Every finding on record at Jamestown Health and Rehabilitation

Based on interviews, clinical record reviews, and facility documentation, it was found that the facility staff failed to ensure residents were provided with necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one resident in a survey sample of 25 residents. The findings included: For Resident #190, the facility failed to provide timely incontinent care for a resident with dementia and incontinence. On April 22, 2024, at approximately 2:00 PM, an interview was conducted with Resident #190's representative, who stated that on July 1, 2023, Resident #190 was found sitting in her wheelchair and was obviously wet and smelled of feces. The representative stated it was evident she had not been changed for a long time. When she complained to staff, she was told, Lunch trays have to be picked up first before we can make rounds to change people. Although interviews with current residents revealed that things are getting better, a review of the grievance log and the Resident Council minutes reflected that during that time frame (June-July 2023), there were many complaints of a lack of incontinent care. A review of the grievance logs revealed the following: 1. On June 12, 2023, Resident #32 complained to the social worker that when he asked to use the restroom, he was told by a CNA to just use his brief. The grievance was acknowledged and staff was educated. 2. On June 13, 2023, a resident complained that he did not have his call bell within reach and was calling for help for 5 hours overnight. The grievance was acknowledged and staff was educated to ensure call bells were in reach and making rounds. 3. On June 16, 2023 - A resident complained that Staff is taking up to 2 hours to answer call lights. Staff was educated on customer service and timely answering of call lights. 4. On June 28, 2023, a resident complained that they did not receive ADL care in a timely manner. The resident stated that he used the call bell multiple times, and a family member called the facility 3 times on that day. The complaint was acknowledged and staff was educated on timely answering of call lights 5. On July 12, 2023, Resident #27 complained that she only gets changed 1 time per shift if she doesn't have her 2 regular CNAs. On April 25, 2024, an interview with the Administrator revealed that the facility identified the issue and held a Town Hall Meeting on July 19, 2023, where Customer Service was among the topics discussed. The facility provided a QAPI document identifying the problem; however, they did not have a documented plan for performance improvement identifying all at-risk residents, monitoring/auditing, and an expected completion date. While the grievances identified responsible staff members and the facility addressed them, there was no evidence of a comprehensive plan to prevent recurrence. Despite acknowledging the issue and taking some corrective actions, the facility failed to implement a structured plan for improvement and monitoring, as well as a completion date, thus rendering them ineligible for past non-compliance status for this tag. On April 25, 2024, the Administrator was made aware of the concerns, and no further information was provided.

Based on interviews, clinical record review, and facility documentation, it was determined that the facility staff failed to ensure that pain management services were provided to residents who required such services, specifically for Resident #190, within a survey sample of 25 residents. The findings included: For Resident #190, the facility staff failed to implement physician orders regarding pain medication / pain management. Resident #190 was admitted on [DATE], with various diagnoses including CKD (Chronic Kidney Disease), DJD (degenerative joint disease) status post right total knee replacement, dementia, depression, anxiety, COPD (Chronic Obstructive Pulmonary Disease), restless leg syndrome, hearing loss, history of breast cancer, history of uterine cancer, and history of scoliosis with spinal fusion. On April 23, 2024, a review of the clinical record revealed that the resident was admitted to the facility on [DATE], with orders that included, among others: - Tramadol HCl Oral Tablet 50 MG: Give 0.5 tablet by mouth every 12 hours as needed for pain - Start Date: June 29, 2023 - Discontinued: June 30, 2023 - Acetaminophen Tablet 500 MG: Give 2 tablets by mouth every 8 hours related to LOW BACK PAIN - Start Date: June 28, 2023 The Tramadol 50 mg was not initiated until June 29, 2023, leaving the resident without the prescribed narcotic pain medication throughout the evening and night. An interview with LPN C on the afternoon of 4/23/24, revealed that if the medication was not available, the facility would set the start date for the next day when pharmacy could bring it. When asked if this meant the resident was without pain medication until the medication arrived the following day, LPN C stated that Residents usually have an order for Tylenol that they can use. LPN C was asked if she felt that Tylenol may was adequate pain control for all types of pain and she stated that it was not. A note from the Medical Director on June 30, 2024, indicated that Resident #190 had Pain associated with the injury that was improved with Tramadol but did not seem to last the prescribed 12-hour interval. New orders for Tramadol were then issued to be administered every 8 hours with an additional dose every 4 hours as needed for pain. A review of the clinical record revealed that on June 30, 2023, Resident #190 had a BIMS (Brief Interview of Mental Status) score of 7/15, indicating Severe cognitive impairment, which may have hindered their ability to verbalize a request for pain medication as needed, requiring nurses to gather non-verbal cues of pain. On April 25, 2024, during the end-of-day meeting, the Administrator was made aware of the findings, and no further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed ensure Residents were free from significant medication errors for 2 Residents in a survey sample of 25 Residents. The findings included: For Resident #240 the facility staff failed to administer medications as ordered by physician causing the Resident to miss 4 consecutive doses of antibiotics. On 4/23/24 a review of the clinical record revealed that Resident #240 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, Acute Hematogenous Osteomyelitis Left ankle and foot with recent surgery for 5th metatarsal head resection, type 2 diabetes mellitus with CKD (Chronic Kidney Disease) Stage 3A, asthma, glaucoma, systolic and diastolic CHF (Congestive Heart Failure), hypertension, chronic atrial fibrillation, anemia in CKD, obstructive and reflux uropathy, gout, and history of CVA (Cerebrovascular Accident) with deficits. A review of the orders revealed that Resident #240 had admission orders from the hospital and approved by the facility Nurse Practitioner that included but were not limited to: 4/19/24 6:00 PM - Piperacillin Sodium Tazobactam So -Intravenous Solution Reconstituted 4.5 (4-0.5) GM Use 4.5 gram intravenously every 6 hours related to cellulitis. start date 4-19-24 6:00 PM end date 4/23/24 2:33 PM [scheduled for 12:00 AM - 6:00 AM- 12 Noon -6:00 PM] On 4/24/24 a review of the MAR (Medication Administration Record) revealed that 4/19/24 6:00 PM dose had been signed off as given, the 12:00 AM dose had been signed out as given, the 6:00 AM dose was left blank no signature, the 12 Noon dose was coded as #9 (#9 = See Progress Note) and the 6 PM dose was also coded as #9. A review of the Progress notes revealed no documentation on 4/19/24/ at 6:00 PM that the antibiotics were unavailable or not given. On 4/20/24 there was no documentation that the 12 AM dose was not given or not available. On 4/20/24 there was no documentation that the 6:00 AM dose was not given or not available and it was not signed out as given the space was left blank on the MAR. On 4/20/24 the 12 Noon dose was coded as #9 (see progress note) and the progress notes read: 4/20/2024 12:39 PM -Medication Administration Note- Note Text: Drug not here yet pharmacy called, and order faxed over. to pharmacy. Waiting for pharmacy to deliver. 4/20/2024 4:14 PM-Nursing Progress Note - Note Text: It was reported to undersigned that the patient is pending antibiotic treatment, and the drug is not in house. Undersigned called and left a message on the answering machine for the medication to be. sent stat. On 4/20/24 the 6:00 PM dose was coded as #9 (see progress note) and the progress notes read: 4/20/2024 5:05 PM -Nursing Progress Note Text: Nurse manager in house and made aware of request for medication IV antibiotic to be sent stat. 4/20/2024 7:02 PM - Administration Note - Note Text: Undersigned spoke with [NAME] Pharmacy tech who reported that the patient antibiotic would come on the night run. She was told to send the medication stat as he has missed doses. She continued to explain that it would be at least a 2-4-hour window for stat drugs.' 4/21/2024 1:02 AM -Note Text: contacted pharmacy and medication is pending arrival. 4/21/2024 12:59 AM -Note Text: Medication administered at 2100 and left message about retiming drug for [physician practice name redacted] on call x2 no response. (This is a contradiction to the previous note that said the medication was pending arrival) On the afternoon of 4/24/24, an interview was conducted with the DON and the Administrator regarding conflicting documentation that the medication was not available, and Resident #240 missed for doses however a review of the MAR revealed that 2 of the 4 missing doses were signed off as given. The facility Administrator and DON stated that they would investigate the issue and get back to the survey team with the results. On the afternoon of 4/25/24 the Administrator presented the survey team with an Ad Hoc QAPI document dated 4/25/24 at 12:27 PM. Excerpts are as follows: Opportunity for Improvement: Failure to follow med administration policy regarding meds that are unavailable. Data: Resident noted with order upon admission for IV antibiotics that was documented in error as given X 2 doses. Resident missed 4 doses of antibiotic. Analysis: Lack of education. Plan: All nurses will be educated regarding medication administration policy and procedure for medications that are unavailable. Audit will be conducted in AM meeting 5X per week for compliance and reported weekly at SOC and monthly to QAPI committee for further recommendations. Responsible Team Members: DON or Designee. On 4/24/24 at approximately 2PM an interview was conducted with LPN who was asked if Resident #240 was supplying his own eye drops. LPN stated that the pharmacy had not sent them, and the eye drops were for glaucoma, and it was very important for the Resident to maintain his scheduled dose so the family brought in his bottle from home and as soon as the pharmacy delivers his drops, they would return the Residents home supply to him. On 4/24/24 an interview was conducted with the DON who stated that it is not usually the policy for Residents to supply their home medications to the facility. She stated that she was unaware of this and would check into it and get the team an update. On 4/25/24 a statement was submitted to the survey team that read: Latanoprost eye drops for Resident #240 - The medication is on the way. Facility paid for it while we wait for a prior authorization from the insurance company. Resident provided his own medication while we waited to receive the medication from the pharmacy. The remaining personal med will be returned to the resident today. A review of the Medication administration policy revealed the following excerpts: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 7. Medications are administered within (1) one hour of prescribed time, unless otherwise specified (for example before and after meals.) On 4/25/24 during the end of day meeting, the Administrator was made aware of the concerns and no further information was provided.

Based on observations, interviews, clinical record reviews, and facility documentation, it was found that the facility staff failed to provide drinks, other than water, consistent with the needs and preferences of one resident in a survey sample of 25 residents. The findings included: For Resident #240, the facility staff failed to provide decaf coffee and tea as the resident has health concerns related to caffeine consumption. On April 23, 2024, at 1:25 PM, Resident #240 was observed in his room, sitting up in his wheelchair with his overbed table in front of him, and his lunch tray was on the overbed table. Resident #240, a new admission, was asked about the admission process. He mentioned encountering a couple of issues, stating, When I was admitted , I was supposed to have a diabetic or heart-healthy diet. I was given a regular diet until Monday (4/22/24), and I am not supposed to have caffeine due to my health conditions. I would like to have coffee and tea, but I need decaf. When questioned if someone from the dietary department met with him during admission to discuss preferences, allergies, and intolerances, he responded, No. If they did, I would have told them no caffeine, and I'm supposed to have a diabetic or heart-healthy diet. Resident #240 pointed to his glass of iced tea, stating that he could not drink it because it's caffeinated. He mentioned having nothing but water to drink unless family comes to visit. On April 24, 2024, at approximately 5:00 PM, an observation was made of Resident #240's dinner tray, which again contained iced tea and water. A review of the baseline care plan revealed that on page 1, under Orders and Services, the section entitled Dietary Orders/Instructions was not filled out. The box was unchecked for the type of diet, TPN (Total Parenteral Nutrition), TF (Tube Feeding), IV/Fluids, or other. The section entitled Dietary Preferences was left blank, and the section for Dietary Goals was also left blank. On 4/24/24 an interview with Employee E was conducted and she stated that the Residents usually meet with the dietician who will go over diets with them. She also stated We have decaf tea and coffee if he requests it we can certainly get it for him. She stated that on admission the nurses usually will put in the physician order for the proper diet and then any allergies or intolerances. A review of the clinical record revealed that on admission (4/19/24), Resident #240 had the following diet order: 4/19/2024 - Regular diet, Regular texture, Regular/Thin Liquids consistency. On 4/22/24, Resident #240 was seen by the attending physician, and the order was changed as follows: 4/22/24 - Consistent Carbohydrates (CCD) diet, Dysphagia Advanced texture, Regular/Thin Liquids consistency. On April 25, 2024, during the end-of-day meeting, the Administrator was made aware of the concerns, but no further information was provided.

