Every finding on record at Kempsville Health & Rehab Center

Based on observation, interview and review manufacturer's instructions for use, the facility failed to maintain a medication error rate below five percent. Out of the 27 opportunities for error, two errors occurred during medication administration with one of one Licensed Practical Nurse (LPN)3. The facility's medication error rate was 7.41%.Findings include:Observation of medication pass on the 400 unit the facility on 02/26/26 revealed the following medication errors:During medication administration with LPN3 on 02/26/25 at 09:01 AM, LPN3 injected 48 units of Lantus (Insulin Glargine - long-acting insulin) using an insulin pen into R110's abdomen and withdrew the insulin pen immediately.During an interview on 02/26/25 at 09:02 AM, LPN3 stated she was unaware of the manufacturer's instructions for use for the insulin pen and how long she was to hold the pen in the patient's body after injecting the medication before withdrawal.On 02/26/25 at 9:10 AM, LPN3 injected one unit of fast acting insulin Novolog Aspart using an insulin pen in R69's abdomen and retracted the insulin after one second.During an interview on 02/26/26 at 9:29 AM, LPN3 was told of the observation, and stated she had counted one to five quickly before withdrawing the injection from R69. LPN3 restated that she was unaware of how many seconds the manufacturer recommends to hold the pen for the patient to get the full dose.During an interview on 02/26/26 at 9:33 AM, the Licensed Practical Nurse (LPN)1 stated it was her expectation that LPN3 follow manufacturer's instructions for use for insulin pens. Review of Manufacture's IFU for the insulin pen titled INSTRUCTIONS FOR USE (insulin aspart-) injection, for subcutaneous use located at https://assets.bioconbiologics.com/asset/225989342563/document_9rdh45bfbl1jr4dbes9j89mb2n/ASP-2025-00011-US%20KIRSTY%20IFU%20glarginePen.pdf?content-disposition=inline revealed:Giving the injectionI. Insert the needle into your skin. Inject the dose by pressing the push-button all the way in until the 0 lines up with the pointer (see diagram I). Be careful only to push the button when injecting.J. Turning the dose selector will not inject insulin. Keep the needle in the skin for at least 6 seconds and keep the push-button pressed all the way in until the needle has been pulled out from the skin . This will make sure that the full dose has been given.During an interview with the Director of Nursing (DON)on 02/26/26 at 4:35 PM, the DON stated it was her expectation that staff follow the manufacturer's instructions for use for medication injections.

Based on record reviews, interviews, and facility policy review, the facility failed to ensure that a person-centered baseline care plan was developed within 48 hours of admission, and provided to the resident or their representative, for five of five residents (Resident (R) 105, R113, R59, R67, and R100) out of 20 sampled residents. This failure to establish initial care instructions for nursing staff placed newly admitted facility residents at risk of not receiving critical care needs, and residents and representatives to be poorly informed of anticipated plans of care.Findings include:1. Review of R105's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab indicated the resident was admitted to the facility on [DATE] and readmitted [DATE]. The document indicated the resident's diagnoses included displaced fracture of greater trochanter of left femur, muscle wasting and atrophy left lower leg, type two diabetes mellitus, cerebral infarction, and protein calorie malnutrition. R105 was discharged on 01/14/26.Review of R105's five day Minimum Data Set (MDS) Assessment with an assessment reference date (ARD) of 12/14/25 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R105's admission Observation dated 12/08/25 and located under the Progress Notes tab revealed a Baseline Care Plan section for review with the resident that stated only that the resident would receive medications as ordered, skilled care, pain medications as ordered, skin care to prevent skin breakdown, dietary needs as ordered, and activities of daily living as necessary. Review of R105's Progress Notes dated 12/08/25 and located under the Progress Notes tab, revealed the resident was admitted with an indwelling urinary catheter and two post-operative surgical wounds to the left hip. The Baseline Care Plan failed to identify the indwelling urinary catheter and two surgical wounds.Review of R105's Baseline Care Plan Checklist dated 12/15/25 and located under the Resident Documents tab revealed the form was completed by the Social Service Director (SSD) on 12/15/25 and was documented to be due on 12/12/25. The Baseline Care Plan Checklist was signed by the resident on 12/15/25. Review of R105's Comprehensive Care Plan, dated 12/23/25 and located in the EMR under the Care Plan tab, revealed R105's foley catheter was not identified in any care planning until it was initiated on 12/23/25. Review of R105's Comprehensive Care Plan, dated 01/05/26 and located in the EMR under the Care Plan tab, revealed R105's skin integrity was not identified in any care planning until it was initiated on 01/05/26.2. Review of R113's Face Sheet located under the Face Sheet tab of the EMR indicated the resident was admitted to the facility on [DATE] with diagnoses of non-traumatic acute subdural hemorrhage, nondisplaced fracture of greater tuberosity of right humerus, dysphagia, type two diabetes mellitus with hyperglycemia, protein calorie malnutrition, and dementia.Review of R113's admission MDS with an ARD of 02/23/26 and located in the EMR under the MDS tab revealed a BIMS score of eight out of 15, which indicated the resident was moderately cognitively intact. Review of R113's admission Observation dated 02/17/26 and located under the Progress Notes tab revealed a Baseline Care Plan section for review with the resident that stated only that the resident would receive medications as ordered, skilled care, pain medications as ordered, skin care to prevent skin breakdown, dietary needs as ordered, and activities of daily living as necessary. Review of R113's Progress Notes dated 02/17/16 and located under the Progress Notes tab, revealed the resident was admitted with a nondisplaced fracture of the right humerus, and a fall with head injury including a neurosurgery recommendation for a soft collar at all times. The Baseline Care Plan failed to identify the fracture or the need for a soft collar after a significant head injury.Review of R113's Baseline Care Plan Checklist, dated 02/23/26 and located under the Resident Documents tab, revealed the form was completed by the SSD on 02/23/26, but was due on 02/21/26. The Baseline Care Plan Checklist was signed by the resident representative on 02/23/26. Review of R113's Comprehensive Care Plan, located in the EMR under the Care Plan tab, revealed R113's fall and humerus fracture were not identified in any care planning until it was initiated on 02/20/26. During an interview on 02/23/26 at 1:02 PM, R113 stated that they did not recall talking to any staff member about their care, or what was going to happen going forward. R113 did not recall anyone keeping them informed about their care needs.3. Review of R59's Face Sheet, located in the EMR under the Face Sheet tab indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included displaced transverse fracture of right patella, protein calorie malnutrition, post-traumatic stress disorder, anxiety, major depressive disorder, and acquired absence of right upper limb.Review of R59's five day MDS with an ARD of 02/11/26 and located in the EMR under the MDS tab revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of R59's admission Observation dated 02/05/26 and located under the Progress Notes tab revealed a Baseline Care Plan section for review with the resident that stated only that the resident would receive medications as ordered, skilled care, pain medications as ordered, dietary needs as ordered, and activities of daily living, as necessary. Under Skin it stated that skin issues were present, and to see Order/Observations, not attached to the document provided to the resident.Review of R59's Progress Notes dated 02/05/26 and located under the Progress Notes tab, revealed the resident was admitted with a surgical incision to right knee with four to five sutures and slough tissue present, wound vac applied. R59 was also admitted with a physician order for Cefazolin 2-gram reconstituted solution, to be administered intravenously. The Baseline Care Plan failed to identify the surgical wound with the wound vac or the intravenous antibiotic.Review of R59's Baseline Care Plan Checklist, dated 02/11/26 and located under the Resident Documents tab, revealed the form was completed by the SSD on 02/11/26, but was due on 02/09/26. The Baseline Care Plan Checklist was signed by the resident on 02/11/26. Review of R59's Comprehensive Care Plan located in the EMR under the Care Plan tab revealed R59's antibiotic and wound vac usages were not identified in any care planning until it was initiated on 02/16/26. 4. Review of R67's Face Sheet located in the EMR under the Face Sheet tab indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included neoplasm of unspecified behavior of brain, protein calorie malnutrition, hemiplegia affecting right dominant side, and bipolar disorder. Review of R67's five day MDS with an ARD of 02/05/26 and located in the EMR under the MDS tab revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of R67's admission Observation dated 01/30/26 and located under the Progress Notes tab revealed a Baseline Care Plan section for review with the resident that stated only that the resident would receive medications as ordered, skilled care, pain medications as ordered, dietary needs as ordered, and activities of daily living, as necessary. Specific care needs including antipsychotic, hypnotic, and antidepressant medications ordered upon admission were not identified.Review of R67's Baseline Care Plan Checklist, dated 02/04/26 and located under the Resident Documents tab, revealed the form was completed by Social Service (SS)1 on 02/04/26, but was due on 02/03/26. The Baseline Care Plan Checklist was signed by the resident on 02/04/26. Review of R67's Comprehensive Care Plan located in the EMR under the Care Plan tab revealed R67's usage of hypnotic, antipsychotic, and antidepressant medications were not identified in any care planning until they were initiated on 02/13/26. During an interview on 02/23/26 at 1:10 PM, R67 said that they had been at the facility for approximately a month. R67 stated that they were not aware of their plan of care and said that no one had sat down with them and gone over specific things about their care, and plan for discharge.5. Review of R100's Face Sheet, located in the EMR under the Face Sheet tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses include acute kidney failure, protein calorie malnutrition, sepsis, and spinal stenosis. R100 was discharged on 12/28/24.Review of R100's five day MDS with an ARD of 12/18/24 and located in the EMR under the MDS tab revealed a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. Review of R100's admission Observation, dated 12/12/24 and located under the Progress Notes tab revealed a Baseline Care Plan section for review with the resident that stated only that the resident would receive medications as ordered, skilled