven (7) residents reviewed for falls and one (1) of one (1) resident reviewed for pain. Resident #57 had orders to obtain orthostatic blood pressure every shift for seventy-two (72) hours following a fall. The facility failed to follow the physician's order [REDACTED].>Orthostatic (postural) [MEDICAL CONDITION] is an excessive fall in blood pressure when assuming an upright position. Assessing whether a resident experiences changes in blood pressure and heart rate can help identify or eliminate whether blood pressure is a factor in residents ' falls and, if present, help determine what actions to implement to prevent additional falls. The facility failed to assess Resident #57 for orthostatic [MEDICAL CONDITION] after she sustained major injuries at the time of a fall on 10/06/15. Her injuries included multiple fractures to the left 3rd, 4th, 5th, 6th, 7th ribs, a broken left scapula, and a pneumothorax. On 08/07/16, the resident sustained [REDACTED]. Further investigation of current residents at the facility with falls, revealed staff failed to complete orthostatic blood pressures as ordered by the physician for Residents #92, #99, and #89. Additionally, there was no evidence the facility analyzed resident falls in an attempt to determine causal factors. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC), the existence of an immediate jeopardy to the welfare of residents with falls was determined. The facility Administrator was notified of the immediate jeopardy at 5:00 p.m. on 11/08/16. The facility provided an acceptable plan of correction at 7:30 p.m. on 11/08/16. After determining the facility had implemented its plan of correction, the immediate jeopardy was abated. After verifying implementation of the plan of correction, the immediate jeopardy was abated at 7:45 p.m., on 11/08/16 After removal of the immediate jeopardy, a deficient practice at a scope and severity of E remained of the failure to assess the effectiveness of Resident #19 ' s pain management. Resident identifiers: #57, #92, #99, #85, and #19. Facility census: 92. Findings include: a) Resident #57 Resident #57 sustained major injuries from a fall on 10/06/15. Her injuries included multiple fractures of the left 3rd, 4th, 5th, 6th and 7th ribs, a [MEDICAL CONDITION] scapula, and a pneumothorax. The resident also complained of dizziness at the time of this fall. The resident experienced another major injury, a left [MEDICAL CONDITION], during a fall on 08/07/16. Record review found Resident #57 fell ten (10) times from 11/06/15 to 10/16/16 with orthostatic vital signs ordered every shift times 72 hours for eight (8) of ten (10) falls. There was no evidence staff completed the physician ordered orthostatic vital signs for any of the eight (8) falls. Resident #57's [DIAGNOSES REDACTED]. Resident #57's medications as of 11/01/16 for hypertension (high blood pressure) included: -- [MEDICATION NAME] 400 mg (milligrams) twice a day, -- [MEDICATION NAME] weekly (0.3 mg every 24 hours). Depression medications included: -- [MEDICATION NAME] 20 mg daily Diabetes medications included: -- [MEDICATION NAME] 10 units at bedtime and -- [MEDICATION NAME] R insulin sliding scale coverage four times a day. During an interview on 11/07/16 at 5:00 p.m., the DON explained that the facility has a standing order to complete orthostatic blood pressures every shift times 72 hours after a resident falls. A review of Resident #57's blood pressures on 11/07/16 at 10:59 a.m., revealed a blood pressure of 190/100 mmHg (millimeters of mercury) with an acceptable range of 90-150/60-90 mmHg. Staffing sheets revealed Licensed Practical Nurse (LPN) #39 was the nurse working with Resident #57 and supervising the nurse aides (NA) working with Resident #57 at this time. Review of nursing notes concerning the blood pressure value on 11/07/16 at 10:59 a.m., found no evidence the LPN was aware of or reported this blood pressure value to her supervisor. During an interview on 11/08/16 at 3:30 p.m., LPN #39 stated her practice was to review the hard copy of blood pressures obtained by the NA and if there was an abnormal value, the NA would retake the blood pressure in one hour and report this value to the LPN. LPN #39 agreed she did not follow-up on the blood pressure value and/or report the abnormal value to her supervisor. At 2:45 p.m. on 11/08/16, LPN #90, randomly chose Resident #96 who fell on [DATE], and after checking the medical records for completion of the orthostatic blood pressures, agreed