Based on interview, clinical record review, and facility documentation, it was determined that the facility staff failed to provide a therapeutic diet as ordered by the physician for 1 Resident (#240) in a survey sample of 25 residents. The findings included: For Resident #240, the facility did not implement the heart-healthy or diabetic diet as ordered by the physician upon admission. On April 23, 2024, at 1:25 PM, Resident #240 was observed in his room sitting up in his wheelchair with his overbed table in front of him, and his lunch tray was on the overbed table. Resident #240, a new admission, mentioned encountering issues with the admission process. He stated, When I was admitted , I was supposed to have a diabetic or heart-healthy diet. I was given a regular diet until Monday (4/22/24), and I am not supposed to have caffeine due to my health conditions. I would like to have coffee and tea, but I need decaf. When asked if someone from the dietary department met with him during admission to discuss preferences, allergies, and intolerances, he responded, No. If they did, I would have told them no caffeine, and I'm supposed to have a diabetic or heart-healthy diet. A review of the clinical record revealed that on the baseline care plan where it read dietary orders/instructions, no boxes were checked for regular or other. Nothing was entered in the box for dietary preferences, and dietary goals were also left blank. A review of the discharge record from the hospital revealed that Resident #240 was on a heart-healthy diet in the hospital. On the afternoon of April 24, 2024, an interview was conducted with Employee E, who stated that the CCD (Consistent Carbohydrate Diet) is usually given to diabetics to maintain stable blood sugar levels. When asked if this differs from the regular diet, she stated that it is different. The dysphagia advanced diet does not allow very hard, crunchy, or sticky foods that may be difficult to chew and swallow. A review of the clinical record revealed that on admission (4/19/24), Resident #240 had the following order for diet: 4/19/2024 - Actions: Regular diet, Regular texture, Regular/Thin Liquids consistency. On 4/22/24, Resident #240 was seen by the attending physician, and the order was changed as follows: 4/22/24 - Consistent Carbohydrates (CCD) diet, Dysphagia Advanced texture, Regular/Thin Liquids consistency. On April 25, 2024, during the end-of-day meeting, the Administrator was made aware of the concerns, but no further information was provided.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to provide routine and emergency drugs and biologicals to 1 Residents, (# 240) in a survey sample of 25 Residents. The findings included: For Resident #240 the facility staff failed to provide the IV Antibiotic ordered on admission, causing the Resident to miss 4 consecutive doses of antibiotic therapy, the facility also failed to provide the Latanoprost eye drops for glaucoma instead having family bring in personal supply to use. On 4/23/24 at 1:25 PM Resident #240 was observed sitting up in wheelchair with his lunch tray in front of him. His IV pole sat near bed with empty iv bag/antibiotic hanging from it. Since Resident #240 was a new admission, he was questioned about his admission process. Resident #240 stated that when he arrived at the facility They didn't have my medicines. When asked to elaborate on that he stated Well I came here, and I missed a few doses of my IV antibiotic because they didn't have it in stock. I just started getting it Saturday, I think. Also, they didn't have the eye drops for my glaucoma and my wife brought mine here from home. They put it in the cart and said when the meds come in from pharmacy, we will give yours back to you. I still haven't gotten them back. On 4/23/24 a review of the clinical record revealed that Resident #240 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, Acute Hematogenous Osteomyelitis Left ankle and foot with recent surgery for 5th metatarsal head resection, type 2 diabetes mellitus with CKD (Chronic Kidney Disease) Stage 3A, asthma, glaucoma, systolic and diastolic CHF (Congestive Heart Failure), hypertension, chronic atrial fibrillation, anemia in CKD, obstructive and reflux uropathy, gout, and history of CVA (Cerebrovascular Accident) with deficits. A review of the orders revealed that Resident #240 had admission orders from the hospital and approved by the facility Nurse Practitioner that included but were not limited to: Latanoprost Ophthalmic Solution 0.005 % Instill 1 drop in both eyes at bedtime for increased pressure in eyes Start Date 4/19/2024 [scheduled for 9:00 PM] 4/19/24 6:00 PM - Piperacillin Sodium Tazobactam So -Intravenous Solution Reconstituted 4.5 (4-0.5) GM Use 4.5 gram intravenously every 6 hours related to cellulitis. start date 4-19-24 6:00 PM end date 4/23/24 2:33 PM [scheduled for 12:00 AM - 6:00 AM- 12 Noon -6:00 PM] On 4/24/24 a review of the MAR (Medication Administration Record) revealed that 4/19/24 6:00 PM dose had been signed off as given, the 12:00 AM dose had been signed out as given, the 6:00 AM dose was left blank no signature, the 12 Noon dose was coded as #9 and the 6 PM dose was coded as #9. A review of the Progress notes reveals no documentation other than notes related to orders that were entered. There was no documentation for 4/19/24 at 6:00 PM that the antibiotics were unavailable or not given. On 4/20/24 there was no documentation that the 12 AM dose was not given or not available. On 4/20/24 there was no documentation that the 6:00 AM dose was not given or not available and it was not signed out as given the space was left blank on the MAR. On 4/20/24 the 12 Noon dose was coded sat #9 (see progress note) and the progress notes read: 4/20/2024 12:39 PM -Medication Administration Note- Note Text: Drug not here yet pharmacy called, and order faxed over to pharmacy. Waiting for pharmacy to deliver. 4/20/2024 4:14 PM-Nursing Progress Note - Note Text: It was reported to undersigned that the patient is pending antibiotic treatment, and the drug is not in house. Undersigned called and left a message on the answering machine for the medication to be sent stat. On 4/20/24 the 6:00 PM dose was coded as #9 (see progress note) and the progress notes read: 4/20/2024 5:05 PM -Nursing Progress Note Text: Nurse manager in house and made aware of request for medication IV antibiotic to be sent stat. 4/20/2024 7:02 PM - Administration Note - Note Text: Undersigned spoke with [NAME] Pharmacy tech who reported that the patient antibiotic would come on the night run. She was told to send the medication stat as he has missed doses. She continued to explain that it would be at least a 2-4-hour window for stat drugs.' 4/21/2024 1:02 AM -Note Text: contacted pharmacy and medication is pending arrival. 4/21/2024 12:59 AM -Note Text: Medication administered at 2100 and left message about retiming drug for [physician practice name redacted] on call x2 no response. On the afternoon of 4/24/24, an interview was conducted with the DON and the Administrator regarding conflicting documentation that the medication was not available, and Resident #240 missed for doses however a review of the MAR revealed that 2 of the 4 missing doses were signed off as given. The facility Administrator and DON stated that they would investigate the issue and get back to the survey team with the results. On the afternoon of 4/25/24 the Administrator presented the survey team with an Ad Hoc QAPI document dated 4/25/24 at 12:27 PM. Excerpts are as follows: Opportunity for Improvement: Failure to follow med administration policy regarding meds that are unavailable. Data: Resident noted with order upon admission for IV antibiotics that was documented in error as given X 2 doses. Resident missed 4 doses of antibiotic. Analysis: Lack of education. Plan: All nurses will be educated regarding medication administration policy and procedure for medications that are unavailable. Audit will be conducted in AM meeting 5X per week for compliance and reported weekly at SOC and monthly to QAPI committee for further recommendations. Responsible Team Members: DON or Designee. On 4/24/24 at approximately 2PM an interview was conducted with LPN B who was asked if Resident #240 was supplying his own eye drops. LPN B stated that the pharmacy had not sent them, and the eye drops were for glaucoma, and it was very important for the Resident to maintain his scheduled dose so the family brought in his bottle from home and as soon as the pharmacy delivers his drops, they would return the Residents home supply to him. On 4/24/24 an interview was conducted with the DON who stated that it is not usually the policy for Residents to supply their home medications to the facility. She stated that she was unaware of this and would check into it and get the team an update. On 4/25/24 a statement was submitted to the survey team that read: Latanoprost eye drops for Resident #240 - The medication is on the way. Facility paid for it while we wait for a prior authorization from the insurance company. Resident provided his own medication while we waited to receive the medication from the pharmacy. The remaining personal med will be returned to the resident today. A review of the Medication administration policy revealed the following excerpts: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 7. Medications are administered within (1) one hour of prescribed time, unless otherwise specified (for example before and after meals.) On 4/25/24 during the end of day meeting, the Administrator was made aware of the concerns and no further information was provided.

Based on clinical record review, staff interview, facility documentation review, and in the course of a complaint investigation, the physician failed to document in the clinical record the need/basis for the facility initiated discharge for one Resident (Resident #115) in a survey sample of 28 Residents. The findings included: During the course of a complaint investigation the clinical record of Resident #115 was reviewed on 6/21/22 and 6/22/22. This review revealed multiple instances of Resident #115 having behaviors towards staff and other Residents. There was also an indication that Resident #115 discharged from the facility on 6/6/22, to another facility. The progress notes revealed the following entries: A social services note dated 4/5/22, that read, Social Services contacted [Resident #115's name redacted] guardian at [guardianship agency name and person's name redacted], to possibly discuss [Resident #115's name redacted] behavior and need for alternative placement. Social Services will continue to follow up. Another note dated 4/11/22, indicated the guardian had given permission for Resident #115 to be transferred to another location. A progress note dated 4/14/22, was noted and it read, Director of Social Services, Administrator, [guardian name redacted], Case Manager Supervisor conferred regarding [Resident #115's name redacted] and the incident on 4/12/2022. [Administrator name redacted] issued a Virginia Involuntary Transfer/Discharge Notice citing that the resident is being discharged due to the health and safety of the resident, other resident, or staff endangerment . The next entry into the clinical record for Resident #115 with regards to discharge/discharge planning was on 6/3/22, which read, writer and ED [executive director/administrator] spoke with [guardian agency name redacted] supervisor in regards to moving [Resident #115's name redacted] to a sister facility- [facility name redacted] on Tuesday 6/7. It was explained that [facility name redacted] was able to provide continued 1:1 care and that we would provide transportation. Writer stated she would notify [guardian agency name redacted] if the date and/or time of transport was to change. On 6/6/22, an entry indicated Resident #115 was transferred to a different sister facility other than the one named in the note dated 6/3/22. There was no indication in the clinical record as to why the change in facilities or the transfer occurring a day earlier than originally discussed. On 6/22/22 at 9 AM, an interview was conducted with the facility Administrator, in the absence of the social worker. The facility Administrator stated that the facility had issued a discharge notice to Resident #115, because of his behaviors, and he was felt to be a danger to himself and others. He was discharged to a sister facility that was better suited to meet his needs than the one initially planned. On 6/22/22, the facility Administrator submitted the facility issued discharge notice. This notice was reviewed and revealed it was dated 4/13/22. This notice read, This is to notify you, you will be transferred/discharged from our facility on May 20, 2022, to an alternate location. You are being discharged because: The health and safety of the resident, other residents or staff is endangered . Review of the clinician progress notes from the medical provider/doctor and nurse practitioner revealed no mention of the facility initiating discharge or that Resident #115 was a danger to himself or others and alternate placement was being sought. Review of the facility policy titled, Transfer/Discharge Notification & Right to Appeal was conducted. This policy read, The documentation must be made by: The physician when the transfer or discharge is necessary due to: The resident no longer needs the services provided by the center; A physician when transfer or discharge is necessary due to: The safety of individuals in the center is endangered due to clinical or behavioral status of the resident; The health of individuals in the center would otherwise be endangered . On 6/22/22 at 9:00 AM and again at approximately 10:30 am, the facility Administrator was made aware that the physician had not entered into the clinical record the reason for discharge of Resident #115 as required. No further information was provided. Complaint related deficiency.

Based on staff interview, clinical record review, facility documentation review, and in the course of a compliant investigation, the facility staff failed to ensure a discharge summary was written after discharge for one Resident (Resident #115) in a survey sample of 28 Residents. The findings include: Resident #115 was discharged from the facility to another long-term care facility on 6/6/22, due to a facility initiated discharge. On 6/21/22 and 6/22/22, a review of the entire clinical record was conducted and revealed no discharge summary was present for Resident #115's discharge on 6/6/2022. On 6/22/22 at 9 AM, the facility Administrator was made aware of the above findings. The Administrator confirmed that all discharges should have a discharge summary and if it was not in the clinical chart, they didn't have one. A review of the facility policy titled, Discharge Planning was conducted. This policy read, .4. At the time of discharge, a discharge summary and home-going instructions are provided to the resident or the resident ' s caregiver which will include the following: Current diagnosis, Rehabilitation potential, Summary of prior treatment, Physician ' s orders for immediate care, Pertinent social information, Community referrals as needed (e.g., home health, mental health, adult day care, etc.) . No further information was provided. Complaint related deficiency.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to assess, notify the physician, obtain and carry out treatment orders, for a pressure wound for one Resident (Resident #119) in a sample of 4 Residents reviewed for wound care. The findings included: On 6/21/22, a clinical record review revealed Resident #119 was admitted to the facility on [DATE]. The nursing data collection form noted the following under in the area of skin: multiple bruises on body, sacrum and both bottom red small opening to right buttocks [sic], and left stump [end of leg where previous amputation was made] has a unstageable [wound] [where the base of the wound is covered and unable to be observed to determine the depth and wound bed is unable to be observed]. This assessment had a lock date of 6/20/22. The physician orders revealed an order dated 6/20/22, that read, Left stump - Cleanse left stump with normal saline or commercial wound cleanser pat dry, skin prep peri area then apply honey and calcium alginate boarder form [sic] dressing every day shift for unsteagable [sic] and as needed for wound care. There was an additional order on 6/20/22, that read, Cleanse Left and Right buttocks with soap and water and apply Zinc, every shift for wiound [sic] care stage 1. On 6/21/22 at X: PM, an interview was conducted with RN B. RN B stated she had assessed Resident #119's wound on 6/20/22, and noted on the left stump a small wound with slough, so she staged it as unstageable. She added that she had obtained the treatment orders and initiated treatment to the stump and sacral areas on 6/20/22. RN B confirmed that she had made the entries on the admission data collection form on 6/20/22. RN B was asked what the lock date of 6/20/22, on the nursing admission data collection form indicated, and she said this was the date it was completed. RN B confirmed that Resident #119's wounds were not assessed or treated until 6/20/22. During the above interview, RN B went on to confirm that Resident #119 had a lot of comorbidities that included but were not limited to: being diabetic, non-compliant, [CONDITION(S)] and ETOH [ethyl alcohol] abuse, which all put him at a high risk and will result in slower healing of wounds. RN B also confirmed that wound(s) can deteriorate very rapidly in a matter of a few days. RN B reviewed the clinical record for Resident #119 and confirmed that no treatment orders had been implemented at the time of admission on 6/17/22, and assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy titled, Admissions Assessment was reviewed. This policy read, At the time of admission or readmission, the Nurse shall initiate the Admission Data Collection Form or its electronic equivalent. Pertinent information shall be collected by physical review, interview with resident and family and review of the resident's available medical records. The Data Collection Form or its electronic equivalent will be completed within 24 hours. A review of the facility policy titled, Clinical Guideline Skin & Wound, was conducted. This policy read, On admission/re-admission the resident ' s skin will be evaluated for baseline skin condition and documented in the medical record .Licensed Nurse to report changes in skin integrity to the physician/practitioner and resident/responsible party and document in the medical record . On 6/21/22, during an end of day meeting the Administrator, Director of Nursing (DON) and Corporate Nurse Consultant were made aware of the above findings. The DON stated that the admitting nurses should observe skin upon admission, which she indicated as within 24 hours of arriving at the facility. During this same time, treatment orders should be obtained and initiated. No further information was provided prior to survey exit on 6/22/22.