care, pain medications as ordered, dietary needs as ordered, and activities of daily living, as necessary. Under Skin it states that skin issues were present, and to see Order/Observations not attached to the document provided to the resident. Specific care needs including antidepressant medications ordered upon admission were not identified.Review of R100's Progress Notes, dated 12/12/24 and located under the Progress Notes tab, revealed the resident was admitted with wounds noted to sacrum, left and right buttocks.Review of R100's Baseline Care Plan Checklist, dated 12/18/24 and located under the Resident Documents tab, revealed the form was completed by the SSD on 12/18/24, but was due on 12/16/24. The Baseline Care Plan Checklist was signed by the resident representative on 02/18/26. Review of R100's Comprehensive Care Plan, located in the EMR under the Care Plan tab, revealed R100's antidepressant medication usage and pressure wounds were not identified in any care planning until they were initiated on 12/19/24. During an interview on 02/26/26 at 9:05 AM, Social Service (SS) 1 said that the facility liked to have a newly admitted resident start therapy services before they had a care conference, which they called a Path meeting. SS1 stated that the Path documents would show who attended the meeting and received the care planning information.During an interview on 02/26/26 at 10:41 AM, Director of Rehab (DOR) confirmed that upon admission the resident would be evaluated, a plan of care would be established, and treatment would start. DOR said that the facility would have a care plan meeting with the resident and representative within the first three to five days and let the resident or representative know then what was needed to be worked on so they could get home.During an interview on 02/26/26 at 1:45 PM, Licensed Practical Nurse (LPN)1 confirmed R59 had been admitted to the facility with a wound vac. LPN1 said that when a resident was admitted to the facility, the nurse would do an initial observation assessment, which would be part of the baseline care plan. LPN1 said that the information at the bottom of the observation (pages 33-35), which included the Baseline Care Plan would be provided to the resident. LPN1 stated that the information documented in the assessment and Baseline Care Plan section was general information only and did not identify anything specific to the residents' care needs. LPN1 confirmed that it was at the Path meeting when specific care needs would be discussed with the residents or representatives, usually three to five days later.During an interview on 02/26/26 at 1:48 PM, SSD said that when a new resident was admitted , they did a general introduction to Social Services to the residents. SSD said that they did an initial assessment observation within 48 to 72 hours and documented it in the Observation tab in the EMR and then documented when it occurred on the Baseline Care Plan Checklist. SSD stated that the facility had a Path meeting within five days for short-term residents, after giving the resident two or three days of therapy to better understand the resident's status, therapy needs, and discharge process. SSD said that the residents and/or representatives were invited to the Path meeting. SSD said that starting with the initial assessment as the base and the discharge summary, they continued to develop the comprehensive care plan. SSD confirmed that different departments each put in their initial assessments for the baseline care plan within 48 to 72 hours. SSD said that they may see the residents right away, but if a resident was admitted on a Friday, it would be completed on a Monday. During an interview on 02/26/26 at 2:49 PM, Minimum Data Set Coordinator (MDSC) 2 stated that the baseline care plan was completed when the floor nurse documented their initial observations. MDSC2 said that the nurse would complete the initial observations daily, except when a resident was admitted on a Friday, which would mean the documentation would be completed on the following Monday. She said that the comprehensive care plan for a resident was developed within seven days of the MDS. MDSC2 said that the baseline care plan was the resident's basic care, which would include activities of daily living. She stated that the facility would add to the baseline care plan after they admit and then use it to develop the comprehensive care plan. She was not aware if specialty care needs would be included in a baseline care plan. During an interview on 02/26/26 at 4:25 PM, the Director of Nursing (DON) stated that the baseline care plan was attached to the initial nursing observation when a resident was newly admitted . The DON confirmed that the initial documented information was not resident specific. She said that the facility staff met with the resident and/or representative with the developed baseline care plan approximately three to five days after admission during the Path meeting. She confirmed the developed baseline care plan was not specific to resident care needs and was not provided in a timely manner to the resident or representative.Review of the facility's undated policy titled, Baseline Care Plan Protocol Checklist indicated, The Baseline Care Plan Protocol Checklist will trigger to be completed for all new admissions within the electronic chart system. Social Services or designee will check off each completed item, save, sign, and lock the assessment.A list of the resident's medications, therapy orders, and dietary instructions.print out orders.Social Service Recommendations Documentation.48 hour Interim/Baseline Care Plan.Social Services will bring the checklist to the Advance Care Planning meeting, and present one copy of all items to the resident/representative.Document on the Checklist the date the documentation was received by resident/representative.Review of the facility's policy titled, Comprehensive Care Planning Policy last reviewed 02/24/26 indicated, An interdisciplinary plan of care will be established and updated as indicated for every resident in accordance with state and federal regulatory requirements.An Interim baseline care plan will be developed within 48 hours of admission to ensure the resident's needs are met until the comprehensive care plan is completed.

Based on interviews, record review, and facility policy review, the facility failed to investigate a potential injury of unknown origin for one of four sample residents (Resident (R) 101) reviewed for allegations of abuse. The facility's failure to thoroughly investigate the injury had the potential to delay protective interventions for residents.Findings include:Review of R101's undated Face Sheet located in the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbances, restlessness and agitation, and bipolar disorder. R101 passed away on 10/18/25.Review of R101's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/29/25 located in the EMR with a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. Review of the facility reported incident (FRI), submitted to the state survey agency (SSA), dated 05/12/25 revealed R101 stated to the Director of Nursing (DON) on 05/12/25 at 7:00 AM .last night (05/11/25) certified nursing assistant [CNA 1] grabbed her hand and hit her face. Continued review of the FRI revealed an incident on 05/11/25 at approximately 10:00 PM when R101 became combative and displayed physical and verbal aggression during care with CNA1. Further review of the FRI revealed that R101 sustained a skin tear to her right fourth finger and a contusion to the right cheek.Review of the facility's investigation file for the incident dated05/11/25 revealed that CNA1 reported to Registered Nurse (RN) 1 that during care R101 became combative and physically aggressive, had grabbed CNA1's wrist and while CNA1 was pulling her hand back from R101, that R101 sustained a skin tear. CNA1 did not mention an injury to the right cheekbone area. RN1 assessed R101, provided treatment to the skin tear, and completed a full body/skin assessment with no other skin impairments noted. RN1 observed a contusion to R101's right cheekbone area, asked R101 what happened and R101 stated .that girl [CNA1] punched her.Review of RN1's written statement of the incident on 05/11/25 revealed CNA1 stated to RN1 .[CNA1] could have hit her face during when she [R101] was swinging. RN1 further noted that R101 .some bruising and mild swelling to under the right eye at bony area.Review of CNA1's written statement of the incident dated05/11/25 revealed, .lay the bed down to reposition [R101], resident grabbed my arm and started to swing at me. I pulled back my arm and resident's hand obtained a skin tear from my watch. A second statement from CNA1 on 05/12/25 provided to the DON revealed, .I do not remember coming in contact with her face at any time. All I remember is her hands swinging.Review of Licensed Practical Nurse (LPN) 2's written statement of the incident on 05/11/25 revealed, .witnessed [R101] had a swollen and discolored right eye (under eye) .and [CNA1] was unaware if [R101's] own hand hit her in the face and [CNA1] did not know how the resident's face got bruised.Continued review of the facility investigation file revealed an undated document titled Abatement Plan: Abuse Allegation which stated, .during care by CNA1 the resident became combative and sustained skin tear and hit self, causing swelling to affected eye. RN1 assessed resident, who at the time reported she was punched in the face. No additional documentation was noted in the facility investigation file, or R101's EMR, that ruled out, or mentioned any facial bruising noted prior to the incident on 05/11/25 at approximately 10:00 PM or possible causes for the contusion on the right cheekbone area. Further review revealed all staff who worked on R101's unit on 05/11/25 were interviewed about the incident. The staff stated that they did not hear, or see, anything occur between CNA1 and R101 but were not specifically asked about the contusion to R101's cheek.During an interview on 02/26/26 at 12:45 PM, RN1 confirmed R101 had been combative, and physically aggressive with CNA1 during care on 05/11/25. RN1 stated she had not observed any bruising to R101's right cheekbone area prior to the incident.During an interview on 02/26/26 at 2:00 PM, the Administrator and Director of Nursing (DON) stated that they were able to clearly identify how the skin tear to R101's right fourth finger occurred but were unable to determine the exact cause of the right cheekbone contusion. The DON confirmed during the interview the possibility that either CNA1, while attempting to remove herself from R101's grasp, may have made contact with R101's right cheekbone area, or R101 could have hit herself, causing the contusion. The DON stated they were unable to establish how the right cheekbone contusion happened and confirmed the documentation was not specific. The DON also stated that during the reenactment of the incident, it was more focused on how the skin tear occurred and not the contusion to the right cheekbone.Review of the facility's policy titled, Virginia Resident Abuse Policy revised 01/05/26, revealed, .After completion of the investigation, all of the evidence should be analyzed, and the Administrator (or his/her designee) will make a determination regarding whether the allegation or suspicion is substantiated, and, for Injuries of Unknown Source, a determination regarding the probable source of the injury.