the physician order [REDACTED]. At 2:58 p.m., on 11/09/16 the facility nurse practitioner (NP) stated she was made aware of each resident ' s fall during morning meetings and that she typically did not have further input related to falls unless the nursing staff reported abnormal findings to her. On 11/10/16 at 9:15 a.m., the attending physician stated he was available to nursing by means of a beeper at any time, communicated with the NP routinely throughout each day and depended on the nursing staff to report abnormal results concerning orthostatic blood pressures. Review of the facility's fall intervention policy revised on 11/16/10, found it included in the procedure section, number 2, that the nursing staff was to monitor blood pressure every four (4) hours for twenty-four (24) hours and every shift for forty-eight hours and then as indicated. At 4:30 p.m., on 11/08/16 the DON confirmed the general practice of nursing staff revealed a failure to follow the physician order [REDACTED]. b) Resident #92 Record review on 11/09/16 at 11:27 a.m., found Resident #92, admitted to the facility on [DATE], had pertinent [DIAGNOSES REDACTED]. His Fall Tracking Log listed five (5) falls since his admission. The dates and times of these falls were as follows: -- 09/26/16 at 3:45 a.m. -- 10/08/16 at 12:45 a.m. -- 10/08/16 at 5:45 p.m. -- 10/10/16 at 2:50 p.m. -- 10/10/16 at 5:30 p.m. Review of the physician's orders [REDACTED]. This order further specified the times for obtaining the orthostatic vital signs as Day Shift, Evening Shift, Night Shift. A review completed of the vital signs throughout his entire stay at the facility found Resident #92 had no orthostatic vital signs taken at any time. When asked during an interview on 11/10/16 at 10:27 a.m. if there was any evidence indicating that the resident's vital signs (specifically blood pressure) were taken in more than one (1) position such as lying, sitting, or standing at any time after a fall, Medical Records Staff #73 shook her head No and said We don't have that. c) Resident #99 Review of Resident #99's clinical record found he had [DIAGNOSES REDACTED]. Resident #99's medications for diabetes included Farixiga 5 mg daily, Jardiance 10 mg daily, [MEDICATION NAME] 55 units daily, and [MEDICATION NAME] regular insulin sliding scale coverage four times daily. His medications for hypertension included: [MEDICATION NAME] 20 mg daily. His medications for depression included: [MEDICATION NAME] 15 mg twice daily and [MEDICATION NAME] 20 mg daily. His medications for [MEDICAL CONDITION] included: Neurotin 600 mg four times daily and [MEDICATION NAME] 5 mg-325 mg every 6 hours as needed. 1. Review of the nurse ' s note dated 05/03/16 at 1:59 a.m., found it identified Resident #99 rang for assistance in bathroom. The resident was found on the floor without injury. The resident stated he felt dizzy and lightheaded prior to going to the bathroom. His blood glucose was 48. The resident was provided a snack and orange juice. The 05/03/16 physician orders [REDACTED]. The clinical record contained no orthostatic vital signs. Review of a 10/19/16 at 3:58 a.m. nurse ' s note revealed the resident was found on the floor. The resident stated he was trying to go to the bathroom and his leg gave way. The resident had no injury. The 10/19/16 physician orders [REDACTED]. The clinical record contained no orthostatic vital signs. During an interview on 11/07/16 at 4:30 p.m., Director of Nursing (DON) #97 stated she would expect the staff to document that the resident was dizzy with his fall. I would expect the staff to take orthostatic blood pressures. They should take orthostatic blood pressures for 72 hrs after a fall. The DON #97 confirmed orthostatic blood pressures had not been done for Resident #99 as ordered by the physician for either the 05/03/16 or10/19/16 fall. d) Resident #85 Review of Resident #85's clinical record indicated she had [DIAGNOSES REDACTED]. The resident ' s medications for diabetes included glimepiride 4mg daily, trajenta 5 mg daily, [MEDICATION NAME] 500 mg twice daily, [MEDICATION NAME] R sliding scale insulin coverage 4 times daily and [MEDICATION NAME] 10 units daily. Her medications for hypertension included trimterene-[MEDICATION NAME] 37.5-25 mg, [MEDICATION NAME] 25 mg daily, [MEDICATION NAME] 2.5 mg daily and [MEDICATION NAME] 40mg daily. Her medications for bradykinesia included [MEDICATION NAME] 25-100mg twice daily. Her medications for [MEDICAL CONDITION] disease included [MEDICATION NAME] ER (extended release) 1500 mg every night, Duloxetine 60 mg daily and [MEDICATION NAME] 0.25 mg every evening. The physician had determined the resident had capacity to make healthcare decisions on 01/9/15. Resident #85 09/26/16 quarterly Minimum Data Set assessment mental status was intact with a maximum score of 15. She required extensive assistance with transferring and tilting of 2 persons. Review of the nursing notes dated 06/01/16 at 11:32 p.m. revealed Resident #85 had slid out of bed and assessed to be without injury. The 06/01/16, the physician ordered orthostatic vital signs every shift for 72 hours and to document them in the progress notes. The clinical record contained no orthostatic vital signs. Review of the 10/02/16 at 8:45 a.m. nurse ' s note revealed Resident #85 was found on the floor between the resident's room and the bathroom door. The resident had a 3 centimeter (cm) by 4 cm skin tear on her left forearm. On 10/02/16, the physician ordered orthostatic vital signs every shift for 72 hours and to document in the progress notes. The clinical record contained no orthostatic vital signs. During an interview on 11/07/16 at 3:28 p.m., Resident #85 stated she had come back from a church meeting on 10/02/16 and went to the bathroom. She stated she had gotten up and got dizzy and, The next thing I knew I was on the floor. The resident stated she did not call for assistance to go to the bathroom, but now she does since the fall. During an interview on 11/07/16 at 4:23 p.m., Director of Nursing (DON) #97 stated she would expect the staff to document that the resident was dizzy with her fall. Review of the incident report confirmed the report did not identify the medications the resident was currently taking that could contribute have to the resident's fall. DON #97 stated if a resident complained of dizziness when they fell , I would expect the staff to take orthostatic blood pressures. They should take orthostatic blood pressures for 72hrs after a fall. DON #97 confirmed orthostatic blood pressures were not done for Resident #85 as ordered by the physician for either the 06/01/16 or10/02/16 fall. e) The facility failed to assess Resident #57 for orthostatic [MEDICAL CONDITION] after she sustained major injuries at the time of a fall on 10/06/15. Her injuries included multiple fractures to the left 3rd, 4th, 5th, 6th, 7th ribs, a broken left scapula, and a pneumothorax. On 08/07/16, the resident sustained [REDACTED]. Further investigation of current residents at the facility with falls, revealed staff failed to complete orthostatic blood pressures as ordered by the physician for Residents #92, #99, and #89. Additionally, there was no evidence the facility analyzed resident falls in an attempt to determine causal factors, which could include orthostatic [MEDICAL CONDITION], medications the resident received, time of day, etc. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC), the existence of an immediate jeopardy to the welfare of residents with falls was determined. The facility Administrator was notified of the immediate jeopardy at 5:00 p.m. on 11/08/16. The facility provided an acceptable plan of correction at 7:30 p.m. on 11/08/16. After determining the facility had implemented its plan of correction, the immediate jeopardy was abated. The plan of correction (POC) included: - The task of orthostatic blood pressures will be taken and recorded in the clinical records, - licensed nurses will be educated with return demonstration regarding the taking and recording of orthostatic blood pressures, - residents found to have orthostatic [MEDICAL CONDITION] will be reported immediately to the attending physician, - staff development coordinator will assure all licensed nurses receive training on completion of orientation, - the restorative nurse coordinator will monitor the completion of orthostatic blood pressures as part of the post fall review of each incident report. - individuals who fail to comply will be subject to re-education and progressive discipline up to and including termination. The facility also completed orthostatic blood pressures on thirty (30) residents who had experienced a fall in the previous three months prior to the immediate jeopardy. After verifying implementation of the plan of correction, the immediate jeopardy was abated at 7:45 p.m., on 11/08/16 After removal of the immediate jeopardy, a deficient practice at a scope and severity of E remained of the failure to assess