Based on staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to mitigate a fall hazard for 1 Resident (Resident #135) and failed to utilize a mechanical lift during a transfer from the wheelchair to the bed for 1 resident (Resident #32) in a sample of 33 Residents, resulting in harm for both Residents. The findings included: 1) Resident #135 fell while left alone in the shower room on 2-4-22 at 5:45 a.m., resulting in a fractured upper femur (hip area). This is harm. Resident #135 was sent out to the emergency roiagnom on [DATE] after the fall and fracture, and returned on 2-14-22 after a 10 day stay. The fractured hip was deemed inoperable at the hospital, and the Resident was sent back to the facility for convalescence. The Resident was no longer in the facility at the time of survey, and so a closed record review was conducted. The Resident's MDS assessment revealed that the Resident required extensive assistance, or was totally dependent for all activities of daily living with 1 to 2 staff member assistance due to stroke and left sided [CONDITION(S)] (paralysis). The Resident required extensive assistance with bathing, and was always incontinent of bowel and bladder. The Resident was cognitively impaired and suffered from seizures. The Resident's Nursing care plan and CNA (Certified Nursing Assistant) Kardex care plan were reviewed and revealed that staff were aware of the Resident's needs and deficits. The documents revealed A Hoyer/mechanical lift was utilized for all surface transfers. The Resident was a known fall risk, with a history of falls, and required hands on staff assistance for all activities of daily living. A Report of Resident Fall investigation document was requested and received. The document revealed the following description of the incident: 2-4-22 at 5:45 a.m., Resident was found on the shower floor next to her shower chair. Resident states she was reaching for soap on the floor when she fell out of the chair onto her left hip. The Hoyer lift was used to return her to her chair and then returned to bed. Fall to floor unwitnessed. was the Resident attended by an employee - No. Location - In her shower chair in the shower Wearing slippers and gripper socks Was the Resident injured - Yes, Major injury left hip, Pain Physician notified at 6:00 a.m. 2-4-22, sent to emergency room Mother of Resident notified at 7:00 a.m. on 2-4-22. The investigation also showed that Staff moved the Resident from the floor, and lifted her in a mechanical lift, to place her back in the shower chair. The Resident was transferred down the hallway in the shower chair while complaining of pain, and put in bed after the fall and fracture. The Resident was then left in bed for nursing to contact the doctor, family, and call EMS. On 5-12-22 at 10:45 a.m., a meeting was held with the Administrator and DON (Director of Nursing). They were asked if they were aware of the incident and both answered we are now. They were asked what happened as a result of the staff leaving the Resident alone in the shower room. They stated the employee was terminated. The DON was asked if it was a standard practice to leave Residents unattended in the shower room, and she stated No, that should have never happened. The DON stated All of our interventions for falls are on the Resident's care plans. When asked what the course of events are after a Resident falls, the DON replied We assess the Resident, seek medical intervention as needed, supervise, write a plan in the care plan, and educate staff on the change. The facility Fall Protocol and policy were requested and supplied. Review of the facility documents revealed that the Resident would be evaluated for fall risk, and precautions, needs, and supervision care planned appropriately. On 5-12-22 at the end of day meeting at 4:45 p.m., Resident #135's fall and lack of supervision was reviewed again with the Administrator and Director of Nursing (DON). No further information was provided. 2) For Resident #32, the facility staff failed to utilize a mechanical lift during a transfer from the wheelchair to the bed on 04/28/2022 resulting in a left distal tibial fracture. This is harm. On 05/10/2022 at 5:00 P.M., the administrator was interviewed. When asked about the investigation and five-day follow up of an incident involving Resident #32, The administrator stated that Resident #32 got a broken distal tibia fracture from an inappropriate transfer by nursing aide trainees. A copy of the investigation was requested. On 05/11/2022, Resident #32's clinical record was reviewed. Diagnoses included but were not limited to nondisplaced fracture of left tibial spine dated 05/03/2022 and [CONDITION(S)] and [CONDITION(S)] following cerebral infarct affecting right dominant side dated 09/22/2017. According to Resident #32's care plan, an intervention initiated on 01/14/2021 associated with ADL [activities of daily living] Self-care performance deficit related to decreased mobility, under the header Transfer documented, The resident requires mechanical lift- full - with two staff assistance for transfers. A change in Condition form dated 04/28/2022 at 1:00 P.M. under the header Situation documented, Resident reports twisting left ankle during transfer from chair to the bed. In Section 9 under the sub-header Pain Evaluation it was documented that [Resident #32] had a new onset of pain in the left ankle at an intensity of 5 out of 10 meaning moderate intensity. Under the sub-header Review and Notify, it was documented that the primary care clinician was notified and recommended an ace wrap. A Change in Condition form dated 04/28/2022 at 10:45 P.M. under the header Situation documented ? [complaint of] left ankle and foot pain, slight swelling noted. In Section 9 under the sub-header Pain Evaluation it was documented that [Resident #32] had a new onset of throbbing pain at an intensity of 8 out of 10 meaning severe intensity. Under the sub-header Review and Notify, it was documented that the primary care clinician was notified and recommended an x-ray. A progress note dated 04/29/2022 at 8:20 A.M. documented, Resident reports twisting left ankle during transfer from the wheelchair to the bed. On call physician and family notified. Physician recommends ace wrap to ankle. X-ray scheduled. A progress note dated 05/01/2022 at 7:24 A.M. documented, Resident C/O [complains of] pain in her lower left extremity when staff was giving care, she moaned and groaned whenever the extremity was touched or moved. She is unable to wiggle the toes or move the left foot. Pain medication given, N/P [nurse practitioner] contacted regarding the pain. An x-ray report dated 05/01/2022 under the header Conclusion documented, Nondisplaced distal tibial fracture. An excerpt of a progress note dated 05/01/2022 at 1:18 P.M. documented, EXRAY [sic] results in, resident has a fractured ankle. Order obtained from the N/P to send resident to the ER [emergency room ] for further evaluation . On 05/11/2022, the administrator provided a copy of the investigation involving Resident #32. A written statement dated 05/02/2022 by Temporary Nursing Aide G (TNA G) documented, On Thursday [Resident 32] was in her wheelchair when coming from the beauty shop. I was not aware of how she had gotten into the wheelchair. Me and another aide put her back in the bed. I took one side of her and the aid took the other side to put her back in bed. Resident 32 didn't have a Hoyer pad under her. There was no way of getting a Hoyer pad under her. A written statement written by Temporary Nurse Aide H (TNA H) documented, I and another CNA [sic] was going to put [Resident 32] in her bed after coming back from a hair appointment, and there was not a Hoyer [mechanical lift] pad under her. Me and another CNA [sic] thought it would be best to lift the patient [name] under her arms, also putting the bed down as far as it could and stand and pivot her onto the bed, when we first tried it the patient did say 0W so we put her back onto her chair and waited a few minutes, and tried lifting her again putting her onto the bed. A written statement by Registered Nurse B (RN B) dated 05/02/2022 documented, On 04/28/2022 [Resident #32] returned from [CONDITION(S)] and the transport company transferred her to the wheelchair from the stretcher. By the time I could inform them she is a hoyer lift, they had left the building. A written statement dated 05/02/2022 by Licensed Practical Nurse C (LPN C), unit manager, documented, When interviewing [Resident 32], Resident stated during transfer that two staff members assisted her back to bed by going under her arms. Resident stated she then twisted her leg when the staff transferred her back to bed. On 05/11/2022 at approximately 2:25 P.M., Resident #32 was interviewed. When asked about how her left ankle was broken, Resident #32 stated that it happened when 2 staff members tried to lift her to stand and her leg got twisted. When asked if she fell to the floor, Resident #32 indicated the 2 staff members put her in the bed and she did not fall to the floor. On 05/11/2022 at 5:00 P.M., the administrator and Director of Nursing (DON) were interviewed. When asked about the incident involving Resident #32, the DON stated they began the investigation on 05/01/2022 once the xray results were known. The administrator stated once they learned about the inappropriate transfer by the two nurse aide trainees, the nurse aide trainees were terminated.

Based on observation, Resident interview, and staff interview, the facility failed to post survey results in a place readily accessible to Residents. The findings included: On 05/11/2022 at approximately 10:30 A.M., a resident Council meeting was conducted. There were six residents in attendance. When the group was asked if they knew where the survey results were located, all of the residents in the meeting indicated they did not know where the survey results were located. On 05/11/2022 11:04 A.M., the binder containing the survey results was observed in a glasstop display table in the front lobby. The glass top display was situated in the corner with a chair and a side table on each side. There was approximately 18 clearance to approach the glass top display table which is not wheelchair accessible. Also, the glass top display table had a heavy, glass frame positioned on the top making it difficult to open. The Health survey and Emergency Preparedness survey result binders were both in the case making it difficult to lift either binder out of the display box. On 05/11/2022 at 11:09 A.M., the administrator was notified of findings. The administrator stated the binders will be put in a more accessible place.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to implement their immunization policy and ensure each Resident is offered influenza and pneumococcal immunization, for 3 Residents (Resident #9, #81, and #287), in a sample of 5 Residents reviewed for immunizations. The findings included: On 5/10/22, clinical record reviews were conducted for the sampled Residents with regards to immunization for flu and pneumonia. This review revealed the following: 1. In Resident #9 electronic health record (EHR) there was no documentation with regards to the pneumonia vaccine status of Resident #9. There was evidence that Resident #9 had refused the flu vaccine for the 2020-2021 flu season. There was no evidence of her being offered the flu shot for the 2021-2022 flu season. Review of the misc. (miscellaneous) tab revealed no evidence of vaccine administration or offering of the vaccine for flu and pneumonia. Review of the Medication Administration Records (MAR) revealed no evidence of the pneumonia or flu immunization being provided to Resident #9. 2. On Resident #81's EHR, there was no recorded information with regards to pneumonia immunization(s). Review of the misc. tab, nursing notes and MAR(s) revealed no evidence of the pneumonia vaccine being offered to Resident #81. 3. On Resident #287's EHR there was no information recorded with regards to flu or pneumonia immunization status. Review of the remainder of the EHR revealed no evidence of Resident #287 being asked or offered either of the immunizations. The miscellaneous tab of the EHR contained a document from the Virginia Immunization Information System that indicated Resident #287 was not up to date with flu or pneumonia immunizations. On 5/11/22 at approximately 2:20 PM, an interview was conducted with the Director of Nursing (DON). During this interview, the DON accessed the clinical record of Resident #9, 81, and 287 and confirmed the above findings. The DON further stated that vaccines have been ordered and will be in on Friday. A review was conducted of the facility policy titled, Influenza, Prevention and Control of Seasonal. This policy read, .Vaccination: 2. all residents and staff are offered the vaccine unless there is a medical contraindication . The facility policy titled, Pneumococcal Vaccine was reviewed. This policy stated, .1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility 2. Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission . The facility policy titled, Vaccination of Residents was reviewed. This policy said, Policy Statement. All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. 1. Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. 2. Provision of such education shall be documented in the Resident's medical record . On 5/11/22 at 4:54 PM, during an end of day meeting, the facility Administrator and Director of Nursing were made aware of the above concerns. On 5/11/22, following the end of day meeting, the DON communicated to Surveyor F that she had talked to the pharmacy and confirmed that pneumonia vaccines were not part of the order that had been placed for immunizations. No further information was provided.

Based on staff interviews and facility documentation review, the facility staff failed to conduct routine COVID-19 testing in accordance with the CDC recommendations for 5 facility staff (RN D, CNA B, CNA D, LPN D and LPN E), who were not up-to-date with COVID vaccinations, in a survey sample of 5 staff reviewed for COVID testing. The findings included: The facility staff failed to conduct routine testing of facility staff who were not fully vaccinated for COVID-19 as per the guidance from CDC and the facility policy. On 5/10/22, during the entrance conference, the facility Administrator was provided a copy of the entrance conference worksheet and asked to submit documentation related to COVID-19 testing, to include the facility's testing plan, log of the level of community transmission, and if there were any testing issues and contact with the local and state health departments with regards to testing issues. On 5/10/22, the facility submitted an employee vaccination matrix and employee testing records for the month of April 2022 and May 2022. On 5/10/22 and 5/11/22, video calls were held with the Director of Nursing (DON) and the Corporate Nurse Consultant. During the video calls, COVID vaccination cards for the sampled employees was reviewed. It revealed: * RN D received COVID vaccinations on 1/13/21 and 2/3/21. RN D had not received any COVID-19 vaccine boosters. * CNA B, had an approved non-medical exemption on file and had not received any doses of a COVID-19 vaccine. * CNA D had received 2 doses of a multi-dose primary vaccine for COVID-19 and was not boosted, but eligible for a booster dose. * LPN D had received 2 doses of a multi-dose primary vaccination series and was not boosted and was eligible for a booster dose. * LPN E, had also received 2 doses to complete the primary vaccination series but had not received a booster dose, even though eligible. Review of the facility submitted document indicating the tracking of the community rate of COVID transmission revealed the following: 4/17/22, community rate of transmission was substantial which indicated twice weekly testing for all staff who were not up-to-date with COVID vaccinations. 4/24/22, the community rate of transmission was moderate, which would still indicate the facility should test twice weekly since they have not been at a lower rate for two consecutive weeks. 5/1/22, the community rate of transmission was high, which required twice weekly testing of staff who were not up-to-date. 5/8/22, the community rate of transmission remained high, which would indicate twice weekly testing of staff who were not up-to-date with COVID vaccinations. Review of the testing logs revealed the following: * RN D was tested for COVID-19 on the following dates: 4/7, 4/12, 4/14, 4/19, and 4/22. * CNA B was tested for COVID-19 on the following dates: 4/7, 4/12, 4/14, 4/19, 4/22, 4/29, and 5/6 * CNA D was tested on : 4/19 * LPN D was tested on : 4/7, 4/12, 4/14, 4/19, and 4/22. * LPN E was not on the staff testing log. On 5/12/22 at 9:26 AM, an interview was conducted with the DON and the Corporate Nurse Consultant. They both indicated that routine testing is performed based on the community transmission rate and is performed on all staff who are eligible for a booster and have not received it. During this same call, the DON accessed the COVID-19 testing log and confirmed the above testing dates for each of the employees as noted above. During the above interview, the DON also stated, [RN D's name redacted] is a prn [as needed] person and came in to help me during the outbreak. [CNA D's name redacted] is prn, she may be out on leave, but she is not a regular worker. [LPN E's name redacted] has only been here a couple of weeks. On 5/12/22 at 1:12 PM, the DON provided Surveyor F with additional testing occurrences which were as follows: RN D was also tested on [DATE]. CNA B was also tested on [DATE]. CNA D was tested on [DATE]. LPN D was tested on ,d+[DATE] and 5/11 LPN E was tested on [DATE]. On 5/12/22, timecards for the above employees were requested and received. They revealed the employees worked the following dates and therefore were available for testing during the week prior to this survey. RN D worked 4/14, 4/19, 4/22, 4/26, 4/29, 5/5, and 5/11 CNA B worked 4/21, 4/22, 4/24, 4/25, 4/27, 4/28, 4/30, 5/1, 5/2, 5/3, 5/4, 5/5, 5/6, 5/9, 5/10, and 5/11. CNA D worked 4/23, 4/24, 4/25, 4/26, 4/27, 4/30, 5/1, 5/2, 5/3, 5/7, 5/8, 5/9, 5/10, and 5/11. LPN D worked 4/21, 4/22, 4/23, 4/24, 4/25, 4/26, 4/27, 4/29, 5/3, 5/4, 5/5, 5/7, and 5/11. LPN E worked 5/7, 5/8, 5/9, and 5/11. The only occurrence of LPN E being tested was after the facility was made aware that LPN E was not up to date and had not evidence of any testing. A review of the facility policy titled, COVID-19- Pandemic Plan with an effective date of 3/11/22, was conducted. This policy on page 11 read, .Expanded Screening Testing of Asymptomatic Staff: Test all staff who are not up to date with the recommended COVID-19 vaccine doses based on the extent of the virus in the community, using the community transmission level available from the CDC .If staff work infrequently in centers with substantial to high community transmission, the staff member should be tested within 3 days before their shift (including the day of the shift) .If the community transmission level decreases to a lower level of activity, the center should continue testing staff at the higher frequency level until the community transmission level has remained at the lower activity level for at least two weeks before reducing testing frequency . A review of the CMS (Centers for Medicare and Medicaid Services) QSO Memo 20-38-NH, with a revision date of 3/10/22, was conducted. This memo stated, Up-to-Date means a person has received all recommended COVID-19 vaccines, including any booster dose(s) when eligible . Routine testing of staff, who are not up-to-date, should be based on the extent of the virus in the community. Routine Testing Intervals by County COVID-19 Level of Community Transmission Level of COVID-19 Community Transmission Minimum Testing Frequency of Staff who are not up-to-date: Low (blue) = Testing Not recommended, Moderate (yellow) = Once a week testing, Substantial (orange) = Twice a week testing, High (red) = Twice a week testing . The CMS memo went on to read, .The facility should test all staff, who are not up-to-date, at the frequency prescribed in the Routine Testing table based on the level of community transmission reported in the past week. Facilities should monitor their level of community transmission every other week (e.g., first and third Monday of every month) and adjust the frequency of performing staff testing according to the table above. o If the level of community transmission increases to a higher level of activity, the facility should begin testing staff at the frequency shown in the table above as soon as the criteria for the higher activity level are met. o If the level of community transmission decreases to a lower level of activity, the facility should continue testing staff at the higher frequency level until the level of community transmission has remained at the lower activity level for at least two weeks before reducing testing frequency. The guidance above represents the minimum testing expected . On 5/12/22, during the end of day meeting the facility Administrator and DON were made aware that facility staff who are not up-to-date with COVID immunizations were not being tested twice weekly as per their facility policy and CDC guidance. No further information was provided.