Based on interviews, record review, document review and facility policy review, the facility failed to ensure allegations of staff-to-resident abuse were reported timely, and in accordance with federal reporting requirements, to the State Survey Agency (SSA) for one of four sample residents (Resident (R) 101) reviewed for allegations of abuse or neglect. The facility's failure to promptly report allegations of abuse limited regulatory oversight and had the potential to delay protective interventions for residents.Findings include:Review of R101's undated Face Sheet located in the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbances, restlessness and agitation, and bipolar disorder. R101 passed away on 10/18/25.Review of R101's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/29/25, located in the EMR revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. Review of the facility reported incident (FRI) submitted to the state survey agency (SSA), dated 05/12/25 revealed, [ R101] stated to the Director of Nursing (DON) on 05/12/25 at 7:00 AM .last night [05/11/25] certified nursing assistant (CNA) 1 grabbed her hand and hit her face. Continued review of the FRI revealed an incident on 05/11/25 at approximately 10:00 PM when R101 became combative and displayed physical and verbal aggression during care with CNA1. Further review of the FRI revealed R101 sustained a skin tear to her right fourth finger and a bruise under right eye/cheekbone area. Review of the facility investigation file for the incident that occurred on 05/11/25 revealed that CNA1 reported the combative episode with R101 to Registered Nurse (RN) 1 at approximately 10:00 PM. CNA1 stated that R101 had grabbed her wrist and while pulling her hand back from R101, that R101 sustained a skin tear. Continued review of the FRI revealed R101 stated to RN1, .staff (CNA1) had punched her. RN1 notified Licensed Practical Nurse (LPN) 2 of the incident and allegation made by R101 at approximately 10:15 PM. LPN2 stated to RN1 that LPN2 would notify the DON regarding the incident and allegation of abuse. Further review of the FRI revealed LPN2 did not notify the DON on 05/11/25. The DON became aware of the incident on 05/12/25 at 7:00 AM.During an interview on 02/26/26 at 12:45 PM, RN1 confirmed R101 had been combative, and physically aggressive with CNA1 during care on 05/11/25. RN1 also stated LPN2 informed her she would notify the DON. RN1 stated she put CNA1's statement and her statement under the DON's door at the end of her shift.Review of the FRI revealed the facility notified the SSA on 05/12/25 at 5:39 PM of the allegation of staff to resident abuse. During an interview on 02/26/26 at 2:00 PM, the DON stated that LPN2 did not notify her on 05/11/25 of the incident and allegation of abuse, and that she was informed on 05/12/25 at 7:00 AM. The DON confirmed that LPN2 should have notified her on 05/11/25 after R101 made the allegation of abuse. The DON also confirmed the initial notification to the SSA was 05/12/25 at 5:39 PM.Review of the facility's policy titled, Virginia Resident Abuse Policy revised 01/05/26, revealed, . All allegations of abuse, neglect, involuntary seclusion, injuries of unknown source and misappropriation of resident property must be reported immediately to the Administrator, DON and the applicable SSA. If the event that caused the allegation involves an allegation of abuse, it should be reported to the Department of Health (DOH) immediately, but not later than 2 hours after the allegation is made .

Based on observations, interviews and policy review, the facility failed to follow appropriate infection prevention practices for two of six residents (Resident (R) 69 and R110) observed during medication administration. This failure had the potential to expose the residents to contaminants in the environment.Findings include:Observation during medication administration on 02/26/25 at 09:01 AM, Licensed Practical Nurse (LPN)3 pierced the rubber septum of an insulin syringe without first cleaning the pen hub. LPN3 donned a gown and a pair of gloves without first performing hand hygiene and entered R110's room to give medications. LPN3 stated R110 was on contact precautions for Methicillin-resistant Staphylococcus Aureus (MRSA). On 02/26/25 at 9:03 AM, after administering R110's medication, LPN3 removed her gown and gloves, discarded them, and exited R110's room without performing hand hygiene. LPN3 returned to her medication cart, did not perform hand hygiene, reached into her pocket to retrieve the cart keys, touched her computer keyboard and mouse, and began to retrieve medications for the next resident.Observation on 02/26/25 at 9:04 AM, LPN3 retrieved medications for R69. LPN3 donned a pair of gloves without first performing hand hygiene and entered R69's room and used a glucometer to obtain R69's blood sugar level. However, was unable to obtain sufficient amount of blood from the finger to use the glucometer. LPN3 removed her gloves and exited R69's room without performing hand hygiene.Observation on 02/26/25 at 9:06 AM, LPN3 donned a pair of gloves to recheck R69's blood sugar. When this was completed, LPN3 removed her gloves, and returned to her medication cart. LPN3 did not perform hand hygiene.Observation on 02/26/25 at 9:10 AM, LPN3 applied a needle to an insulin pen without cleaning the hub of the pen. LPN3 donned a pair of gloves, gave the insulin medication per the insulin pen to R69, removed her gloves, and exited R69's room without performing hand hygiene. During an interview on 02/26/26 at 9:29 AM, LPN3 was told of the foregoing observations, and confirmed that she had failed to perform hand hygiene before donning gloves, in between glove changes, before and after entering residents' rooms, and from one resident's room to another. LPN3 acknowledged she did not scrub the insulin pens before applying a needle to the pensDuring an interview on 02/26/26 at 9:33 AM, LPN1 stated it was her expectation that LPN3 should perform hand hygiene before and after glove changes, and between residents' rooms. LPN1 stated it was also her expectation that LPN3 would scrub the hub of insulin pens before use.During an interview on 02/26/26 at 2:20 PM the Infection Preventionist (IP) stated it was her expectation that nurses perform hand hygiene before and after glove changes, and before entry, and after exiting residents' rooms. Review of facility's policy titled Hand Hygiene Policy dated 02/18/2026 revealed:.PROCEDURE:Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices Before moving from work on a soiled body site to a clean body site on the same patient After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal.

Based on observations, interviews, and review of facility policy, the facility failed to ensure that two of two residents' insulin pens (Resident (R) 110 and R69) were labeled with the date they were opened. This failure had the potential for medications to be administered past their use by date and affect the residents' quality of life.Findings include:Observation during medication administration on [DATE] at 9:00 AM, Licensed Practical Nurse (LPN)3 withdrew an insulin pen of Lantus (Insulin Glargine - long-acting insulin) from the medication cart for R110. The pen had a bright pink label on the base indicating good for 28 days. Interview on [DATE] at 9:04 AM, when asked when the insulin pen was first opened and used, LPN3 stated she did not know the open date, but she just knew it was good for 28 days. LPN3 confirmed the opened date was not written on the pen.Observation on [DATE] at 9:09 AM, LPN3 pulled an insulin pen of fast acting insulin (Novolog Aspart) from the medication cart for R69. The insulin pen was marked as good for 28 days but did not have an open date. LPN3 acknowledged the pen did not have an open date, and stated R69 was admitted on [DATE], so that must be the open date. LPN3 proceeded to mark the insulin pen with an open date of [DATE].During an interview on [DATE] at 9:33 AM, LPN1 stated it was her expectation that insulin pens should be marked with the date they are first opened and the last date of use per pharmacy and manufacturer instructions for use.During an interview on [DATE] at 2:20 PM, the Infection Preventionist (IP) stated it was her expectation that medications are not given beyond the use by dates and should be labeled with the opened and expiration dates.During an interview on [DATE] at 4:35 PM, the Director of Nursing (DON) stated it was her expectation that medications should be appropriately labeled.Review of the facility's policy titled Storage and Expiration Dating of Medications and Biologicals dated [DATE], revealed:.10. Facility should ensure medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier.11. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened.11.1 Facility staff may record the calculated expiration date based on date opened on the primary medication container.