the effectiveness of Resident #19 ' s pain management. f) Resident #19 Clinical record review indicated Resident #19's [DIAGNOSES REDACTED]. The 06/26/16, physician orders [REDACTED]. The 06/26/16 physician orders [REDACTED]. The physician determined on 06/26/16 the resident had capacity to make healthcare decisions. The 07/02/16 admission Minimum Data Set (MDS) assessment indicated Resident #19's cognitive status was intact with a maximum score of 15. The resident received scheduled and prn (as needed) pain medication and no non-medication intervention for pain. The resident had pain frequently and rated it a 9 on scale of 1 to 10 (10 being the worst pain experienced). The 07/06/16 Pain Care Area assessment included, pain triggered related to resident identified with frequent pain, rated a 9 on pain scale. Episodes of pain related to [MEDICAL CONDITIONS] joint disease, history of bursitis bilateral shoulders, history of bilateral hip replacements, wound infection right breast. Risk factors: increased episodes or unrelieved pain. Referrals nursing to assess for pain every four hours and prn and medicate per physician order. Reason to proceed to care plan: will voice relief of pain within one hour of receiving prn pain medication. The 09/26/16 Quarterly MDS assessment indicated Resident #19's cognitive status was intact with a maximum score of 15, the resident received scheduled and prn pain medication and no non-medication intervention for pain and the resident had pain constantly and rated it a 5 on scale of 1 to 10 (10 being the worst pain experienced). The 10/05/16 Care plan for pain included a goal of, Will voice relief of pain within one hour of receiving prn pain medication thru (through) next review. The interventions included: -- [MEDICATION NAME] 5-325mg three times daily per order -- observe for side effects of [MEDICATION NAME] -- observe for side effects of Tylenol -- offer non-medication interventions for pain (massage, back rubs, soothing music, dimmed lighting etc) -- keep room temp comfortable -- observe for signs/symptoms of pain or lying still. Notify the nurse. -- observe for pain prior to care. If resident is in pain, notify the nurse and return at a later time. During an interview on 11/01/16 at 9:19 am, Resident #19 stated her pain was a level 5 before pain medication administration and remained a level 5 after pain medication administration on a scale of 1 to 10 (10 being the worst pain). During an interview on 11/03/16 at 4:34 p.m., Resident #19 stated she has had lower back pain for the last two to three years. She stated she takes [MEDICATION NAME] three times daily and as needed Tylenol for her pain. Resident #19 stated the pain is right above her hips and lower back, her current pain level was a 5, and she asks for Tylenol when it gets to a 8 or 9. Resident #19 stated after the Tylenol the pain goes back to a 5, which is an acceptable level for her. Resident #19 stated nurses do not ask her to rate her pain and she had not been offered any non-medication approaches to treat her pain. Resident #19 stated she would like to have a back rub but did not know if heat would help her pain. She stated when she moved around her pain would get worse. During an interview, on 11/03/16 at 4:48 pm, Licensed Practical Nurse (LPN) #118 stated for residents with pain, she would ask if they were having pain, if they looked like they were having pain. If they did not look like they were in pain, she would put a zero on the MAR for the every 4 hour pain assessment. If a resident stated they were in pain, I would put the location, have the resident rate the pain and give the prn medication. I would chart E (effective) if the pain was completely relieved. I would chart SE (somewhat effective) if the pain was decreased but would not have the resident rate their pain after the medication. During an interview on 11/07/16 at 12:40 p.m., LPN #24 stated Resident #19 gets regular pain medication. If I ask her if she is hurting she would just tell me no. I usually just chart zero pain unless she tells me she is having pain, then, I would tell her to rate the pain on a scale of 1 to 10. I would give her prn Tylenol and then chart E (effective) if it was totally relieved. I would document her pain if it was decreased at SE (somewhat effective). LPN #24 stated she did not routinely ask the resident to rate their pain after giving prn medication. Review of Medication Administration Record [REDACTED] -- she received [MEDICATION NAME] 