Based on staff interview, clinical record review, facility documentation review, and in the course of a compliant investigation, the facility staff failed to ensure a discharge summary was written after discharge for one Resident (Resident #115) in a survey sample of 28 Residents. The findings include: Resident #115 was discharged from the facility to another long-term care facility on 6/6/22, due to a facility initiated discharge. On 6/21/22 and 6/22/22, a review of the entire clinical record was conducted and revealed no discharge summary was present for Resident #115's discharge on 6/6/2022. On 6/22/22 at 9 AM, the facility Administrator was made aware of the above findings. The Administrator confirmed that all discharges should have a discharge summary and if it was not in the clinical chart, they didn't have one. A review of the facility policy titled, Discharge Planning was conducted. This policy read, .4. At the time of discharge, a discharge summary and home-going instructions are provided to the resident or the resident's caregiver which will include the following: Current diagnosis, Rehabilitation potential, Summary of prior treatment, Physician ' s orders for immediate care, Pertinent social information, Community referrals as needed (e.g., home health, mental health, adult day care, etc.) . No further information was provided. Complaint related deficiency.

Based on observation, Resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure a Resident's right to a dignified existence for 1 Resident (#24) in a survey sample of 33 Residents. For Resident #24, the facility staff failed to dress the Resident in her own clothing, and instead dressed her in a hospital gown. The Resident expressed embarrassment and requested her own clothing for appointments and anytime she was out of her room or out of the facility. The findings included; Resident #24's most recent MDS (minimum data set) assessment was dated 3-17-22. The document coded the Resident continent of bowel and bladder, No Cognitive impairment, and required extensive assistance from one staff member for bathing, however, with set up help could dress herself. On 5-11-22 at approximately 11:30 a.m., during Resident Council meeting, the Resident stated her clothing had been removed to the laundry 2 weeks prior and she had not received them back. After the meeting, the surveyor went to the Resident's room and inspected the chest of drawers, and closet. There were no clothes in either place. After the inspection of the Resident's room, the surveyor proceeded to the laundry and interviewed Employee (H), and Employee (F). The employees described the clean personal laundry as being housed in a particular room after it was laundered. They proceeded to the room which was located in the old therapy department, and some distance from the laundry. There they found a large laundry bin piled with unfolded laundry, and racks full of Resident clothing mixed together so that no one Resident's clothing could be distinguished from another Resident's clothing. The employees were asked why the clean laundry was not in the Resident rooms, and further asked where Resident #24's laundry was in particular. They stated they could not tell which was hers, and that staffing was short and the laundry had not been folded or delivered because of that, but the Laundry Manager Employee (F) stated she had developed a new system, and was implementing a new house keeping system as well, she went on to say she had only worked in the facility for about 4 months, and she had come from a well known hotel chain. When asked how long it would be before Resident #24 could get her clothing, as she complained it had been 2 weeks since she sent it to laundry, and Employee (F) stated we will get it to her this week. On 5-11-22 at the end of day debrief at 4:30 PM, the DON (Director of Nursing) was asked her expectation of clothing for residents to wear in public. The DON stated the residents should be dressed in their own clothing every day if they wished. On 5-12-22 at 11:30 a.m. the Administrator told the surveyor that clothing articles had been purchased for Resident #24, and that the laundry services would be fixed immediately so that clothing is returned to Residents the day after they were received for service. On 5-12-22 during the end of day meeting the Administrator and DON were made aware of the concerns and no further information was provided.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to complete a SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice) for 1 Resident (Resident #286) in a survey sample of 3 Residents reviewed for Beneficiary Notifications. For Resident #286, the facility staff failed to provide a SNF ABN notice prior to skilled care services ending. As a result of this deficient practice Resident #286 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services, known as a demand bill. The findings included: Resident #286, was admitted to the facility on [DATE], for skilled care following a hospitalization for a fall resulting in a right [CONDITION(S)]. Resident #286 was discharged from a Medicare covered Part A stay on 4/6/22, she remained in the facility. Review of the clinical record revealed the facility staff issued a NOMNC (notice of Medicare non-coverage) which contained Resident #286's signature of receipt of the notice on 4/4/22. The clinical record revealed no evidence of an ABN (Advanced Beneficiary Notice) being issued. The progress notes made no reference with regards to an ABN. However, a blank ABN form was scanned into the electronic health record under the miscellaneous tab. On 05/12/22 at 9:55 AM, an interview was conducted with the facility Administrator, in the absence of the social worker. The Administrator stated the ABN is issued if a Resident files for an appeal and loses their second level of appeal on the NOMNC. He went on to say, That is when we issue the ABN. We have not had any demand bills or ABN's. The Administrator was informed that the ABN is a separate document that is issued and is not based upon a NOMNC response. A review of the facility policy titled, Advance Beneficiary Notice-ABN, was conducted. It read, An ABN will be utilized to notify resident of the possibility that Medicare will not pay for the item(s) or service(s) that are described on the form 1. The facility will give a completed copy of the ABN far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice 2. The resident must comprehend the contents. If the resident is unable to comprehend the contents of the notice, it must be delivered to and signed by an authorized representative . CMS identifies when the ABN is required to be issued in their document titled Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) read, Medicare requires SNFs to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: Not medically reasonable and necessary; or Considered custodial. The SNFABN provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNFABN when applicable for SNF Prospective Payment System services (Medicare Part A). SNFs will continue to use the ABN Form CMS-R-131 when applicable for Medicare Part B items and services. Accessed online at: https://www.cms.gov/search/cms?keys=ABN The Administrator was informed on 5/12/22 at 11:20 AM, of the failure of facility staff to provide Resident #286 with a SNFABN notice prior to skilled care services ending, which would have allowed Resident #286, to make a decision about continuation of services and have Medicare make the coverage determination. On 5/12/22, during an end of day meeting the facility Administrator, Director of Nursing and Corporate staff were made aware of the above concern. The Administrator stated they had no further information to provide with regards to this. No further information was provided.

Based on observation, Resident interview, staff interview, and clinical record review the facility staff failed to provide one Resident (Resident #28) with a homelike environment, in a survey sample of 33 Residents. For Resident # 28, the facility staff failed to hang a framed picture (a portrait of the resident as a young child drawn by her brother). The findings included: Resident # 28's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/22/2022 was coded as a quarterly assessment. Resident # 28 was coded as having a BIMS (brief interview for mental status) score of 15 indicating no cognitive impairment. Resident # 28 was coded as being totally dependent on one to two staff persons for activities of daily living. On 5/10/2022 at 12: 15 p.m.during the initial tour, there was an observation of a large framed personal picture sitting on the floor behind the wardrobe. It was not hanging up on the wall. A Resident interview was conducted with Resident # 28 who stated her brother drew it (the picture for her as a Christmas gift and framed it. Resident # 28 stated it was a picture of her as a young child. Resident # 28 stated she would like to have it on the wall but Maintenance has been busy, he will get to it. Resident # 28 stated it had been on the floor for a long time. On 5/11/2022 at 9:30 a.m., the framed picture was observed still sitting on the floor behind the wardrobe. On 5/11/2022 at 4:00 p.m., the picture was still on the floor. On 5/11/2022 at 5:05 p.m., during the end of day debriefing, the Administrator and Director of Nursing were informed of the findings. The Director of Nursing stated she would have the Maintenance Director hang the picture immediately. On 5/12/2022 at 9:00 a.m., Licensed Practical Nurse H was observed in the doorway of Resident # 28's room preparing to pass medications. Resident # 28 was lying in the bed. The framed picture was observed hanging on the wall to the right of the bed. Resident # 28 was smiling and stated the Maintenance Director hung the picture on the wall the previous evening. Resident # 28 stated she was very happy to have it on the wall. LPN-H stated as soon as she made rounds that morning, Resident # 28 told her that her picture had been hung up on the wall. LPN- H stated Resident # 28 was really happy. No further information was provided.

Based on clinical record review, staff interview, facility documentation review, and in the course of a complaint investigation, the physician failed to document in the clinical record the need/basis for the facility initiated discharge for one Resident (Resident #115) in a survey sample of 28 Residents. The findings included: During the course of a complaint investigation the clinical record of Resident #115 was reviewed on 6/21/22 and 6/22/22. This review revealed multiple instances of Resident #115 having behaviors towards staff and other Residents. There was also an indication that Resident #115 discharged from the facility on 6/6/22, to another facility. The progress notes revealed the following entries: A social services note dated 4/5/22, that read, Social Services contacted [Resident #115's name redacted] guardian at [guardianship agency name and person's name redacted], to possibly discuss [Resident #115's name redacted] behavior and need for alternative placement. Social Services will continue to follow up. Another note dated 4/11/22, indicated the guardian had given permission for Resident #115 to be transferred to another location. A progress note dated 4/14/22, was noted and it read, Director of Social Services, Administrator, [guardian name redacted], Case Manager Supervisor conferred regarding [Resident #115's name redacted] and the incident on 4/12/2022. [Administrator name redacted] issued a Virginia Involuntary Transfer/Discharge Notice citing that the resident is being discharged due to the health and safety of the resident, other resident, or staff endangerment . The next entry into the clinical record for Resident #115 with regards to discharge/discharge planning was on 6/3/22, which read, writer and ED [executive director/administrator] spoke with [guardian agency name redacted] supervisor in regards to moving [Resident #115's name redacted] to a sister facility- [facility name redacted] on Tuesday 6/7. It was explained that [facility name redacted] was able to provide continued 1:1 care and that we would provide transportation. Writer stated she would notify [guardian agency name redacted] if the date and/or time of transport was to change. On 6/6/22, an entry indicated Resident #115 was transferred to a different sister facility other than the one named in the note dated 6/3/22. There was no indication in the clinical record as to why the change in facilities or the transfer occurring a day earlier than originally discussed. On 6/22/22 at 9 AM, an interview was conducted with the facility Administrator, in the absence of the social worker. The facility Administrator stated that the facility had issued a discharge notice to Resident #115, because of his behaviors, and he was felt to be a danger to himself and others. He was discharged to a sister facility that was better suited to meet his needs than the one initially planned. On 6/22/22, the facility Administrator submitted the facility issued discharge notice. This notice was reviewed and revealed it was dated 4/13/22. This notice read, This is to notify you, you will be transferred/discharged from our facility on May 20, 2022, to an alternate location. You are being discharged because: The health and safety of the resident, other residents or staff is endangered . Review of the clinician progress notes from the medical provider/doctor and nurse practitioner revealed no mention of the facility initiating discharge or that Resident #115 was a danger to himself or others and alternate placement was being sought. Review of the facility policy titled, Transfer/Discharge Notification & Right to Appeal was conducted. This policy read, The documentation must be made by: The physician when the transfer or discharge is necessary due to: The resident no longer needs the services provided by the center; A physician when transfer or discharge is necessary due to: The safety of individuals in the center is endangered due to clinical or behavioral status of the resident; The health of individuals in the center would otherwise be endangered . On 6/22/22 at 9:00 AM and again at approximately 10:30 am, the facility Administrator was made aware that the physician had not entered into the clinical record the reason for discharge of Resident #115 as required. No further information was provided. Complaint related deficiency.