Based on observation, staff interviews, and clinical record review, the facility staff failed to provide care and services to prevent pressure ulcer development and to identify a pressure ulcer prior to progression to an advanced stage for 1 of 37 residents, (Resident #15) and the facility staff failed to ensure the necessary assessment, treatment, care, and services was provided for 1 of 37 Residents (Resident #278) impaired skin to prevent deterioration, necessitating surgical debridement which constituted harm. The findings included: 1. The facility staff failed to provide care and services to prevent a pressure ulcer and to identify the pressure ulcer at an early stage; Resident #15's sacral pressure ulcer was first identified on 10/12/21 as unstageable (due to containing 70 percent of necrotic tissue), Resident #15 was originally admitted to the facility 03/29/2021 and readmitted [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/30/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #15's cognitive abilities for daily decision making were moderately impaired. In section G (Physical functioning) the resident was coded as requiring total care of one person with toileting and bathing, extensive assistance of one person with bed mobility, personal hygiene and dressing, limited assistance of one person with eating and she was coded activity didn't occur for transfers, walking and locomotion. The Braden Scale for Prediction of Pressure completed on 10/6/21; revealed Resident #15 had responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness or has a sensory impairment which limits the ability to feel pain or discomfort over half of the body, skin most often moist and linen must be changed at least once a shift, is bedfast-confined to bed, mobility is very limited-makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently, rarely eats a complete meal and generally eats only half of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement, and moves feebly or requires minimum. During a move, skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. The score was 14; indicating a high risk. On 1/13/21 at approximately an interview was conducted with Certified Nursing Assistant (CNA) #6 at approximately 2:15 p.m., who stated resident #15 requires total care, exhibited no behavioral concerns, is usually quiet, and enjoys eating. CNA #6 also stated the resident doesn't get out of bed to the wheelchair or participate in group activities. An observation was made on 1/12/21 at approximately 11:30 a.m. The resident was lying in a low air loss bed turned to partially face in the direction of the window. She appeared very pale, weak, fatigued, and with cachexia. The resident's speech was limited and she paused before she answered simple questions. The Resident was observed again 1/13/21 at approximately 9:00 a.m., in bed consuming breakfast. She was being fed by staff and appeared to enjoy the meal. She accepted 100 percent of the oatmeal, bread, and thickened water and tolerated only two small spoonful's of the eggs. On 1/13/21 at approximately 12:35 p.m., the resident was observed being fed the midday meal by staff. She accepted 100% of the pureed bread, magic cup, fortified potatoes, and rejected the puree chocolate cake. Neither of the two observed meals had protein or a protein substitute on the tray other than the eggs at breakfast. The resident asked if there was any milk at the midday meal. Review of the facility's matrix revealed Resident #15 had a facility acquired pressure ulcer, currently staged at a stage III. Review of the clinical record revealed upon admission from the hospital on 10/6/21, Resident #15 had redness to the sacrum. Further review of the weekly skin evaluations provided no evidence that the redness to Resident #15 sacrum on 10/6/21 was a pressure ulcer. An additional skin evaluation completed on 10/7/21 read blanchable redness (indicates an area of skin that has been subjected to pressure and other forces) to the sacrum and the 10/8/21 skin evaluation read new onset; open area to the coccyx measuring 1.5 cm x 1.5 cm. The documentation further read the opened area was covered with bruised tissue with a small amount of serosanginous discharge but there was no odor. After the 10/8/21 weekly skin assessment there wasn't evidence of another until 11/29/21. The weekly skin evaluation continued through 12/27/21 and stopped again. No weekly skin assessments were available on the clinical record for January 2022. Blanchable [CONDITION(S)] is not considered a pressure injury but an important warning sign that preventive measures are needed. If, however, the forces are not removed, blanching [CONDITION(S)] can quickly develop into a pressure injury (https://www.ncbi.nlm.nih.gov/books/NBK 1/#:~:text=Blanchable%20erythema%20is%20not%20considered,blanchable%20erythema%20of%20intact%20skin.) Review of Resident #15's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 10/11/21, skin checks weekly day shift on Monday. Notify the physician of any abnormal findings. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was also no weekly wound assessment on the clinical record until 10/8/21, for the new onset coccyx wound and it had no treatment plan. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 1/13/21 at approximately 2:40 p.m. LPN #1 stated Resident #15 was readmitted to the facility 10/6/21 with blanchable redness to the sacrum which progressed to the current pressure. LPN #1 also stated pressure ulcer are assessed weekly by the wound care physician if no other outside practice is treating the specified area but if for some reason the wound care physician can't keep the regular visit LPN #1 assesses and documents on the wounds. Review of the in-house weekly wound assessment dated [DATE] 12:00 a.m., read as follows; Wound type is pressure. Stage: Unstagable Wound Location coccyx. The measurements are Length (cm) 2.0, Width (cm) 1.5, and Depth (cm) 0.0. The area is community acquired. Skin impairment was present on admission, 10/06/2021 Drainage type: No Drainage Wound bed has Slough, No odor. Periwound appearance is Pink. Wound is unchanged. Pain Level is zero. The treatment is Santyl. Review of the wound care physician's progress note dated 10/12 21 read initial evaluation; Full Thickness. Resident presents with a wound on her sacrum; at the request of the referring provider, (name of the provider) a thorough wound care assessment and evaluation was performed today. The sacral wound is unstageable (due to necrosis). There is light serous exudate. The patient appears to have associated pain evidenced by restlessness and grimacing. The etiology was pressure. The pressure ulcer measured 2.0 centimeter by 1.5 centimeters and presented with 40 percent necrotic tissue, 30 percent devitalized necrotic tissue and 30 percent granulation tissue. The treatment plan was Dakins apply once daily for 30 days, Santyl apply once daily for 30 days, Gauze island with a border apply once daily for 30 days and Skin prep apply once daily for 30 days. The wound care physician's 10/19/21 wound care progress continued to address treatment to an unstageable sacral pressure ulcer which; was debrided that day to remove necrotic tissue and establish the margins of viable tissue. Resident #15 remained under the wound care physician's care for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was made of Resident #15's sacral wound on 1/13/21 at approximately 10:10 a.m. The wound bed was clean, beefy red and with a small amount of drainage. The wound care was tolerated well by the resident. She was wearing pressure relieving boots to bilateral lower extremities. An interview was conducted with the wound care physician by phone on 1/14/21 at approximately 11:40 a.m. The wound care physician stated it appears the delay in notifying her of the areas of concern compromised Resident #15. The wound care physician stated there is no reason for delays in wound care assessment and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound care physician stated she would have been instituted orders immediately for pressure ulcer prevention. On 1/14/22 at approximately 1:30 p.m., the above information was shared with the Administrator, Director of Nursing and Corporate Consultant. They provided additional documents on 1/18/22 at approximately 9:00 a.m., for consideration regarding the above information. That information is reflected in this report. The below information was obtained 1/21/22 from (https://medlineplus.gov/ency/patientinstructions/ 7.htm) Preventing pressure ulcers Pressure ulcers are also called bedsores, or pressure sores. They can form when your skin and soft tissue press against a harder surface, such as a chair or bed, for a prolonged time. This pressure reduces blood supply to that area. Lack of blood supply can cause the skin tissue in this area to become damaged or die. When this happens, a pressure ulcer may form. You have a risk of developing a pressure ulcer if you: · Spend most of your day in a bed or a chair with minimal movement · Are overweight or underweight · Are not able to control your bowels or bladder · Have decreased feeling in an area of your body · Spend a lot of time in one position You will need to take steps to prevent these problems; you, or your caregiver, need to check your body every day from head to toe. Pay special attention to the areas where pressure ulcers often form. These areas are the; heels and ankles, knees, hips, spine, tailbone area, elbows, shoulders and shoulder blades, back of the head, and the ears. After urinating or having a bowel movement; clean the area right away. Dry well, and ask your provider about creams to help protect your skin in this area. Call your health care provider if you see early signs of pressure ulcers. These signs are: Skin redness, Warm areas, Spongy or hard skin, Breakdown of the top layers of skin or a sore. The below information was obtained 1/21/22 from (https://www.ncbi.nlm.nih.gov/books/NBK2650/table/ch12.t2/) National Pressure Ulcer Staging System Stage III - Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Unstageable - Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. 2. The facility staff failed to ensure the necessary assessment, treatment, care, and services was provided to Resident #278 to promote healing of excoriations, and intact and opened blisters of bilateral buttocks. The deterioration of the right buttock resulted in an unstageable pressure ulcer and the deterioration of the left buttock resulted in a stage III pressure ulcer; both presenting with necrotic tissue necessitating surgical debridement. Resident #278 was originally admitted to the facility 5/14/21 and discharged from the facility 5/28/21 after becoming ill during a [CONDITION(S)] session. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/20/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #278's cognitive abilities for daily decision making were moderately impaired. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of two people with bed mobility, extensive assistance of one person, with toileting, supervision of two people with transfers, and supervision after set-up with eating. In Section M (Skin Conditions) the resident was coded for having one stage III pressure ulcer on admission and one unstageable pressure ulcer present on admission. The Braden Scale for Prediction of Pressure Ulcers was completed 5/21/21. The Resident scored 18.0, which indicated he was a Low Risk Resident. The resultes revealed Resident # 278; Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain. Skin is usually dry, linen only requires changing at routine intervals. Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. Makes frequent though slight changes in body or extremity position independently. Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. Review of the admission weekly skin assessment revealed the following skin impairments; a tunneled [CONDITION(S)] catheter to the chest, left upper area has bruises/discoloration, scattered tiny bruises to the abdomen, an old scar to the mid abdomen, redness, irritation with excoriations to the groin, excoriations and blisters some are intact and some burst at different shapes and sizes of the right buttock, excoriations, blisters of the left buttock; some are intact and some burst open at different sizes and shapes, moist, reddened and excoriated sacrum, moist, reddened and excoriated coccyx, red and moist areas to the left inner leg, left hip has surgical incision with staples, well approximated, left upper outer thigh has short surgical incision with 2 staples, left lower outer thigh has surgical incision with 2 staple, well approximated, a left outer heel scab, a middle left toe scab, right first and 4th toes has scab on top of each, and old amputations of the 2nd and 3rd toes. Review of the active care plan dated 5/15/21 revealed a problem which read; Resident has impaired skin integrity; surgical wound to the left upper outer thigh/left hip. The goal read; area will show signs of improvement and be free of signs/symptoms of infection. The interventions included; Administer medications as ordered. Administer treatments as ordered. Assess and document the status of the area (healing vs declining. Monitor and report to the physician, redness, swelling, local warmth, tenderness, discharge, elevated temperature. Another care plan dated 5/15/21 revealed a problem which read; Resident has a potential for skin breakdown due to decreased mobility. The goal read; the resident will maintain intact skin. The interventions included; complete the Braden scale per protocol. Complete the skin assessment per protocol. Diet as ordered. Turn and reposition as indicated. Use pressure relieving devices as indicated. Review of the resident's admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Skin checks twice weekly every day shift on Monday and Thursday for prevention report to the physician any abnormalities. Turn and re-position every two hours as tolerated while in bed, every shift for prevention. An excoriation is a scratch/abrasion to the skin. Opened blisters to the buttock are classified as pressure ulcers. A stage II pressure ulcer is a partial thickness skin loss involving the epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater; partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed without slough. May also present as an intact or open/ruptured serum-filled blister. (Obtained from the following website 1/25/22; https://www.ncbi.nlm.nih.gov/books/NBK2650/table/ch12.t2/) [MEDICATION(S)] Ointment 0.44-20.6 % (Menthol-[MEDICATION(S)]); this medication is used to treat and prevent minor skin irritations (such as from diarrhea, [CONDITION(S)], cuts, scrapes). It works by forming a barrier on the skin to protect it from irritants/moisture. (https://healthy.kaiserpermanente.org/health-wellness/drug-encyclopedia/drug.