5-325mg three times daily from 09/01/16 through 11/03/16 at 6:00 a.m., 2:00 p.m., and 10:00 p.m. -- she received prn Tylenol for back pain (the pain was not rated on a scale from 1 to 10) on 09/26/16 at 12:05 p.m., 09/30/16 at 11:30 a.m., and 10/31/16 at 2:55 p.m. -- Her pain management scores performed every four hours from 10/17/16 through 11/03/16 were listed as zero for 103 of 106 opportunities. During an interview on 11/07/2016 at 12:48 p.m., Resident #19 stated her lower back and hip pain remained at a level 5. She stated no nurse had asked her to rate her pain on any pain scale. During an interview on 11/07/16 at 1:09 p.m., LPN #9 and LPN #76 stated they had performed the MDS assessments and care plan for Resident #19. Both LPNs stated Resident #19 was never pain free and her care plan goal and interventions had not been individualized to meet her acceptable pain level of 5 on a scale of 1 to 10. During an interview on 11/07/16 at 1:09 p.m., Director of Nursing (DON) #97 stated the facility policy was to rate a resident's level of pain utilizing a pain score every fours hours, before and after prn pain medication administration. DON #97 stated SE (somewhat effective) could mean anything and the expectation would be to document an appropriate pain score. DON #97 stated she was aware Resident #19 always was in some level of pain and she had a concern regarding the accuracy of the pain management scores in the clinical record for Resident #19. Additionally, DON #97 stated she expected the care plan to be individualized to meet the resident's needs, have a reasonable care plan goal and include the resident's acceptable pain score of 5. Review of facility ' s policy entitled Pain Management found it included, It is the policy of this facility to assess each resident for pain using standard tools. 2. The level of pain is to be assessed every four hours using the most appropriate scale for the resident. This should be recorded in the MAR indicated [REDACTED]. The licensed nurse should consider the effectiveness of any pain medication being ordered.

Based on observation, record review, and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible and failed to provide supervision to Resident #69 with toileting. The facility failed to prevent accident hazards by storing care and cleaning equipment in a hallway resident bathroom and failed render a pipe end protruding from the floor safe. This is true for one (1) of two (2) resident hallway bathrooms. Resident #69 fell in the bathroom while attempting to toilet herself. These findings resulted in a determination of immediate jeopardy due to the potential for harm to residents. The Administrator and Director of Nursing were notified of the immediate jeopardy 5:00 p.m. on 11/02/16. An acceptable plan of correction (POC) was received at 7:05 p.m. After verifying implementation of the POC, the immediate jeopardy was abated at 7:45 p.m. No deficient practice remained for this requirement after removal of the immediate jeopardy. This had the potential to affect more than a limited number of residents. Resident Identifier: #69. Facility census: 92. Findings include: a) Resident Restroom At 2:40 p.m. on 11/02/16, observation of the resident restroom located between the 300 and 400 halls found the room had two (2) patient lifts, one commercial mop bucket with the mop and half-full of soiled water, one empty linen bag attached to a frame, and the stored items blocked access to the sink. A metal pipe protruded from the floor beside the commode approximately four (4) inches with exposed sharp edges. On 11/02/16 at 3:09 p.m., the director of nursing (DON) said any mobile resident would have access to the bathroom; Residents #69 and #23 regularly used that bathroom. Resident #69 fell in the bathroom on 10/15/16 at 9:15 a.m. and sustained a major injury of a left hip fracture. The DON stated consideration of locking the bathroom had recently been discussed, but a decision had not yet been made. b) Resident #69 A review of Resident #69 ' s medical record on 11/02/16 revealed the Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 07/20/16, the resident assessed as requiring the extensive assistance of one (1) staff for transfers, toileting, locomotion off the unit, and supervision of one (1) staff for locomotion on the unit. A review of the Fall Risk (Acuity) evaluations completed by Restorative Nursing for Resident #69 on 01/08/16, 04/08/16, 07/07/16, 07/22/16, and 08/22/16 found the scores higher