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review facility staff failed to revise the resident's care plan for one resident (Resident 7) in a sample size of 33 residents. Resident #7's care plan was not re-evaluated or additional interventions added related to the ongoing complaints of tooth pain. The findings included: On 05/12/22, at approximately 1:43 p.m. Surveyor E asked Resident 7 how was lunch. Resident 7 stated that he could not eat that. The basis for not being able to eat the lunch as served according to Resident 7 was explained as having been served a piece of beef that was too tough and caused the resident's tooth to hurt. Resident 7 went on to state I could not eat that beef, my tooth is still hurting from trying to eat it. The resident was observed to be eating chocolate candy to supplement the meal that resident felt unable to eat to being too tough. Resident 7 stated he keeps snacks at the bedside because the food is too tough to eat. Resident 7 went on to explain that the food is often too tough and the tough food bothered (hurt) the resident's tooth when attempting to chew the tough food presented by the facility. On 05/12/22 at approximately 11:00 a.m. the electronic health record (EHR) was reviewed. Resident 7's care with a target completion date of 3/1/22 was noted to be the most current care plan on record. The care plan addressed the resident's concern and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal: will minimize the risk of complications related to infection through the review. Interventions included: Will monitor oral cavity for inability to tolerate foods. Subsequently, there was no re-evaluation or additional interventions related to the ongoing complaints of tooth pain. Resultantly, resident has experience on-going oral pain for a period of approximately two months. The facility's Policies and Procedures for Dentist Services (last revised 11/27/17) stipulates if dental consult/referral unable to be obtained within 3 days the nurse will evaluate and document changes in ability to eat and drink. Review ability with physician and obtain orders as indicated. On 5/12/22 the EHR does not exhibit a plan of care that demonstrates a 3-day reassessment as to resident's ability to eat; nor, is there evidence of review of ability with physician within a 3 day interval with new orders. The Administrator and Director of Nursing were notified of findings on 5/12/22 at approximately 2:00 p.m. and stated they had no other findings to submit.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to provide care and services based on the professional standards of nursing practice for Two Residents (Resident # 168 & Resident #7) in a survey sample of 33 residents. Findings included: For Resident # 168, the facility staff failed to obtain neurological checks per policy after a fall with a head injury. Resident # 168's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (Minimum Data Set) was an initial assessment, dated 4/10/2022 was reviewed. Resident # 168 was coded as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. Resident # 168 was coded as requiring limited physical assistance of 1 staff person for Activities of Daily Living except required total assistance of one staff person for bathing. Review of the closed clinical record was conducted on 5/10/2022 -5/12/2022. Review of the Progress Notes revealed documentation of: 4/13/2022 a 07:06 a.m.- Nursing Progress Note Residents bathroom call light was on, answered call light and found Resident lying on floor of bathroom in room #_______ (room number redacted) . Resident was lying on stomach with head facing wall and feet and legs in bathroom doorway. Resident was assessed for injuries could move all extremities WNL's (within normal limits) without c/o (complaint of) pain or discomfort voiced. Pupils reactive. Resident hit head on floor, obtained laceration over eye brow with light bruising and goose egg. Resident was awake and alert answering questions appropriately. Resident helped staff roll him over on hoyer lift pad and hoyer lifted to bed. Resident with c/o pain to left side of forehead rated pain an 5/10,medicated with Tylenol 1000 mg._______of (name of physicians group redacted) notified of fall and injuries to forehead ________(name redacted) LPN (Licensed Practical Nurse) 11-7 Supervisor and ______ (name redacted) notified of fall and injuries to forehead. Continuing to monitor. The next Progress Note was a Medication Administration Note on 4/13/2022 at 8:07 AM documenting the administration of [MEDICATION(S)] 50 milligrams one tablet (ordered for one tablet every 6 hours as needed for pain.) Then Medication Administration Note on 4/13/2022 at 9:07 AM documenting the administration of [MEDICATION(S)] Pain Patch-apply to back topically one time a day for pain. Medication Administration Note on 4/13/2022 at 13:51 (1:51 PM) documenting the administration of [MEDICATION(S)] 50 Milligrams one tablet-effective- Follow up pain scale was rated as 2. The next Nursing Progress Note was dated 4/13/2022 at 17:05 (5:05 PM) and stated Resident # 168's granddaughter called the facility and inquired about Resident # 168's fall. The nurse informed the granddaughter that the facility staff could not discuss anything with her since she was not the RP (Responsible Party) listed in the clinical record. The nurse documented that the granddaughter became upset and stated she was going to call the cops and hung up the phone. Minutes later rescue squad showed up, and resident was taken to the ER (emergency room ) for eval & TX (evaluation and treatment. RP made aware. MD (medical doctor) was here in facility and supervisor called and made aware. According to the Progress Notes, on 4/13/2022 at 2252 (10:52 PM), Resident # 168 returned to the facility via stretcher. Resident alert and verbal. Review of the Nurse Practitioner's Progress note dated 4/13/2022 revealed the following excerpts: Chief complaint: Headache, recent fall Had a fall today. Slipped in bathroom and hit left side of face. Has bruise of left eye Complains of headache, moderate intensity Headache has improved No change in mental status No vomiting Complains of intermittent blurry vision States he feels okay right now Under PLAN was written: While plan of care was being discussed, the EMT (Emergency Medical Technicians) showed up. Granddaughter had called 911 as she felt the patient was in urgent need of evaluation. Given blurry vision and headache, CT scan of head may be beneficial. On 5/11/2022 at 11:15 AM, an interview was conducted with the Administrator who stated the facility had written a summary of the events surrounding the fall and the transport to the emergency room . Review of the Summary report revealed the following documentation: Resident # 168 was found on the floor of the bathroom at midnight on 4/13/2022. Neurochecks were done at 1:05, 1:20, 1:35 and 150 AM. From 2:15-2:23 AM: the nurse performed a fall risk assessment, administered pain medication (Tylenol 500 milligrams two tablets) for complaints of pain in the left side of the head, pain rated as a 5 out of ten. When reassessed for pain, Resident # 186 reported the pain medication helped and rate the pain at 2 out of 10. The next Neurocheck was conducted at 4:50 AM. There was no documentation of any other Neurochecks being done prior to Resident # 186 being transported to the emergency room after 5 PM on 4/13/2022. On 5/12/2022 at 9:50 AM, a copy of the Facility's policy on Neurological checks was requested from the Director of Nursing and received. Review of the Facility Policy and Procedure on Neurological Evaluation, effective 11/30/2014, Revision 09/14/2021 revealed the following Procedures: 4. Perform neurological checks as follows unless otherwise ordered by the physician. a. Every 15 minutes x 8 then, b. Every 30 minutes x 4 then, c. Every 60 minutes x 4 then, d. Every 8 hours x 8 or until 72 hours is completed. 5. Document neurological checks, vital signs and observations on the appropriate form or electronic equivalent. 6. Notify Physician of changes in condition 7. Place completed form in medical record. During the end of day debriefing on 5/12/2022, the facility Administrator, Corporate Nurse consultant and Director of Nursing were informed of the findings. The documentation showed Neurochecks were completed 5 times from 1:05- 4:50 AM. No other Neurochecks were documented. The Director of Nursing stated the nurses should have completed the neurological checks as per the facility's policy and procedure. The Director of Nursing stated that was deficient and that the staff had been educated about the policy on Neurochecks. No further information was provided. COMPLAINT DEFICIENCY For Resident #7 the facility staff failed to ensure physician orders for applying [CONDITION(S)]-Embolic Deterrent (TED) hose were followed. On 05/10/22 at approximately 1:43 p.m. Resident 7's TED hose were noted to be at the bedside. Surveyor E asked Resident 7 as to the frequency that the Ted hose were worn. Resident 7 stated that they were applied for therapy. In addition, Resident 7 stated that the TED hose are to be worn daily. Resident 7 granted Surveyor E permission to view both legs. No TED Hose were seen. Both legs were edematous (swollen with an excessive accumulation of fluid). On 05/11/22 at approximately 2:18 p.m. per direct observation, Resident 7 did not have TED hose applied to either leg. Both legs demonstrated [CONDITION(S)]. Resident 7 stated the TED are only applied like two to three times per week when I go to therapy. On 05/12/22 at approximately 9:00 a.m. per review of the electronic health record (EHR) of physician orders last reviewed on 5/10/22 noted an active order with a start date of 6/03/22 at 7 a.m. prescribing: TED hose apply every morning remove at night. On 5/12/22 at approximately 10:22 a.m. per direct observation of Surveyor E, Resident 7 did not have TED hose applied to either leg. Both legs were edematous. On 5/12/22 an interview with Registered Nurse (RN) B was conducted. RN B stated that she is aware of the need for residents to have TED hose applied per the electronic health record (EHR). RN B proceeded to make known that she does not apply the TED hose for the resident(s). Accordingly, the TED hose, per RN B - are applied by the certified nursing assistant (CNA). RN B stated that the CNAs are not aware of the need to have TED hose applied without notification of licensed nurse. RN B stated that the licensed nurse is aware of the resident's need to have TED hose applied based on review of the EHR. RN B stated that the CNA duty caring for Resident 7 was not made aware of the need to place the TED hose to the legs of Resident 7 this morning. The Administrator and Director of Nursing were notified of findings on 5/12/22 at approximately p.m. and stated they had no other findings to submit.

Based on resident interview, staff interview, facility documentation review, and in the course of a complaint investigation the facility staff failed to provide an environment free from physical abuse for one resident (Resident #1) in a survey sample of four residents. Findings included: On 11/14/2019, Resident #1 was pushed to the floor by Resident #2 causing Resident #1 to hit her head on a table, requiring 3 sutures to Resident #1's head. Resident #1, an [AGE] year old female was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/21/2019 was coded as a Significant Change Assessment. Resident #1 was coded a BIMS (Brief Interview of Mental Status) score of 0/15 indicating severe cognitive impairment. She required only supervision for most of her activities of daily living, and was always continent of bowel and frequently incontinent of bladder. Her room was located in the memory unit with a locked door to the main facility area. She ambulated freely with a steady gait throughout this unit. Resident #2, a [AGE] year old male, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His most recent MDS with an ARD of 10/14/2019 was coded as a quarterly assessment. Resident #2 was coded a BIMS score of 3/15 indicating severe cognitive impairment. He required only supervision for most of his activities of daily living and was frequently incontinent of bowel and always incontinent of bladder. His room was also located in the memory unit with a locked door to the main facility area. He also ambulated freely with a steady gait throughout this unit. Care Plans were examined for both Residents. Resident #1 was described as having behavior problems such as hitting staff, throwing items, pacing, being combative, and kicking. Numerous Progress Notes document this behavior for Resident #1. Resident #2's Care Plan described him as having agitation, anxiety, inappropriate touching, and using sexually inappropriate comments. There were Progress Notes describing his agitation and anxiety. On 12/3/2019 at 3:30 PM an interview was conducted with Employee A, Administrator and Employee B, Director of Nursing. They stated that Resident #1 considers Resident #2 her boyfriend. (On 11/14/2019) They were sitting at a table in the common area of the unit when Resident #1 suddenly stood. Resident #2 then pushed Resident #1 causing her to fall backwards hitting the rear of her head and causing a 3 inch laceration. Resident #1 was immediately sent to a local hospital for assessment and treatment. Hospital records were reviewed showing that she received three surgical sutures in the back of her head. A scan of the head revealed an old infarct but no acute abnormalities. A scan of the cervical spine showed no acute issues. She was returned from the hospital that same day. On 12/3/2019 at 4:15 PM, an interview was conducted with LPN B. She stated that she witnessed Resident #2's pushing Resident #1 and saw her fall to the floor. She assesses Resident #1's wound and arranged for transfer to a local Emergency Department. She stated that staff are now on high alert to watch these two residents. On 12/3/2019 at 4:30 PM an interview was conducted with Resident #1. She recalled that she had an injury but does not recall the circumstances. Her wound was healed and no longer visible through her hair. On 12/3/2019 at 4:20 PM an interview was conducted with Resident #2. He stated that he heard that Resident #1 had hit her head but that he had nothing to do with it. Based on the injury to Resident #1, Employee A, Administrator stated that he felt a Plan of Correction was required and it is detailed as follows: 1. (Resident #2) was immediately removed from the unit and (Resident #1) was transferred to the Emergency Department where she received three staples to mend the laceration sustained from hitting her head on a table. 2. Interviews with staff were conducted determining that (Resident #2's) behavior was most likely directed at (Resident #1) due to the territorial behavior she exhibits toward him. In this instance, he viewed her actions as confrontational in which he reacted with aggression. 3. Staff education related to this recent incident was conducted. Education included awareness of the incident, awareness of causal factors per the investigation, daytime off-unit activities for (Resident #2) and continual awareness of proximity of both Residents for redirection. 4. Resident #2 received a psychiatric assessment with medication changes. Nursing staff are to monitor him for sedation, aggression, mood changes or behaviors and report immediately to the unit manager. 5. Alleged date of compliance: Friday (MONTH) 22, 2019. Staff education documents were reviewed and found to be acceptable. This is a PAST NON-COMPLIANCE citation.