[MEDICATION(S)]-0-44-20-6-topical-ointmentXXX 6). No further wound care orders were noted to the buttocks until 5/18/21. New orders for wound care dated 5/18/21 read as follows; Santyl Ointment 250 UNIT/GM ([MEDICATION(S)]) Apply to the left buttock topically every day shift for wound care. Cleanse with normal saline, pat dry, apply Santyl followed by calcium alginate, cover with a dry dressing, and change every day and as needed. Santyl Ointment 250 UNIT/GM ([MEDICATION(S)]) Apply to the right buttock topically every day shift for wound care. Cleanse with normal saline, apply [MEDICATION(S)] to eschar areas, and apply Santyl to open areas, cover with dry dressing, change every day and as needed. Resident #278 was seen by the wound care physician on 5/19/21. The documentation revealed the following; the etiology of the wound to the left buttock was pressure. It was classified as a stage III pressure ulcer measuring 5.5 centimeters by 3.0 centimeters by 0.2 centimeters. It was with a moderate amount of serosanguinous drainage, 40 percent thick adherent devitalized necrotic tissue and 60 percent granulation tissue. The etiology of the wound to the right buttock was also pressure and it consisted of a cluster of wounds. It was classified as unstageable, measuring 9.0 centimeters by 13.0 centimeters. It was with a moderate amount of serosanguinous drainage, 50 percent thick adherent black necrotic tissue (eschar), 20 percent granulation tissue and 30 percent skin. The left buttock pressure ulcer treatment orders for 5/19/21 were as follows; Alginate calcium apply once daily for 30 days; Santyl apply once daily for 30 days. Gauze island with a border, apply once daily for 30 days. Skin prep apply once daily for 30 days. The recommendations were as follows; Low air loss mattress; Off-load wound; Reposition per facility protocol. The right buttock pressure ulcer treatment orders for 5/19/21 were as follows; Alginate calcium apply once daily for 30 day: to all medial open areas; Santyl apply once daily for 30 days: to all medial open areas. [MEDICATION(S)] apply once daily for 30 days : to all eschar areas. Gauze island with a border, apply once daily for 30 days. Skin prep apply once daily for 30 days. The recommendations were to off-load the wound and reposition per facility protocol. The wound care physician assessed Resident #278's bilateral buttock pressure ulcer again on 5/25/21. The left buttock measured 4.5 cm by 1.0 cm by 0.2 cm, with a Moderate amount of serosanguinous drainage 40 percent thick adherent devitalized necrotic tissue and 60 percent granulation tissue. The right buttock measured 10.5 cm by 11.0 cm by not measurable cm with 50 percent thick adherent black necrotic tissue (eschar), 20 percent granulation tissue and 30 percent skin. Review of the hospital records dated 5/28/21 revealed the resident was admitted with a right buttock pressure ulcer which included multiple skin necrosis and overall redness. The infected pressure ulcer may be contributing to his leukocytosis. Will plan for the operating room tomorrow for debridement (removal of necrotic tissue from a wound) of the right buttock ulcers. The plan is to remove the necrotic skin and debride unhealthy tissue underneath. An interview was conducted with Resident #278's daughter on 1/14/22 at approximately 10:45 a.m. The daughter stated she was unable to visit the resident because of COVID-19 restrictions and when she called the facility the nurses dismissed her concerns and talked negatively about her father. The daughter also stated she wasn't informed about her father's pressure ulcers by the facility's staff. The daughter further stated her father never recovered from the pressure ulcers acquired even after multiple surgeries. An interview was conducted with the wound care physician by phone on 1/14/21 at approximately 11:40 a.m. The wound care physician stated it appeared the delay in notifying her of the areas of concern compromised Resident #278's coordination of care. The wound care physician stated there is no reason for delays in wound care assessment and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/14/22 at approximately 1:30 p.m., the above information was shared with the Administrator, Director of Nursing and Corporate Consultant. They provided additional documents on 1/18/22 at approximately 9:00 a.m., for consideration regarding the above information. That information is reflected in this report. COMPLAINT DEFICIENCY

Based on staff interviews, clinical record review and facility documentation the facility staff failed to revise 1 of 37 residents (Resident #47) comprehensive personal centered care plan in the survey sample. The finding include: The facility staff failed to revise Resident #47's comprehensive person centered care plan to include parameters of antibiotics, monitoring for side effects of antibiotics. ([MEDICATION(S)] and [MEDICATION(S)]). The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/14/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible. This indicated Resident #47 cognitive abilities for daily decision making were intact. The resident's MDS was coded for the usage of antibiotic medications. Section N on the MDS under medications reads as follows: Indicate the number of DAYS the resident receiving the medication during the last 7 days, the MDS was coded for receiving an antibiotics for 2 days In sectionG(Physical functioning) the resident was coded as requiring Extensive assistance of one person with bed mobility, dressing and personal hygiene. Total dependence of one person with eating, toilet use and bathing. According to the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 23:59 (11:59 PM) for 27 doses Verbal Order Date: 12/10/2021. Start Date: 12/10/2021 End Date: 12/19/2021. [MEDICATION(S)] Tablet 500 MG ([MEDICATION(S)]) Give 1 tablet by mouth in the morning for [CONDITION(S)] (Urinary Tract Infection) until 12/14/2021 23:59 (11:59 PM). Order Date: 12/10/2021. Start Date:12/11/2021 End Date: 12/14/2021. *[MEDICATION(S)] ([MEDICATION(S)]) is used to treat certain infections caused by bacteria such as pneumonia and other respiratory tract infections; and infections of the bone, skin, ears, , genital, and urinary tract. [MEDICATION(S)] is in a class of medications called cephalosporin antibiotics. It works by killing bacteria. Antibiotics such as [MEDICATION(S)] will not work for colds, flu, or other [CONDITION(S)] infections. Using antibiotics when they are not needed increases your risk of getting an infection later that resists antibiotic treatment. https://medlineplus.gov/druginfo/meds/a 3.html [MEDICATION(S)] is used to treat certain infections such as pneumonia, and kidney, prostate (a male reproductive gland), and skin infections. [MEDICATION(S)] is also used to prevent [CONDITION(S)] (a serious infection that may be spread on purpose as part of a bioterror attack) in people who may have been exposed to [CONDITION(S)] germs in the air, and treat and prevent plague (a serious infection that may be spread on purpose as part of a bioterror attack. [MEDICATION(S)] may also be used to treat [CONDITION(S)], sinus infections, or urinary tract infections but should not be used for [CONDITION(S)] and certain types of urinary tract infections if there are other treatment options available. [MEDICATION(S)] is in a class of antibiotics called fluoroquinolones. It works by killing bacteria that cause infections. Antibiotics such as [MEDICATION(S)] will not work for colds, flu, or other [CONDITION(S)] infections. Using antibiotics when they are not needed increases your risk of getting an infection later that resists antibiotic treatment. https://medlineplus.gov/druginfo/meds/a 0.html#:~:text=[MEDICATION(S)]%20is%20in%20a%20class,flu%2C%20or%20other%20viral%20infections The review of the Resident #47's comprehensive care plan did not include a care plan to include parameters of antibiotics, monitoring for side effects of antibiotics. On 1/18/22 at approximately 5:30 PM., an interview was conducted with the MDS Coordinator/LPN (Licensed Practical Nurse) #5. She stated, It's listed in the care plan that resident has pneumonia. Interventions are listed. The MDS Coordinator handed the surveyor the care plan. A pre-exit interview was conducted on 1/18/22 at approximately 5:45 PM., the above findings were shared with the Administrator, The Corporate Consultant and the DON (Director of Nursing). The DON stated, The nurses should complete the care plan.

Based on staff interview and facility documentation review, the facility staff failed to implement their abuse policy regarding the screening of employees for 2 employees, Dietary Employee #3 and LPN #2, in a sample of 20 employee records reviewed. The findings included: On 1/12/22, a review of 20 employee files was conducted and revealed the following: 1. The facility staff failed to obtain a criminal background check within 30 days of hire for 1 Employee, Dietary Employee #3. A criminal background check request for Dietary Employee #3 was received on 11/23/20 by The Central Criminal Records Exchange of the Virginia State Police and indicated, Transaction being Processed. Dietary Employee #3 was hired by the facility on 11/24/20. On 1/12/22, the findings for Dietary Employee #3 were shared with the HR Director and the Facility Administrator who stated they were unable to locate any results for the Criminal Background Check that was submitted on 11/23/20 for Dietary Employee #3, therefore, facility staff have not confirmed Dietary Employee #3's criminal background status. Review of the facility's policy entitled, Virginia Resident Abuse Policy, last revision date 5/26/2021, subheading, Procedure--Screening, item 1 read, It is the policy of the Facility to undertake background checks of all employees and to retain on file applicable records of current employees regarding such checks .a. The Facility will do the following prior to hiring a new employee: iv. Conduct a criminal background check in accordance with State law and Facility policy . 2. The facility staff failed to verify the professional license was active and in good standing for LPN #2 prior to allowing LPN #2 to provide direct resident care. LPN #2 was hired on 5/13/21. LPN #2's professional license verification was dated 9/8/21. Therefore, from 5/13/21-9/8/21, facility staff was unaware if LPN #2's license was active and in good standing. Additionally, on the license verification dated 9/8/21, there was no indication that LPN #2's professional license was unencumbered and in good standing. LPN #2 was permitted to provide direct care to Residents beginning on 5/20/21 which was confirmed by the Human Resources Director. An interview was conducted with the Human Resources (HR) Director and the Facility Administrator who confirmed the hire date for LPN #2. The Human Resources Director stated, The purpose of obtaining a license verification is to make sure that they [nursing staff] have an active license that is in good standing, that there is no disciplinary action against their professional license. The HR Director confirmed that the license verification for LPN #2 had not occurred until 9/8/21 and there was no indication of whether or not the license was in good standing. Review of the facility's policy entitled, Virginia Resident Abuse Policy, last revision date 5/26/2021, subheading, Procedure--Screening, item 1 read, It is the policy of the Facility to undertake background checks of all employees and to retain on file applicable records of current employees regarding such checks .a. The Facility will do the following prior to hiring a new employee: iii. Check with all applicable licensing and certification authorities to ensure that employees hold the requisite license and/or certification status to perform their job functions and have no disciplinary action as a result of abuse or neglect . The findings were shared with the Facility Administrator and HR Director. No further information was received.