than ten (10), which indicated this resident was at a high risk for falls. The care plan for Resident #69, revised on 08/23/16, indicated this resident needed the extensive assistance of one (1) staff for transfers, toileting, and locomotion off the unit, and supervision of one (1) staff for locomotion on the unit. A review of the Incident and Accident Reports indicated Resident #69 had a fall in the Resident Restroom located in the hallway between the 300 and 400 hallways on 10/15/16 at 9:15 a.m. Staff were alerted to go to this restroom when they heard a loud banging noise on the restroom door. Upon entering the Resident Restroom, staff found Resident #69 on the floor on her right side. She was complaining of severe hip pain, had a large abrasion on her left lower back, and was unable to roll to her back. The report stated the resident was incontinent of bowel and appeared to have slipped in the feces on the floor in front of the toilet and her chair alarm was not sounding and was in the off position. A review of the x-ray completed on 10/15/16 found Resident #69 had an acute left hip fracture, which had required surgical repair. A review of the Fall Intervention Policy and Procedure revised on November 16, 2010 found it included, 5. Assess the location where the fall occurred to identify any causative factors in the environment that may have affected the accident - wet floor, debris on the floor, rolling bed, etc. and 6. Implement an immediate keep-safe intervention post-fall based on the preliminary root cause. During an interview on 11/03/16 at 10:10 a.m., Licensed Practical Nurse (LPN) #134 reported she thought Resident #69 was independent with toileting. She did not know whether this resident required assistance for transferring, toileting and supervision for locomotion on the unit, and if she did need help, how much help. She also reported this resident was unsupervised and entered the Resident Restroom and received no assistance with transferring or toileting. c) These findings resulted in a determination of immediate jeopardy due to the potential for serious harm to residents. The facility was notified of the immediate jeopardy 5:00 p.m. on 11/02/16. An acceptable plan of correction (POC) was received at 7:05 p.m. After verifying implementation of the POC, the immediate jeopardy was abated at 7:45 p.m. No deficient practice remained for this requirement after removal of the immediate jeopardy. d) Plan of corrections -- Both restrooms in question have been removed from patient service, will remain locked and used as employee or visitor restroom. -- This citation has potential to affect all residents dependent on staff for toileting located in the back section of facility. These residents will be monitored and assisted to their personal restrooms to ensure safety by all staff. Resident care equipment has been removed to the storage building. - All cleaning equipment has been removed and is maintained in the soiled utility room. Housekeeping staff will be educated to the proper placement of all cleaning supply storage. 11/5/2016. -- Nursing staff will be reeducated to review the resident profile and/or plan of care at the beginning of each shift. The resident profile, Point of Care software, is located on the kiosk. -- The Staff Development Coordinator and Director of Nursing are currently instructing staff located in the facility regarding how to review the resident profile. -- The staff for the oncoming shifts will be provided this in service information via phone and/or upon entrance to facility for next scheduled shift. -- All staff has been trained in the falling star fall prevention program. This training on the policy and procedure will be reviewed today, 11/2/2016 and throughout the coming week, 11/5/2016 to accommodate all shifts and staff. The CNA/Nursing staff will provide visual contact with the residents to assure assistance with toileting. The Licensed Nursing staff will perform rounds and monitor the residents that are in the Falling Star Program including the functional status of bed and chair alarms every two hours. This will be documented in Matrix electronic health record. -- The Restorative Nurse Coordinator will assess each resident upon admission, at least quarterly and with change of condition to determine the fall safety risk. Residents that fall into the high risk category will be determined as candidates for the falling star program. The Restorative Nurse Coordinator will report this to QA quarterly.