Based on observation, staff interview, clinical record review and facility documentation review the facility staff failed for 1 resident (Resident #70) of 31 residents in the survey sample to identify a right heel wound prior to the development of necrotic tissue resulting in harm. Resident #70's right heel wound was first identified on 7/18/18 and was described as center of heel (right) necrotic 0.5 x 0.8. The findings included: Resident #70, an [AGE] year old, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent Minimum Data Set assessment was a significant change assessment with an assessment reference date of 8/13/18. Resident #70 was coded with a Brief Interview of Mental Status score of 2 indicating severe cognitive impairment and required extensive assistance with activities of daily living. On 8/28/18 at 12:05 p.m., Resident #70 was observed seated at a table in the common area waiting for her lunch tray to be delivered. The most current Braden scale was dated 1/13/18 and signed by the nurse on 2/9/18. Resident #70 scored a 17 which indicated she was At Risk for developing a pressure wound. Resident #70's wound documentation was reviewed. Wound tracking documents were completed as electronic forms. A wound to the right heel was documented in the wound tracking. Tracking was documented as follows: 7/18/18- Weekly Skin Integrity Review form: Skin intact- no. Skin impairment described as right heel red non-blanchable 8 x 1.5 x 0 and center of heel (right) necrotic 0.5 x 0.8. The wound descriptions were typed into a text box on the form. The form was completed by the former Assistant Director of Nursing/ Registered Nurse. 7/18/18- Pressure Ulcer Wound Rounds form: Site- Right heel, Type- Pressure, Measurements-8 x 1.5 x 0, Stage- Suspected Deep Tissue Injury, Wound bed tissue- eschar, Wound bed color- black, Wound edges- Firm/ No Redness, Drainage- none. The wound descriptions were selected from a pre-populated menu on the form. The form was completed by the former Assistant Director of Nursing/ Registered Nurse. Prior to 7/18/18, the most recent Weekly Skin Integrity Review form was dated 5/11/18. The 5/11/18 assessment documented that Resident #70 had a skin tear. Weekly skin checks were not performed during the two months between 5/11/18 and 7/18/18. 7/27/18- Pressure Ulcer Wound Rounds form: Site- Right heel, Type- Pressure, Measurements-1.2 x 1.6, Stage- Suspected Deep Tissue Injury, Wound bed tissue- eschar, Wound bed color- black, Wound edges- Firm/ No Redness, Drainage- none. This form was not signed. 7/27/18- Nursing note: IDT (interdisciplinary team) wound meeting held resident continues to have area to right heel tx (treatment) to be done as ordered, heels floated as resident allow while in bed, prostat ordered to aid in skin integrity will continue to monitor. 8/4/18- Pressure Ulcer Wound Rounds form: Site- Right heel, Type- Other, DTI, Measurements-1.2 x 3.0, Stage- Unstageable, Wound bed tissue- eschar, Wound bed color- black, Wound edges- Firm/ No Redness, Drainage- none. Signed by Licensed Practical Nurse C (LPN C), Unit Manager. 8/10/18- Pressure Ulcer Wound Rounds form: Site- Right heel, Type- Pressure, Measurements-1.4 x 1.4 x 0.1, Stage- II, Wound bed tissue- granulation, Wound bed color- pink, Wound edges- Firm/ No Redness, Drainage- none. Signed by the Unit Manager, LPN C. 8/15/18- Pressure Ulcer Wound Rounds form: Site- Right heel, Type- Pressure, Measurements-1.6 x 1.4, Stage- II, Wound bed tissue- granulation, Wound bed color- pink, Wound edges- Firm/ No Redness, Drainage- none. Signed by the Unit Manager, LPN C. 8/24/18- Pressure Ulcer Wound Rounds form: Site- Right heel, Type- Pressure, Measurements-2.0 x 1.0, Stage- II, Wound bed tissue- granulation, Wound bed color- red, Wound edges- Firm/ No Redness, Drainage- none. Signed by the Unit Manager, LPN C. 8/30/18- Pressure Ulcer Wound Rounds form: Site- Right heel, Type- Pressure, Measurements-1.0 x 1.0, Stage- Unstageable, Wound bed tissue- slough, Wound bed color- yellow, Wound edges- Firm/ No Redness, Drainage- small. Signed by the Unit Manager, LPN C. The following treatment orders were documented in the clinical record: 11/4/17- Skin Prep Wipes, Apply to heels topically every day and evening shift for prevention 7/27/18- Skin Prep Right heel every shift for DTI. Discontinued 8/28/18 7/28/18- Prostat 30 milliliters twice a day for 30 days for wound healing 8/8/18- MedPass 60 milliliters twice a day for 30 days 8/29/18- Cleanse right heel with normal saline pat dry and apply hydrogel and dry dressing every day 8/30/18- Santyl ointment apply to right heel The following preventative measures were documented in the clinical record: 9/15/17- Turn and reposition every frequently (sic) and as needed 10/3/17- Float heels when in bed 10/6/17- Medpass 60 milliliter two times per day 10/6/17- Weekly skin checks Activities of Daily Living (ADL) care plan dated 10/4/17 read, has an actual ADL Self Care Performance Deficit d/t (due to) Dementia AEB (as evidenced by) unable to bathe, dress, groom, ambulate, propel self, move in bed, toilet, transfer without assistance. Interventions dated 10/4/17 included ADL- Observe skin for redness, open areas, scratches, cuts, bruises and report to charge nurse and Bathing: Provide the resident with assistance to bathe daily and PRN (as needed). The Activities of Daily Living (ADL) tracking completed by the Certified Nursing Assistants (CNA) was reviewed for the month of (MONTH) (YEAR). In the days prior to the identification of the right heel wound, it was documented that Resident #70 was bathed on the following occasions: 7/17/18, 3-11 shift: shower with total dependence on staff, 1 person physical assist. 7/17/18, 7-3 shift: bed bath with total dependence on staff 7/16/18, 7-3 shift: partial bed bath with total dependence on staff 7/15/18, 3-11 shift: partial bed bath with total dependence on staff 7/13/18, 3-11 shift: bed bath with total dependence on staff 7/13/18, 7-3 shift: bed bath with total dependence on staff 7/12/18, 7-3 shift: bed bath with total dependence on staff The CNA ADL tracking for dressing was also reviewed and documented as follows: 7/17/18, 3-11 shift: dressing with extensive assistance, 1 person physical assist. 7/17/18, 7-3 shift: dressing with total dependence on staff, 1 person physical assist. 7/16/18, 7-3 shift: dressing with total dependence on staff, 1 person physical assist. 7/15/18, 3-11 shift: dressing with extensive assistance, 1 person physical assist. 7/13/18, 3-11 shift: dressing with total dependence on staff, 1 person physical assist. 7/13/18, 7-3 shift: dressing with total dependence on staff, 1 person physical assist. 7/12/18, 7-3 shift: dressing with total dependence on staff, 1 person physical assist. In the week prior to the identification of the necrotic heel wound, it was documented that staff provided assistance with dressing and bathing on 14 occasions. Bathing and dressing are opportunities for staff to monitor for and report any new skin impairment noted during care. Resident #70's impaired skin integrity care plan dated 10/4/17 was reviewed. The Focus included Pressure ulcer right heel- under TX (treatment). Interventions included administer supplements and treatments as ordered (10/4/17), assess/ record/ monitor wound healing weekly (8/10/18), Assist with turning and repositioning (10/4/17), Braden scale quarterly (10/4/17), Encourage nutrition/ hydration (10/4/17), float heels (10/4/17), monitor for and report any new skin impairment noted during care (10/4/17). On 8/29/18 at 9:08 a.m. the survey team observed Resident #70's wound care provided by Licensed Practical Nurse H (LPN H). Upon entrance to the room, Resident #70 was lying in bed. The heels up cushion was on top of a regular pillow. Resident #70's heels were not touching the mattress. She was not wearing socks. LPN H removed the dressing and performed the wound care per physician order. Issues with hand hygiene and infection control were observed. The heel wound was observed to be approximately the size of a dime, pink in color with a thin, white center approximately 1 cm x .3 cm in size. Minimal drainage was noted in the wound. The peri-wound appeared pink. The wound edges were intact. LPN H stated the wound appeared to be healing. She stated it looked better than it did the week before. On 8/30/18 at 10:30 a.m., the Administrator, Director of Nursing (DON) and Corporate Nurse were notified of the concern with the stage for which Resident #70's heel wound was first identified. It was reviewed that the wound was first identified with necrosis and eschar. The DON and Corporate Nurse stated that there was an issue with the Pressure Ulcer Wound Rounds form. They stated that due to a lack of wound description choices on the form, staff often chose the descriptors of black and eschar to describe a deep tissue injury because there was no appropriate choice. It was reviewed with the facility staff that the other form, the Weekly Skin Integrity Review form, included a text box where the nurse could free type in a description. The Registered Nurse who completed the Weekly Skin Integrity Review form for Resident #70 typed in the word necrotic. She also choose the words eschar and black on the Pressure Ulcer Wound Rounds form. It was reviewed that the wound descriptions on both forms were the same. The DON was asked to identify the stage of a wound that would have necrotic tissue. She referred to the facility document titled Wound Classification Guide and stated a wound with necrosis would be unstageable. The guide referenced the National Pressure Ulcer Advisory Panel (NPUAP) definition for Unstageable Pressure Injury, see below. Guidance on pressure wound staging provided by the NPUAP website located at http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ was accessed on 9/5/18 at 11:19 a.m Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. During the interview, it was also reviewed with the facility staff that no weekly skin checks had been performed for two months between 5/11/18 and 7/18/18. The DON was asked to explain the facility's process for monitoring skin. She stated that the weekly skin check was supposed to be completed on the Weekly Skin Integrity Review form by the nurse. The floor nurses were assigned to specific residents. If a Licensed Practical Nurse (LPN ) identified a skin issue during the weekly skin check, the LPN was supposed to report to the Registered Nurse (RN) so the RN could stage the wound. The RN would also put a treatment in place according to the facility document Skin and Wound Care Guidelines and the doctor. The DON stated that the facility did not use a wound care doctor. The floor nurses completed wound care treatment. The DON stated that wounds were measured weekly. The facility staff were asked to submit any documentation they wanted to be reviewed by the survey team related to Resident #70's right heel wound. On 8/30/18 at 3:20 p.m., the DON and Corporate Nurse stated that they had identified prior to the survey that weekly skin checks were not being done timely and wound dressings were not consistently being completed. When asked why the weekly skin checks were not being completed, the DON stated that there were a lot of new staff in the building and there were issues with the case load per nurse. They stated that they completed a 100% skin sweep on 8/24/18- 8/27/18.

Based on staff interview, Resident interview, clinical record review, Resident interview, and facility documentation and in the course of a complaint investigation staff failed to ensure medications were available for 2 Residents (Residents # 4, and #5) resulting in harm for Resident #4. 1. For Resident #4 the facility failed to provide (as needed) PRN pain medicine for 1 day (7/18/18) resulting in harm. 2. For Resident #5, the facility staff failed to ensure medications were available. Findings Included: 1. For Resident #4 the facility failed to provide (as needed) PRN pain medicine for 1 day (7/18/18) resulting in harm. Resident # 4 a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview with Resident #4 on 7/24/18 Resident #4 stated There was a day that was really the worst pain I have had and it was because they ran out of my pain medicine. I had to go to therapy and the appointment with my orthopedic surgeon without anything for pain and it was horrible. On 7/25/2018 at 11:17 AM an interview with the DON was conducted and the DON stated that it is expected practice for the nurses to take the following action when out of a medication for patients: First call the pharmacy and get the medication re-ordered and get a code to use for the stat box, and let the MD know, also let the DON know if we are having trouble getting the medication or the hard script. Nurse's notes on 7/17/2018 at 10:21 AM stated Resident #4 was out of narcotic pain medicine and needed a new script. On 7/17/2018 at 11:59 AM Resident #4 attended Physical Therapy with a pain level of 9-10 out on a pain scale of 10 this is documented on Physical Therapy notes submitted by Employee A. On 7/17/2018 at 3:58 PM the nurses notes state that Resident c/o (complained of) pain to right lower extremity r/t/ (related to) right knee surgical repair. Resident did not have any [MEDICATION NAME] ([MEDICATION NAME]) to give and a hard script was needed. NP (nurse practitioner) was here and made aware of needing script and script was faxed over to pharmacy. Tylenol given at the time to help with pain which is 6/10 to right knee before leaving for f/u (follow up) appt. (orthopedic specialist) On 7/17/2018 at 4:15 PM Nurses notes stated Resident Orthopedic called concerning pain medication and stated that if Resident becomes low again just call the orthopedic specialist (named doctors) for hard script to be faxed to pharmacy if cannot get to NP or rounding MD. In an interview with Physical Therapy Employee A on 7/26/18 at 2:15 PM employee A stated I did physical therapy with Resident #4 on the 7/17/2018 it took me a couple of trys to get her to come. She did complain of pain at 9-10 out of 10 on a pain scale. On 7/26/2018 at 2:30 PM administration was made aware. No further information was provided. 2. For Resident #5, the facility staff failed to ensure medications were available. Resident #5 was originally admitted to the facility on [DATE]. The Resident's [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was an admission assessment with an Assessment Reference Date (ARD) of 7-19-18. The MDS coded Resident #5 with no cognitive impairment, no impaired range of motion, however, requiring limited to extensive assistance on one staff member for transfers, walking, dressing, bathing, toilet use and personal hygiene. On 7-24-18 the Resident was interviewed, and when asked if she received her medications as ordered by her doctor she stated most of the time, but sometimes they don't have them. On 7-24-18, and 7-25-18 Resident #5's clinical record, was reviewed. The review revealed physician orders, and Medication Administration Records (MARs) which included the following orders to be administered and documented as such: Insulin [MEDICATION NAME] solution inject 10 units subcutaneously at bedtime (9:00 p.m.). Ordered to begin on 7-13-18. The insulin was omitted on 7-14-18, 7-21-18, 7-22-18, and 7-23-18, (4 times in 11 days). Cyclosporin [MEDICATION NAME] antibiotic eye drops Instill one drop in both eyes every 12 hours (9:00 a.m., and 9:00 p.m.). Ordered to begin 7-12-18. The eye drops were omitted on 7-12-18 at 9:00 a.m., 7-13-18 for both times, 7-15-18 at 9:00 p.m., and 7-23-18 at 9:00 p.m., (5 times in 11 days). [MEDICATION NAME] sodium 200 micrograms, give 1 tablet by mouth in the morning (6:00 a.m.) Ordered to begin 7-13-18. The [MEDICATION NAME] was omitted on 7-13, 7-23-18, and 7-24-18. (3 times in 12 days). Nursing notes on these days of omissions of drugs, do at times describe medications unavailable, or, awaiting pharmacy, however, they do not state which drugs are unavailable. The Resident's care plan was reviewed and stated Administer medications as ordered. On 7-25-18 the Director of Nursing, and Administrator were made aware of the findings, and asked for any further information they wished to present. They stated they were aware of the omission of medications, and had begun a 4 point plan of correction on 7-13-18 for it, however, it had not been completed as of the time of survey. It is notable to mention that with this Resident, the omissions continued during survey. The failure of staff to recognize and intervene timely to make sure significant medications were available to Residents was reviewed with the Administrator and Director of Nursing at the end of day meeting on 7-26-18. No further information was provided.