Based on resident interview, staff interviews and clinical record review, the facility staff failed to ensure a recommended referral from the Ophthalmologist for cataract extraction was provided for 1 of 37 residents (Resident #46) in the survey sample. The findings included: Resident #46 was originally admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #46's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 12/13/21 coded the resident's Brief Interview for Mental Status (BIMS) score 15 of a possible 15 with no cognitive impairment for daily decision-making. In section G (Physical functioning) the MDS coded Resident #46 requiring total dependence of one with bathing, limited assistance of one with dressing, hygiene, bed mobility and toilet use and supervision with one assist with transfer and eating for Activities of Daily Living (ADL) care. The care plan with a created on 01/13/22 identified Resident #46 with the potential to decline in her visual status related to her cataract. The goal set for the resident by the staff is to be able to safely participate in ADL's and remain free from complications related to cataract. Some of the interventions/approaches the staff would use to accomplish this goal is schedule appointment for a cataract follow up, maintain room free of clutter and place call bell, water pitcher, personal belongings always in the same place. On 01/12/22 at approximately 11:55 a.m., an interview was conducted with Resident #46 who stated, The eye doctor saw me about (3-4 months) and said I needed to come to his office because I may need to have cataract surgery. She said I never heard anything back related to my follow up appointment with the eye doctor. Review of Resident #46's clinical record a Summary Ocular Progress Note dated 09/24/21 revealed the following information: -Chief compliant: blurred vision; hard to see at a distance. -Physician orders: Cataract OU (both eyes) moderate progressive - recommended referral for cataract extraction. An interview was conducted with the Social Worker on 01/12/22 at approximatley 3:19 p.m. He (SW) said the information related to the referral for cataract extraction was given to the old Unit Manager. The SW reviewed the resident clinical record then stated, I do not see a follow-up note or an upcoming appointment. A nurses' note entered by the Social Worker on 1/13/22 at approximately 5:22 p.m., revealed the following: Social Worker called (name of eye center) to make an appointment for resident to have a cataract evaluation as requested by (name of Ophthalmologist). Social Worker scheduled the appointment for 1/19/22 at 8:00 AM and faxed referral paperwork to the office. Social Worker informed the resident of her appointment and confirmed resident was agreeable to the early appointment time. Transportation arranged through resident's Medicaid with a 7:00 AM pickup time. Social Worker called the resident's daughter and informed her of the appointment. A debriefing was conducted with the Administrator, Director of Nursing and Corporate on 01/17/22 at approximately 4:05 p.m. The Administration team were informed of the above findings; no further information was provided prior to exit. The facility's policy titled Social Services Policy with a revision date of 04/16/21. Policy: The facility provides social services to assure that each resident can attain or maintain his/her highest practicable physical, mental and/or psychosocial well-being. -Procedure: K. Responsible to coordinating needed ancillary services (ie Dental, Audiologist, and Optometrist), including ensuring consent forms are completed. (1) Social Services/designee will ensure referrals are made when need and (2) Social Services/designee will ensure follow up on any ancillary needs. Definitions: A Cataract is a clouding of the lens in your eye. It affects your vision. [CONDITION(S)] are very common in older people (https://medlineplus.gov/cataract.html).

Based on clinical record review, staff interviews and facility documentation, the facility staff failed to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #281 was originally admitted to the facility 01/7/22 and had not been discharged . The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment had not been completed therefore; information was gained from Licensed Practical Nurse (LPN) #3. LPN #3 stated the resident was alert and oriented to person, family, situation and place but required assistance to make daily decisions. LPN #3 also stated the resident required total care with all care including eating and she required use of an indwelling catheter. On 1/12/22 at approximately 10:15 a.m., Resident #281 was observed sitting across from the nursing station. The resident's head was lowered and her nose was draining a large amount of thick light yellow [MEDICATION(S)] which the Resident wiped away with the back of her hand. The Resident appeared very pale, had facial bruising and spoke very softly. She was wearing an untied hospital gown, had a blanket over her lap, her hair was severely matted and the catheter drainage bag was very full, containing approximately 800 milliliter of light but cloudy urine. The Resident stated she had a stroke and was found on the floor by her daughter and she had come to the facility to regain her strength after hospitalization . On 1/13/22 at approximately 9:50 a.m., Resident #281 was observed in bed. The floor near the catheter drainage bag had a large amount of fluid on the floor. Certified Nursing Assistant (CNA)#1 stated she saw what was wrong the drainage bag and proceeded to clean the fluid off of the floor. Review of the Admission assessment completed 1/7/22 was coded to indicate Resident #281 had bladder incontinence and the box for urinary catheter was not coded. Review of the hospital's discharge summary dated 1/7/22 revealed the resident had [CONDITION(S)] requiring placement of a Foley. Review of a progress note dated 1/8/22 at 13:53 which read; Urinary Elimination: Resident has voided this shift: within normal limits, Resident has urinary catheter. Urinary catheter was noted to be patent. A progress note on 1/10/22 read; Urinary Elimination: Resident has voided this shift: yellow Resident has urinary catheter. Urinary catheter was noted to be patent. Urinary catheter is draining. Urinary catheter is anchored. A progress note on 1/10/22 read; Urinary Elimination: Resident has voided this shift: within normal limits. Resident has urinary catheter. Urinary catheter was noted to be patent. Urinary catheter is draining. Urinary catheter is anchored. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Document Foley output every shift. Foley catheter care every shift and as needed. Further review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the baseline care plan dated 01/09/22 which read; Resident is incontinent of bladder. The goal read; Resident will receive assistance with toileting, maintain comfortable, clean and dry, and free from skin breakdown. The interventions included; Assess resident pattern of urination and episodes of incontinence. Provide incontinence care as needed. Monitor peri-area for redness, irritation, skin excoriation/breakdown. The baseline care plan didn't address requiring the use of an indwelling catheter. On 1/13/22 at approximately 10:25 a.m., an observation was made of the indwelling catheter currently inserted in Resident #281 with LPN #2. It revealed a 16 french with a 30 cubic centimeter balloon. An interview was conducted with LPN #2. LPN #2 stated there wasn't an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #2 obtained an order on 1/13/22 for the indwelling catheter use of an indwelling catheter 16 french with a 30 cc balloon secondary to [CONDITION(S)]. On 1/14/22 at approximately 1:30 p.m., the above information was shared with the Administrator, Director of Nursing and Corporate Consultant. The facility's staff was offered the opportunity to provide additional information but they did not.

The facility staff failed to ensure one resident with a potential for weight loss received adequate protein, portion sizes, and preferences at each meal, and to obtain weights as a means of measuring weight management for Resident #15, failed to obtain weekly weights for Resident #47 and failed to record meal consumption for Resident #127. The findings included: 1. Resident #15 was originally admitted to the facility 03/29/2021 and readmitted [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARID) of 10/30/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #15's cognitive abilities for daily decision making were moderately impaired. In section G (Physical functioning) the resident was coded as requiring total care of one with toileting and bathing, extensive assistance of one person with bed mobility, personal hygiene and dressing, limited assistance of one person with eating and coded activity didn't occur for transfers, walking and locomotion. In section K Swallowing/Nutritional Status the resident was coded no loss of liquids/solids from mouth when eating or drinking, no holding food in mouth/cheeks or residual food in mouth after meals, no coughing or choking during meals or when swallowing medications and no complaints of difficulty or pain when swallowing but the resident was coded for weight Loss of 5% or more in the last month or loss of 10% or more in last 6 months without being on a prescribed weight loss regimen. The current physician ordered diet dated 10/25/21 read; Low Concentrated Sweets diet Pureed texture, Nectar consistency, Mechanical soft snacks for pleasure. The following orders were also noted; 03/29/21 Cardiac diet Regular/Ground texture, thin consistency 04/23/2021 Magic cup one time a day to prevent weight change, send with lunch. 5/7/21 Med Pass 2.0 to prevent weight change; Give by mouth 240 cc (cubic centimeter) three times each day. 10/6/21 [MEDICATION(S)] ES (extra strength) Suspension 625 MG/5ML; Give 5 ml by mouth one time a day for Low prealbumin. 10/12/21 Pro-Stat AWC (Advanced Wound Care) Give by mouth 30 cc two times each day. A current care plan problem dated 7/3/21 read; the resident has unplanned/unexpected weight loss related to poor food intake. The goals read; the resident's weight will return to baseline range between 2-4 pounds by review date and the resident will consume 50 percent of two of three meals per day through the review date. The interventions included; assist/feed all meals as needed. Give resident supplements as ordered. Labs as ordered and Report results per protocol. Monitor and record food intake at each meal. Fortified foods, Offer substitutes as requested or indicated. Weights per orders. Monitor/assess and evaluate any weight loss. Refer to physician any significant findings. Review of the resident's weights revealed on 3/30/21, the resident weighed 150.0 pounds and they fluctuated between 150 and 172 pounds until 5/1/21 when a weight of 116 pounds was obtained. The resident was reviewed in the Nutrition at Risk Committee meeting 5/7/21 and the 40 pound weight loss, (a loss of 25 percent of the resident's body weight) was addressed. The notes stated the rationale for weight change was poor by mouth intake, use of the diuretic [MEDICATION(S)], a texture change and congestive heart failure. The intervention was to add Medpass. During the Nurse Practitioner's (NP) regulatory visit on 5/11/21 the resident weight loss was addressed as follows; current weight is 118 pounds, at the last regulatory review the weight was 152 pounds. This gives a Body mass index of 23.6 putting the resident in the normal weight category. The NP plan read; draw a complete blood count with differential, basic metabolic panel and pre-[MEDICATION(S)] late fall. The NP further documents the resident/nursing offers no concerns as it relates to adequate nutrition, sleep, pain and elimination of bowel or bladder. After the facility staff identified the 40 pound weight loss on 5/1/21, the Registered Dietitian (RD) recommended Medpass supplements three times daily which was ordered and the NP ordered late fall labs and [MEDICATION(S)] 100 milligrams by mouth daily for 2 weeks for oral candidiasis (yeast). No immediate labs were ordered and no root cause analysis was conducted to determine a plan of action to prevent further weight loss. Neither was there documentation that a physical assessment was conducted to identify true signs and symptoms of rapid weight loss such as; sagging skin, muscle wasting, etc. Additionally there was no documentation that the significant weight loss was addressed with the resident and the responsible party. Further there was no evidence the facility staff addressed the rationales for the weight loss identified by the RD on 5/7/21; a rationale for poor by mouth intake, no change was made in the diuretic dosage, no change was made in the diet texture and a congestive heart failure work up wasn't conducted. During the month of May 2021 the resident's weight fluctuated between 109 and 119 pounds, in June 108 and 119. On 6/23/21 the resident's weight loss was addressed by the NP because the son had voiced concern about the Resident's nutritional status. The NP ordered [MEDICATION(S)] 30 milligrams at bedtime which was started on 6/23/21 and a RD consult. The 7/6/21 RD consult revealed the resident's weight was 108 pounds; recommendations were given for fortified potatoes at lunch daily, extra margarine, gravies, whole milk and meats, an appetite stimulant, and to increase the Medpass to three time each day. The [MEDICATION(S)] was ordered 7/9/21. On 7/12/21 a Cardiac/Low Concentrated Sweet diet Regular/Ground texture, thin consistency was ordered secondary to an elevated A1C. The resident's weight was 108 pounds. The resident was reviewed also in the Nutrition at Risk Committee on 7/30/21 for a low pre-[MEDICATION(S)] levels, 8/6/21 for weight and skin concerns, the weight remained 108 pounds. On 8/20/21 the resident was reviewed in the Nutrition at Risk Committee for a skin disorder, adding the supplement Zinc. From 8/20/21 through 10/27/21 the resident's weight fluctuated between 99 and 109, then no further weights were obtained. Interventions were instituted to include increasing the fortified potatoes to lunch and dinner, calorie counts, starting Prostat AWC. The resident's last review by the Nutrition at Risk Committee was 10/12/21 and the last RD consult was 10/30/21. After the 10/27/21 weight no further weights were obtained for the resident even though her lasted recorded weight indicated she had lost forty-six pounds since admission to the facility. Calorie Counts were instituted 7/23/21 and 8/1/21 but there was no evidence of evaluation of the calorie counts and no evidence interventions were necessary/initiated based on the calorie count information Review of the clinical record revealed a Nutritional assessment dated [DATE]. It read the resident consumed 25-50 percent of all meals and the resident had an estimated fluid intake of 1,060 milliliters per day and the resident's current diet provided 1,700 calories, 90 grams of protein and 1,700 milliliters of fluids per day. An observation was made on 1/12/22 at approximately 11:30 a.m. The resident was lying in bed partially facing the window. She appeared very pale, weak, fatigued, and with cachexia. The Resident's speech was limited and there was a pause before she answered simple questions. The resident was observed again 1/13/22 at approximately 9:00 a.m., in bed consuming breakfast. She was being fed by Certificate Nursing Assistant (CNA) #6 and appeared to enjoy the meal. She accepted 100 percent of the oatmeal, bread, and thickened water (4 ounces) and tolerated only two small spoonful of the eggs. The listed items were the only items served at that meal. On 1/13/22 at approximately 12:35 p.m., the resident was observed being fed by CNA #6 again. She accepted 100% of the pureed bread, magic cup, fortified potatoes, and rejected the puree chocolate cake. The resident asked if there was milk with the meal. The listed items were the only items served at that meal. There was no protein or a protein substitute on the tray for the two observed meals other than the eggs at breakfast which the resident didn't appear to tolerate Further review of the clinical record revealed the resident required intravenous fluids in the nursing facility 7/12/21, 7/15/21, 8/1/21, 10/25/21 and 11/12/21. Intravenous (IV) fluid therapy is used to prevent or correct problems with fluid and/or electrolyte status. (https://pubmed.ncbi.nlm.nih.gov/ 240/) An interview was conducted with CNA #1 on 1/13/22 at approximately 2:10 p.m. CNA #1 stated the resident is fed and receives total care. She stated often the resident receives yogurt for breakfast and she eats 100% of it and the oatmeal. She also stated the resident consumes approximately two spoonful of the eggs and never the gritty white item served. CNA #1 stated the resident enjoys any sweet foods, applesauce and milk but recently she hadn't seen milk on the tray, just thickened water. CNA #1 stated she also hadn't seem cottage cheese served to the resident. An interview was conducted with CNA #6 on 1/13/22 at approximately 2:15 p.m., she stated Resident #15 is fed and all of her care is provided by the staff. CNA #6 also stated the resident enjoys her meals and usually ask if there is more after consuming the items she enjoys on her tray. CNA stated no one has asked about which items on the resident's tray are usually consumed or about items the resident doesn't eat or tolerate. Review of the Resident's food intake from 12/13/21 through 1/13/22 revealed ninety-six meals were served and the percentage eaten of the ninety-six meals was of the documented only thirty-seven times. Out of the thirty-seven documented meals the resident consumed seventy-six to one hundred percent of thirty-two meals. An interview was conducted with LPN #2 on 1/13/22 at approximately 1:50 p.m. LPN #2 stated the resident required assistance with meals and the resident had experienced a decreased appetite. LPN #2 also stated the resident didn't have a current order to obtain weights therefore the protocol was to weigh each resident once per month unless there were other orders such as daily, weekly, etc. On 1/13/22 at approximately 2:20 p.m., staff provided the results of the weight obtained for Resident #15. She weighed 98.3 pounds for a total loss of 51.7 pounds. On 1/13/22 at approximately 2:35 p.m. an interview was conducted with the Dietary Manager (DM) and the RD concerning the resident's weight loss, food preferences, food portions, and lack of protein monitoring at meals. The DM stated to resident should have received cottage cheese for the protein substitute breakfast and lunch on 1/13/22 and for some reason it wasn't served. The DM also stated the resident doesn't eat meats except chicken therefore; the yogurt and cottage cheese are used as the resident's protein substitutes. The DM further stated she wasn't aware of the resident's intolerance of eggs, or a preference for milk and she would review serving sizes with the dietary staff as well as visit the resident to update her preferences. The RD stated she would conduct a nutritional review for Resident #15 and make recommendations based on the review. The RD also stated there was no need to review the resident's pre-[MEDICATION(S)] because they don't necessarily utilized that lab to determine nutritional needs. On 1/14/22 at 11:07 a nutritional assessment was conducted and documented on Resident #15's behalf. the note is as follows; Weight/wound review. Current Body Weight: 97.6; body mass index classified as within normal limits. 10/13: 103- showing -5.2% x 90 days, 7/13: 104- showing -6.2% x 180 days. Resident eating 76-100% of meals on LCS diet with pureed texture and nectar thick liquids. Blood Glucose range: 150-252. Sacral wound present, showing improvement per latest skin assessment. Pro-stat AWC 30 ml two times each day in place to provide 200 kcal + 30 grams (g) protein, yogurt offered at all meals to provide 336 kcal + 14 g protein and magic cup added lunch and dinner to provide 580 kcal + 16 g protein. Food preference updated. Recommend add 4 oz cottage cheese to each meal (to provide an additional 591 kcal + 33 g) and 2% nectar thick milk with all meals to provide 510 kcal + 24 g protein). Recommend monitor weight weekly x 4 weeks related to weight trending down. Will continue to monitor weights, labs, skin integrity, intakes, Plan Of Care. The 1/14/22 RD assessment was conducted after our interview 1/13/22. It reflects the continuous weight loss trends from 7/13/21 forward but did not address the initial weight loss of 46 pounds. On 1/14/22 at approximately 1:20 p.m., The DM presented a copy education give to the dietary staff concerning Resident #15's meals. It included a review of portion sizes and which scoop to use based on the portion sizes. She also presented update meal slips which included likes, dislikes, portion sizes, supplements and each meal protein substitutes. On 1/14/22 at approximately 1:30 p.m., the above information was shared with the Administrator, Director of Nursing and Corporate Consultant. The Director of Nursing stated the resident's weights were not obtained because the resident was going to become a comfort care resident based on the acute care hospital's recommendations but when the information was presented to the son he declined the comfort care for the resident and the resident's nutritional status wasn't revisited. They facility provided additional documents on 1/18/22 at approximately 9:00 a.m., for consideration regarding the above information. That information is reflected in this report. 