Based on staff interviews, clinical record review, hospital medical record review and in the course of a complaint investigation, the facility staff failed for one Resident (Resident #1) in the survey sample of 9 Residents, to identify bilateral heel pressure wounds prior to their becoming dark, hard and unstageable, resulting in harm. The findings included: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1 was transferred from the facility to the emergency room and admitted to the hospital on [DATE]. A closed record review was conducted. On 2/6/17 at 4:00 p.m., a review of Resident #1's electronic clinical record and hospital medical record was initiated. Review the Admission MDS (minimum data set) with an ARD (assessment reference date) of 12/30/16 revealed Resident #1 was coded as having a BIMS (brief interview of mental status) of 15 out of a possible 15. The resident was coded as requiring limited to total assistance for her ADLs (activities of daily living), such as transfers, dressing and bathing. Section M, under Pressure Ulcers, was coded zero (0) pressure ulcers. The MDS defined unstageable as, a pressure ulcer with slough and/or eschar-Known but not stageable due to coverage of wound bed by slough and/or eschar. On the 14 day assessment, with an ARD of 1/4/17, Resident #1 was coded for one (1) unstageable pressure ulcer. Review of the Discharge MDS with an ARD of 1/11/17, in Section M, under Pressure Ulcers, one (1) unstageable pressure ulcer was coded. The MDS defined unstageable as, a pressure ulcer with slough and/or eschar-Known but not stageable due to coverage of wound bed by slough and/or eschar. Review of an SBAR (Situation, Background, Assessment, Request) dated 1/8/17 revealed a change in Resident #1's skin integrity. Under Situation read, Dark, Hard Area on Bilateral Heels. No new orders or treatments were given. The comprehensive care plan included , Bilateral UTS (unstageable) heel wounds noted 1/8/17-under TX (treatment). No new or revised interventions were noted. Further review of the clinical record revealed the following regarding Resident #1's skin integrity: a. Admission Skin Assessment - 12/23/16 - Skin Intact. b. Physician Orders-12/23/16-Turning and Reposition every frequently and as needed every shift for prevention. 1/1/17-Apply blue sage boots to bilateral heels when in bed every shift for prevention. 12/23/16-Float heels when in bed every shift for prevention. c. Physician Admission history and physical examination [REDACTED]. d. Weekly Skin Integrity Reviews performed on 12/30/16 (sacral redness identified) and 1/6/17 (sacral deep tissue injury). e. December and January 2017 TAR (Treatment Administration Record) - from 12/23/17 through 12/26/17 there was no documentation on the TAR that turning and reposition was performed. Skin Prep Wipes to the heels were not reordered or documented on the TAR as having been given between 1/6/17 and 1/8/17. f. January 2017 ADL Report (CNA (certified nursing assistant) Documentation) -Coding of ADL tasks was incomplete and not consistently documented. Resident #1's heel pressure ulcers were identified on 1/8/17, there was no ADL documentation for the day and evening shift of 1/7/17. CNA A was assigned to Resident #1 on five of the 11 day shifts in January. CNA A coded Resident #1 as requiring limited to extensive assistance with her ADLs, including hygiene, bathing and dressing. An interview with CNA A was requested. On 2/7/17 at 2:15 p.m., an interview was conducted with unit nurse that identified Resident #1's bilateral heel wounds, LPN (licensed practical nurse) A. When asked about the implementation of interventions to prevent Resident #1's from acquiring pressure ulcers, LPN A said, She didn't like to turn. LPN A was asked about interventions for the prevention of Resident #1's bilateral heel ulcers. LPN A stated, There was an order for [REDACTED].#1's bilateral heel ulcers were identified on 1/8/17 as unstageable. LPN A stated, Oh, I thought I had renewed the order to continue the applying skin prep to her heels. LPN A said she would come to work on day shift and at times Resident #1 did not have on the blue sage heel protectors. When asked if wounds should be initially identified at unstageable, LPN A did not offer a response. LPN A said the dark and hard areas on Resident #1's heels were about the size of a dime. There were no measurements of the bilateral heel wounds in Resident #1's clinical record. 2/7/17 at 3:10 p.m., an interview was conducted with CNA A regarding Resident #1's skin care. CNA A said she could not recall any specifics regarding Resident #1, but she did admit to being assigned to her. CNA A said it was her responsibility to report any skin irregularities she would observe on a resident. CNA A also stated she would have had opportunities to observe Resident #1's feet and heels. On 2/7/17 at 4:00 p.m., an end of day meeting was conducted with the DON (director of nursing). The DON was informed of the staff's identification of bilateral heel wounds at unstageable. No additional information was provided at this time. On 2/8/17 at 9:00 a.m., an interview was conducted with the administrator and the DON at which time both were informed of the staff's identification of heel wounds at unstageable, resulting in harm for Resident #1. A request for all information regarding the characteristics and measurements of the heel wounds was requested. The DON stated, We don't necessarily measure wounds when initially identified. It depends on the skill level of the person that initially identifies the wound. No addition information was provided at this time. On 2/8/17 at 10:25 a.m., the administrator announced that a modification to Resident #1's Discharge MDS was completed on 2/7/17 to reflect the correct number of Resident #1's unstageble pressure ulcers. The MDS was corrected to reflect that upon discharge there were 3 unstageable pressure ulcers instead of the prior coding of 1 unstageable pressure ulcer. On 2/8/17 at 10:30 a.m., an interview was conducted with LPN B and the unit supervisor RN (registered nurse) A regarding Resident #1's heel wounds. No explanation was provided as to the heel wounds being initially identified when hard and dark. No measurements on the size of the heel wounds were provided. On 2/8/17 at 2:15 p.m., the administrator and the DON were informed of the facility staff's identification of bilateral heel wounds at unstageable, resulting in harm for Resident #1. COMPLAINT DEFICIENCY

Based on observation, staff interview, clinical record and facility documentation review, the facility staff failed for one resident, (Resident #107), in the survey sample of 11 residents to assess for fall risk and bed mobility on admission, and failed for one, (Resident #106), of 11 residents in the survey sample to ensure a bed alarm was in place. A. For Resident #107, the facility staff failed to assess on admission the resident's fall risk and bed mobility status. B. For Resident #106, the facility failed to ensure a bed alarm was in place while the resident was in bed. The findings included: A. Resident #107, a female, was admitted to the facility 4/11/13. Her [DIAGNOSES REDACTED]. Resident #107 had not had her MDS (minimum data set) completed as she was a new admission. The staff had noted her as alert and oriented times 2-3, and required moderate independence with daily decision making. The staff also noted that she required total assistance with her ADL's (activities of daily living, such as dressing and toileting). On 4/17/13 at 8:45 AM, Resident #107 was observed sitting up in bed with cervical collar in place. One half side rails were present on both sides of the bed. There was no alarm in place. The resident had multiple bruises and swellings present on her face and forehead. She stated, "I can't find my callbell (observed in place near her chest), and "I don't try to get out of bed by myself." Review of the clinical record revealed the fall risk assessment was not completed, nor was the transfer, mobility status criteria completed. These tools provide a risk score upon which interventions to prevent falls and to ascertain bed mobility assistance needed for the resident. Review of the facility's policy and procedure on the"Falling Star" program revealed the following: "To decrease the number of falls in the facility, the Falling Star program is designed to facilitate recognition of residents who are high risk for falls. A fall risk assessment will be initiated by the Clinical Nurse and will be completed on admission, quarterly , and as needed. A resident with a score of of 10 or more is considered at risk for falls. Residents identified in the program will have a star placed outside the room by their name plate, and on the outside of the chart near the name label." On 4/17/13 at 9:45 AM, LPN (licensed practical nurse) C stated, "The assessments (Fall, Braden, etc) should be completed within 24 hours of admission." On 4/17/13 at 10:32 AM, The ADON (assistant director of nursing) stated, "The bed mobility status should be completed within 24 hours." She went on to state that audits for the POC (plan of correction) were "random" and Resident #107 was not on the random audits. On 4/17/13 at approximately 10:45 AM, a fall risk assessment was completed for Resident #107, which scored her as a "17", 10 or above deems resident at high risk. B. Resident #106, a female, was admitted to the facility 4/13/13. Her [DIAGNOSES REDACTED]. Resident #106 had not had her MDS (minimum data set) completed as she was a new admission. The staff had noted her as alert and oriented times 2 and required one person assistance with ADL's (activities of daily living, such as bed mobility). On 4/16/13 at 3:15 PM, Resident #106 was observed in the bed with her oxygen at 2 liters per minute. She asked for her callbell, which was in reach. No bed alarm was in place. On 4/16/13 at 4:45 PM, LPN (A) went with writer into the room. LPN (A) stated, "there is no bed alarm." Review of the clinical record revealed a TAR (treatment administration record) with orders for "bed/ chair alarm to alert staff of un-assisted transfers. Check placement/ function every shift." The alarm was signed off every shift since 4/14/13. On 4/17/13 at 8:10 AM, Resident #106 was observed in the bed, with a bed alarm in place and functional. On 4/17/13 at 8:50 AM, LPN (B) was questioned about the alarm. She stated, "The nurse's can make a decision to initiate the alarm, there doesn't have to be a physician's orders [REDACTED]." On 4/17/13 at approximately 11:00 AM, the Administrator and DON (director of nursing) were notified of above findings.

Based on observation, staff interview, family interview, facility documentation review, clinical record review and in the course of a complaint investigation, the facility staff failed to provide an environment free from safety hazards for one Resident (Residents #3) in the survey sample of seven Residents. For Resident #3, the facility staff failed to provide adequate supervision during bathing. While Resident #3 had been assessed as requiring two staff for bed mobility and during care, only one staff performed care resulting in Resident #3 falling out of bed and breaking her leg in two places; and The findings included: For Resident #3, the facility staff failed to provide adequate supervision during bathing. While Resident #3 had been assessed as requiring two staff for bed mobility and during care, only one staff performed care resulting in Resident #3 falling out of bed and breaking her leg in two places. Resident #3, a female, was admitted to the facility 2/13/13. Her [DIAGNOSES REDACTED]. Resident #3 was discharged to the hospital on [DATE] and did not return to the facility. Resident #3's 5 day Medicare assessment with an ARD (assessment reference date) of 2/18/13 was reviewed. She was coded as having no memory deficits and was able to make her own daily life decisions. She was also coded as requiring extensive assistance of two staff members for bed mobility and extensive assistance of one staff member for bathing and dressing. Resident #3 was coded as having range of motion deficits for both lower extremities and as not being transferred out of her bed during the ARD period. Her weight was coded as 354 pounds and she was 60 inches tall. Review of Resident #3's interim care plan revealed, upon admission, a care plan was developed that included Resident #3 requiring an assist of one staff member to bathe, dress, eat, toilet, ambulate or transfer and bed mobility. The "NURSE TECH INFORMATION KARDEX," a tool used by the CNAs (certified nursing assistants) to provide care for Resident #3, revealed one staff member was to provide assistance with bed mobility and personal hygiene. Documentation on the "ADL FLOW RECORD", the form the CNAs used to document the care required by Resident #3, revealed Resident #3 required extensive assistance of two staff members for bed mobility on 2/14 and 2/15/12. Documentation was evident she also required extensive assistance of two staff for toileting during her stay at the facility. Upon admission, Resident #3 was ordered to be on bed rest after having a surgical repair of a decubitus ulcer on her back. While PT (physical therapy) was not ordered, OT (occupational therapy) was and an evaluation was conducted on 2/15/13. The OT recommended for "2 people in room" to be utilized during all care. When interviewed, Other B, the OT staff member that conducted the initial assessment and trained staff for the recommendations stated 3/7/13 at 10:08 a.m., after evaluating Resident #3, she recalled Resident #3 was a large lady with good upper body movement. She recalled her recommendations were to protect her skin and prevent further skin breakdown and to promote healing of the surgical repair of her wound. Other B stated she felt that two staff members were necessary to prevent further damage to Resident #3's skin. Other B further stated, after her evaluation, she developed a plan including goals and strategies to include two staff to assist Resident #3. Other B stated she educated staff on 2/15 and 2/18/13 for Resident #3's care needs. Additionally a "TRANSFER/MOBILITY STATUS CRITERIA" assessment tool was completed on 2/13/13. The assessment determined "3B Not able to bear weight on lower extremities, but has upper body strength for head, neck, shoulders and arms." For assessment of "Mobility Status" Resident #3 was assessed, "May or may not be able to assist with movement while in bed. Assistance Required Needs two or more persons for assistance in bed mobility or use of device." Documentation was evident that on 2/18/13, Resident #3 was being bathed by CNA A. CNA A assisted Resident #3 to turn on her side and proceeded to wash her back. Upon finishing her back, CNA A left the side of the bed and went to the door way to call for the nurse to do wound care. While CNA A was at the door and returning to the bedside, Resident #3 rolled off her bed and to the floor. Resident #3 was assessed by the nurse and after being returned to her bed, xrays were obtained on Resident #3's leg with the following findings: "ANKLE Possible fracture along the medial malleolus of indeterminate age. KNEE Modestly displaced fracture of the distal femur." The medial malleolus is a bony prominence at the inner lower end of the tibia (the stronger bone as compared to the fibula that are both below the knee) at the ankle. The distal femur is the lower end of the long thigh bone above the knee. When interviewed by phone, 3/6/12 at 4:52 p.m., CNA A stated she had only cared for Resident #3 twice. On 2/18/13, she stated she was assigned to care for Resident #3. CNA A stated after Resident #3 washed her top half, CNA A helped her to turn in bed to her side, after washing Resident #3's back and bottom half, CNA A stated she left the bedside and went to the door way to call for the nurse. CNA A stated the nurse was to perform Resident #3's wound care. CNA A stated the nurse was the second person required to help with Resident #3's care. CNA A stated the nurse was in the hall way passing medications and had told CNA A to call her when her bath had been completed. After calling for the nurse, CNA A said she turned around at the doorway and Resident #3 was rolling out of the side of the bed onto the floor. CNA A stated the side rails were up on the top of the bed and Resident #3 was holding onto them as she fell . CNA A stated while Resident #3 could help a lot with her upper body, Resident #3 needed total assistance with washing, positioning and moving her lower body. CNA A said Resident #3 was a large lady. CNA A stated the first time she cared for Resident #3, the nurse informed her of what type of care the Resident required. CNA A also stated Resident #3 was alert and could make her needs known. When interviewed, 3/7/13, at 6:10 p.m. LPN C, an MDS coordinator, stated she had completed the MDS assessment for Resident #3. LPN C stated the MDS was completed after her transfer to the hospital due to the time frame involved. LPN C stated the MDS was coded based on the information available, and while two person extensive assistance had been coded, some days Resident #3 only needed one person assistance. The ADON (assistant director of nursing) stated 3/7/13 at 9:24 a.m. that care planning was a process all staff was involved in. The ADON said, had Resident #3 been at the facility longer, her "Kardex" would have been updated to reflect her needs. LPN C stated Resident #3's care plan meeting was conducted after her fall and before she was transported to the hospital. The ADON stated a specialty bed was ordered for Resident #3 prior to admission. Her preadmission information revealed she had developed a pressure ulcer on her back while at home. She had been admitted to the hospital for surgical repair of the area. She was to be admitted to the facility on "strict bed rest" and was morbidly obese. A low loss air mattress on a large bed frame was ordered due to Resident #3's healing pressure ulcer and size. The administrator, DON (director of nursing), and ADON were advised of the failure of appropriate and safe staff support during bathing and bed mobility for Resident #3 resulting in a fall from her bed with two fractures to right leg, on 3/7/13 at 11:30 a.m. COMPLAINT DEFICIENCY

Based on staff interview, clinical record review, facility documentation review and complaint investigation, the facility staff failed to adequately assess and develop an interim care plan and failed to follow professional standards of nursing for medication and treatment administration for four Residents (Resident #3, #1, #2 and #7) in the survey sample of seven Residents. 1. For Resident #3, the facility staff failed to develop an appropriate interim care plan to address bed mobility and ADL (activities of daily living) resulting in harm; 2. For Resident #1, the facility staff failed to document medication and treatments were administered ; 3. For Resident #2, the facility staff failed document medications and treatments were administered; and 4. For Resident #7, the facility staff failed to document medications and treatments were administered. The findings included: 1. For Resident #3, the facility staff failed to develop an appropriate interim care plan to address bed mobility and ADL (activities of daily living) resulting in harm. Resident #3 was assessed by OT (occupational therapy) and on the MDS (minimum data set) assessment as requiring extensive two person assistance. And on her interim care plan, Resident #3 was care planned to require one person assistance for bed mobility and her activities of daily living. One staff member was assisting with bed mobility and bathing- the staff member left the side of the bed; Resident #3 rolled off the bed to the floor, breaking her leg in two places. Resident #3, a female, was admitted to the facility 2/13/13. Her [DIAGNOSES REDACTED]. Resident #3 was discharged to the hospital on [DATE] and did not return to the facility. Resident #3's 5 day Medicare assessment with an ARD (assessment reference ) date of 2/18/13 was reviewed. She was coded as having no memory deficits and was able to make her own daily life decisions. She was also coded as requiring extensive assistance of two staff members for bed mobility and extensive assistance of one staff member for bathing and dressing. Resident #3 was coded as having range of motion deficits for both lower extremities and as not being transferred out of her bed during the ARD period. Her weight was coded as 354 pounds and she was 60 inches tall. Review of Resident #3's interim care plan revealed, upon admission, a care plan was developed that included Resident #3 requiring an assist of one staff member to bathe, dress, eat, toilet, ambulate or transfer and bed mobility. The "NURSE TECH INFORMATION KARDEX," a tool used by the CNAs (certified nursing assistants) to provide care for Resident #3, revealed one staff member was to provide assistance with bed mobility and personal hygiene. Documentation on the "ADL FLOW RECORD", the form the CNAs used to document the care required by Resident #3, revealed Resident #3 required extensive assistance of two staff members for bed mobility on 2/14 and 2/15/12. Documentation was evident she also required extensive assistance of two staff for toileting during her stay at the facility. Upon admission, Resident #3 was ordered to be on bed rest after having a surgical repair of a decubitus ulcer on her back. While PT (physical therapy) was not ordered, OT (occupational therapy) was and an evaluation was conducted on 2/15/13. The OT recommended for "2 people in room" to be utilized during all care. When interviewed, Other B, the OT staff member that conducted the initial assessment and trained staff for the recommendations stated on 3/7/13 at 10:08 a.m., after evaluating Resident #3, she recalled Resident #3 was a large lady with good upper body movement. She recalled her recommendations were to protect her skin and prevent further skin breakdown and to promote healing of the surgical repair of her wound. Other B stated she felt that two staff members were necessary to prevent further damage to Resident #3's skin. Other B further stated, after her evaluation, she developed a plan including goals and strategies to include two staff to assist Resident #3. Other B stated she educated staff on 2/15 and 2/18/13 for Resident #3's care needs. Additionally a "TRANSFER/MOBILITY STATUS CRITERIA" assessment tool was completed on 2/13/13. The assessment determined "3B Not able to bear weight on lower extremities, but has upper body strength for head, neck, shoulders and arms." For assessment of "Mobility Status" Resident #3 was assessed, "May or may not be able to assist with movement while in bed. Assistance Required Needs two or more persons for assistance in bed mobility or use of device." Documentation was evident that on 2/18/13, Resident #3 was being bathed by CNA A. CNA A assisted Resident #3 to turn on her side and proceeded to wash her back. Upon finishing her back, CNA A left the side of the bed and went to the door way to call for the nurse to do wound care. While CNA A was at the door and returning to the bedside, Resident #3 rolled off her bed and to the floor. Resident #3 was assessed by the nurse and after being returned to her bed, xrays were obtained on Resident #3's leg with the following findings: "ANKLE Possible fracture along the medial malleolus of indeterminate age. KNEE Modestly displaced [MEDICAL CONDITION] femur." The medial malleolus is a bony prominence at the inner lower end of the tibia (larger, stronger bone below the knee) at the ankle. The distal femur is the lower end of the long thigh bone of the leg. When interviewed by phone, 3/6/12 at 4:52 p.m., CNA A stated she had only cared for Resident #3 twice. On 2/18/13, she stated she was assigned to care for Resident #3. CNA A stated after Resident #3 washed her top half, CNA A helped her to turn in bed to her side, after washing Resident #3's back and bottom half. The CNA A stated she left the bedside and went to the door way to call for the nurse. CNA A stated the nurse was to perform Resident #3's wound care. CNA A stated the nurse was the second person required to help with Resident #3's care. CNA A stated the nurse was in the hall way passing medications and had told CNA A to call her when her bath had been completed. After calling for the nurse, CNA A said she turned around at the doorway and Resident #3 was rolling out of the side of the bed onto the floor. CNA A stated the side rails were up on the top of the bed and Resident #3 was holding onto them as she fell . CNA A stated while Resident #3 could help a lot with her upper body, Resident #3 needed total assistance with washing, positioning and moving her lower body. CNA A said Resident #3 was a large lady. CNA A stated the first time she cared for Resident #3, the nurse informed her of what type of care the Resident required. CNA A also stated Resident #3 was alert and could make her needs known. When interviewed, 3/7/13, at 6:10 p.m. LPN C, an MDS coordinator, stated she had completed the MDS for Resident #3. LPN C stated the MDS was completed after her transfer to the hospital due to the time frame involved. LPN C stated the MDS was coded based on the information available, and while two person extensive assistance had been coded, some days Resident #3 only needed one person assistance. The ADON (assistant director of nursing) stated 3/7/13 at 9:24 a.m. that care planning was a process all staff was involved in. The ADON said, had Resident #3 been at the facility longer, her "Kardex" would have been updated to reflect her needs. LPN C stated Resident #3's care plan meeting was conducted after her fall and before she was transported to the hospital. The administrator, DON (director of nursing), and ADON were advised of the failure of accurate assessment and development of appropriate care planning by the staff to provide necessary and safe support for Resident #3 resulting in a fall from her bed with two fractures to right leg, 3/7/13 at 11:30 a.m. COMPLAINT DEFICIENCY 2. For Resident #1, the facility staff failed to document medication and treatments were administered. Resident #1, a female, was admitted to the facility 10/12/12. Her [DIAGNOSES REDACTED]. Resident #1's most recent MDS with an ARD of 2/13/13 was coded as a significant change assessment. Resident #1 was coded as requiring moderate assistance with making daily life decisions, and had short and long term memory deficits. She was also coded as requiring extensive assistance of two staff persons to perform her activities of daily living. Review of Resident #1's clinical record revealed no documentation that the following medications and treatments were administered per physician's orders [REDACTED]. [MEDICATION NAME] cream apply to affected areas to bil (bilateral) hands twice daily for redness and rash: 1/13 3-11 shift, 1/15/13 on 7-3 and 3-11 shift, 1/27/13 on 3-11 shift, 1/28/13 on 7-3 and 3-11 shift, 2/22/13 on 7-3 shift, 2/23/13 on 3-11 shift, 2/25/13 on 7-3 and 3-11 shift, 2/27/13 on 7-3 shift Wanderguard at all times check placement every shift: 1/13 on 3-11 shift, 1/2/13 on 3-11 shift, 1/15/13 on 7-3 and 3-11 shift, 1/25/13 on 3-11 shift, 1/27/13 on 7-3 and 3-11 shift, 1/28/13 on 7-3 and 3-11 shift Bed alarm for safety: 2/25/13 on 7-3 and 3-11 shift Pt (patient) is non wgt (weight) bearing: 2/25/13 on 7-3 and 3-11 shift Antifungal cream to buttocks every shift: 2/20/13 on 11-7 shift, 2/24/13 on 7-3 shift, 2/25/13 on 7-3 and 3-11 shift, 2/28/13 on 11-7 shift Cleanse left knee with normal saline pat dry apply [MEDICATION NAME] and dry dressing every day until healed: 2/25 and 2/27/13 Aspirin 81 mg (milligram) one by mouth daily: 1/10/13 and 1/28/13 [MEDICATION NAME] 0.5 mg one by mouth every morning: 1/10/13 and 1/28/13 Folic Acid 1 mg by mouth every day: 1/10/13 and 1/28/13 Haldoperidol 2 mg one tab by mouth twice daily: 1/10 at 9 a.m. and 9 p.m., 1/28/13 at 9 a.m. Oyster shell Calcium 500 mg one tablet twice daily: 1/10/13 at 9 a.m. and 1/28/13 at 9 a.m. [MEDICATION NAME] 100 mg one tablet every day: 1/10/13 Thera tablet one by mouth daily: 1/10/13 Vitamin B-1 100 mg one tablet every day: 1/10/13 Med Pass 120 ml (milliliter) three times a day: 1/28/13 at 1 p.m., 1/13/13 at 5 p.m. [MEDICATION NAME] 0.5 mg one three times a day: 1/13/13 at 5 p.m. Valid physician's orders [REDACTED]. When interviewed, the ADON (assistant director of nursing) stated 3/6/13 at the end of day meeting, nurse's were to document the medications and treatments they give. Review of the facility's policy entitled "Medications-Oral Administration of" included; "16. Chart on MAR (medication administration record) according to policy." Guidance was given to nursing by "Fundamentals of Nursing 7th Edition, Potter-Perry, p. 713, "After administering a medication, record it immediately on the appropriate record form. Never chart a medication before administering it. Recording immediately after administration prevents errors. The recording of a medication includes the name of the medication, dose, route, and exact time of administration." The administrator, DON (director of nursing) and ADON were advised of the failure of the staff to document medications and treatments as having been administered to Resident #1, 3/7/13 at 11:42 a.m. 3. For Resident #2, the facility staff failed to document medications and treatments were administered. Resident #2, a female, was admitted to the facility 7/9/08. Her [DIAGNOSES REDACTED]. Resident #2's most recent MDS with an ARD of 12/14/12 was coded as a quarterly assessment. Resident #2 was coded as having short and long term memory deficits and required total assistance with making daily life decisions. Resident #2 was also coded as requiring extensive one person assistance with her activities of daily living. Review of Resident #2's clinical record revealed no documentation the following medications and treatments were administered per physician's orders [REDACTED]. Med Pass 90 ml by mouth four times a day: 2/22/13 at 1 p.m., 2/28/13 at 5 p.m. and 9 p.m., 1/28/13 at 9 a.m. and 1 p.m. Magic Butt Paste apply to peri area after each incontinence episode of incontinence of urine of (sp) stool every shift: 2/25/13 on 7-3 and 3-11 shift, 2/27/13 on 7-3 and 3-11 shift, 1/13/13 on 3-11 shift, 1/3/13 on 7-3 shift, 1/15/13 7-3 and 3-11 shift, 1/28/13 on 7-3 and 3-11 shift Bed alarm check for placement every shift and function: 2/1/13 on 11-7 shift, 2/25/13 on 7-3 and 3-11 shift, 2/27/13 7-3 and 3-11 shift, 1/3 on 7-3 shift, 1/9/13 on 7-3 shift, 1/13/13 on 3-11 shift, 1/15/13 on 7-3 and 3-11 shift, 1/28/13 on 7-3 and 3-11 shift Ensure vanilla can one can by mouth three times a day: 1/27 and 1/28/13 at 9 a.m. and 1 p.m. Polyethylene [MEDICATION NAME] 17 grams in 8 ounces of liquid and drink by mouth every other day: 1/4/13, 1/10/13, 1/20/13, 1/28/13 Cranberry juice with each meal: 1/27 and 1/28/13 at 8 a.m. and 12 noon Encourage fluids 1800 ml/24 hours: 1/27 and 1/28/13 on 7-3 shift, The administrator, DON (director of nursing) and ADON were advised of the failure of the staff to document medications and treatments as having been administered to Resident #2, 3/7/13 at 11:42 a.m. 4. For Resident #7, the facility staff failed to document medications and treatments were administered per physician's orders [REDACTED]. Resident #7, a female, was admitted to the facility 1/19/12. Her [DIAGNOSES REDACTED]. Resident #7's most recent MDS with an ARD of 2/8/13 was coded as a significant change assessment. Resident #7 was coded as having short and long term memory deficits and required assistance with making daily life decisions. Resident #7 was also coded as requiring extensive one person assistance with her activities of daily living. Review of Resident #7's clinical record revealed the following medications and treatments were not documented as having been administered per physician's orders [REDACTED]. Aspirin 81 mg one tablet by mouth every day: 2/17/13 [MEDICATION NAME] HBR 10 mg one tablet by mouth every day: 2/9/13 and 2/22/13 Donepezil 10 mg one tablet by mouth at bedtime: 2/19/13 Simvastin 10 mg one tablet by mouth at bedtime: 2/19/13 Vitamin D 400 units one tablet twice daily: 2/19/13 at 5 p.m. Vitamin D 2000 unit one capsule by mouth every day: 2/19/13 Thera M one every day: 2/22 and 2/23/13 Med Pass 120 ml by mouth three times daily: 2/22/13 at 9 a.m. and 1 p.m., 2/19/13 at 5 p.m., 1/28/13 at 1 p.m. Wanderguard on at all times-check placement every shift: 2/22/13 on 3-11 shift, 2/23/13 on 3-11 shift, 2/25/13 on 7-3 and 3-11 shift, The administrator, DON (director of nursing) and ADON were advised of the failure of the staff to document medications and treatments as having been administered to Resident #7, 3/7/13 at 11:42 a.m.