2. The facility staff failed to obtain weekly weights on Resident #47. Resident #47 was originally admitted to the facility on [DATE] then readmitted on [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/14/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible. This indicated Resident #47 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded as requiring extensive assistance of one person with bed mobility, dressing and personal hygiene. Total dependence of one person with eating, toilet use and bathing. The care plan dated 12/11/21 reads: Focus-CHF (Congestive Heart Failure). Goals-Resident will experience decrease episodes of shortness of breath, and chest pain. Interventions -Monitor weight per protocol. The POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the admissions MDS, Resident #47 was admitted on [DATE]. A review of Resident #47's weekly weights in the clinical record show that he was only weighed on admission (12/10/21) at 169 lbs (weighed by bed scale). (Since facility was being surveyed) Resident was recently weighed on: 1/17/22 133.0 lbs, 1/18/22 133.0 lbs. weighed by mechanical lift. Weights Policy: Effective Date: May 2015. Last Revision Date: 2/01/2020. Policy reads: Weights will be obtained routinely in order to monitor parameters of nutrition over time. Each individual's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified. Obtaining accurate weights is vital for the nutritional assessment of each resident and can be used as a basis for medical and nutritional intervention. Nursing is responsible for the determination of each individual's weight. Procedure: (A).Admission/Readmission: 1.Upon admission/readmission, the resident will be weighed as soon as practicably possible, but not later than 24 hours after admission/readmission. 2. After admission weight is obtained, the individual will be weighed weekly for 4 weeks, or more often per provider order. 3. After the first 4 weeks, the Resident Review Committee will determine the need for continuation of weekly weights or a change to monthly weights, (or more often per provider order). (C). Weekly Weights: All weekly weights will be obtained on the same day of each week. On 01/14/22 at approximately, 12:34 PM an interview was conducted OSM/RD (Other Staff Member/Registered Dietician) #1, concerning Resident #127. She stated, Typically we would like to have weekly weights. They should be weighed on admission. I put in weekly weights or x 4 weeks. He is weighed in the bed. On 01/18/22 at approximately 3:33 PM an Interview was conducted with RN Registered Nurse) #2 concerning Resident's weight. She stated, The resident was weighed by the CNA (Certified Nursing Assistant). Sometimes if there's a weight discrepancy we will re-weigh them. On 1/18/22 at approximately 5:30 PM, an interview was conducted with resident #47 concerning him being weighed. He stated they haven't weighed me in a while. Resident was asked by surveyor if he weighed 169 lbs or 133 lbs. He stated, I don't think I ever weighed that much. A review of the hospital History and Physical dated 12/03/21 show Resident #47 weighing 169.0 lbs. On 01/18/22 at 5:47 PM an interview was conducted with the DON (Director Of Nursing) concerning the resident's weight. She stated, I will have to look at that closer to try to get an very accurate weight. We weighed on the 17th and 18th for accuracy. We would have the doctor and dietician follow up if that wasn't accurate. A review of the clinical record show that Resident #47 was weighed on 1/18/22 at 133 lbs. A pre-exit interview was conducted on 1/18/22 at approximately 5:45 PM., the above findings were shared with the Administrator, The Corporate Consultant and the DON (Director of Nursing). An opportunity was offered to the facility's staff to present additional information but no additional information was provided. 3.The facility staff failed to document meal consumption for resident #127. Resident #127 was originally admitted to the facility 11/11/2016 and readmitted [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #127 was admitted to the facility on [DATE] and readmitted on [DATE]. Then discharged to an acute care facility on 12/27/20. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Minimum Data Set (MDS), a Quarterly assessment with an Assessment Reference Date (ARD) of 11/01/20 having memory coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 4 out of a possible 15. This indicated Resident #127 cognitive abilities for daily decision making were severely impaired. According to the complainant she wrote that resident #127 was not fed because he had no teeth. A review of the meal consumption record reveal resident #127 missed meals on the following days in 2020: The August meal consumption record shows missed meals on the following days: lunch-8/02/20, 8/03/20,8/05/20, 8/06/20, 8/07/20 and 8/08/20. Breakfast-8/2/20, 8/05/20, 8/03/20-8/08/20, Dinner 8/03/20, 8/08/20, 8/09/20 and 8/14/20. The December missed meal consumption record reads: 12/18/20-12/23/20, 12/24/20. 12/25/20 and 12/27/20. Breakfast: 12/18/20-12/23/20. Dinner-12/15/20-12/18/20, 12/20/20-12/22/20 and 12/27/20. An interview was conducted on 01/14/22 at 12:16 PM with OSM/RD (Other Staff Member/Registered Dietician) #1. She stated, The former dietician retired and I'm filling in. On 10/30/20 the Dietary assessment showed resident was eating 75% of his meals. He is above the ideal body weight for his height and frame. He has poor glucose control. He needed assistance at times with feeding. He didn't have any weight loss. An interview was conducted on 1/18/22 at approximately 3:40 PM, with RN (Registered Nurse) #2 concerning resident #127. She stated, He can feed himself with a set up tray. He loves to eat a lot of junk food. On 1/18/22 at approximately, 3:45 PM., an interview was conducted with LPN (Licensed Practical Nurse) #9 concerning the above. She stated, He was very non-compliant, rude and ugly acting. His daughter would bring in snacks. His dentures got lost. He chewed tobacco. You had to make sure his food was cut up and set him up. This is a complaint deficiency

Based on observation, resident interview, staff interviews, clinical record review, facility documentation review, the facility staff failed to provide 1 of 37 residents (Resident #1) in the survey sample with respiratory care in accordance with professional standards of practice. The findings included: The facility staff failed to ensure Resident #1's oxygen order contained a prescribed flow rate to be administered. Resident #1 was admitted to the nursing facility on 11/22/16. Resident #1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 10/05/21 coded the resident's Brief Interview for Mental Status (BIMS) score 15 of a possible 15 with no cognitive impairment for daily decision-making. In section G (Physical functioning) the MDS coded Resident #1 requiring total dependence of one with hygiene, bathing and toilet use, extensive assistance of two with bed mobility and extensive assistance of one with dressing for Activities of Daily Living (ADL) care. In section O (Special Treatment and Programs) was coded for oxygen therapy. A [CONDITION(S)] care plan with the use of oxygen therapy was created and given to the surveyor on 01/13/22. The care plan identified Resident #1 on oxygen therapy with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal set for the resident by the staff is to be free from signs and symptoms of [CONDITION(S)] thru the next review date of 02/26/22. Some of the interventions/approaches the staff would use to accomplish this goal is to administer oxygen as ordered (2 liters via nasal cannula) to maintain oxygen saturation greater than 92% and to assess, monitor and educate resident on sign/symptoms of distress, increased heart rate, restlessness, lethargy, confusion, blood in the sputum, use of accessory muscles and change in skin color. During the initial on 01/11/22 at approximately 3:38 p.m. Resident #1 was observed lying in bed with oxygen on at 2 liters minute via nasal cannula. On 01/12/22 at approximately 10:48 a.m., Resident #1 was observed sitting up in the wheel chair with oxygen on at 2 liters minute via nasal cannula. Review of the Order Summary Report for January 2022 revealed an order with a start date of 12/09/20: Oxygen to keep oxygen saturation above or equal to 92% each shift. On 01/13/22 at approximately 9:43 a.m., License Practical Nurse (LPN) #1 and this surveyor went to Resident #1's room to check the oxygen setting. After checking Resident #1's oxygen setting, she replied, That's right, Resident #1 is supposed to be on oxygen at 2 liters. The LPN checked the oxygen orders in the computer then stated, The order does not contain a flow rate, let me contact the physician right now. The LPN returned, then stated, The order now reads for 2 liters. A new order was provided by the LPN which read: Oxygen at 2 liters to keep oxygen saturations greater than or equal to 92% every shift. A debriefing was conducted with the Administrator, Director of Nursing (DON) and Corporate on 01/17/22 at approximately 4:05 p.m. Corporate said the oxygen order was not a complete order but once it was brought to our attention, a new order was written to include the oxygen liter. The facility's policy titled Oxygen Administration (all routes) policy - revision date 12/16/19. -Administration via nasal cannula: Set flow rate as prescribed. Definition: [CONDITION(S)] is a group of lung diseases ([CONDITION(S)] and Chronic [CONDITION(S)]) that make it hard to breathe and get worse over time. Normally, the airways and air sacs in your lungs are elastic or stretchy. When you breathe in, the airways bring air to the air sacs. The air sacs fill up with air, like a small balloon. When you breathe out, the air sacs deflate, and the air goes out (https://medlineplus.gov/[CONDITION(S)].htmlIf).

Based on staff interview, clinical record review and facility document review the facility staff failed to develop a care plan for 1 of 37 residents (Resident #1) in the survey sample. The findings included: The facility staff failed to develop a person-centered care plan to include a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was admitted to the nursing facility on 11/22/16. Resident #1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 10/05/21 coded the resident's Brief Interview for Mental Status (BIMS) score 15 of a possible 15 with no cognitive impairment for daily decision-making. In section G (Physical functioning) the MDS coded Resident #1 requiring total dependence of one with hygiene, bathing and toilet use, extensive assistance of two with bed mobility and extensive assistance of one with dressing for Activities of Daily Living (ADL) care. In section O (Special Treatment and Programs) was coded for oxygen therapy. During the initial on 01/11/22 at approximately 3:38 p.m. Resident #1 was observed lying in bed with oxygen on at 2 liters minute via nasal cannula. On 01/12/22 at approximately 10:48 a.m., Resident #1 was observed sitting up in the wheel chair with oxygen on at 2 liters minute via nasal cannula. Review of the Order Summary Report for January 2022 revealed an order with a start date of 12/09/20: Oxygen to keep oxygen saturation above or equal to 92% each shift. The review of Resident #1's comprehensive care plan did not include a care plan for [CONDITION(S)] with the use of oxygen therapy. An interview was conducted with the Director of Nursing on 01/13/22 at approximately 9:40 a.m., who stated, If Resident #1 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A [CONDITION(S)] care plan with the use of oxygen therapy was created and given to the surveyor on 01/13/22, but created after it was requested by the surveyor. The care plan identified Resident #1 on oxygen therapy with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal set for the resident by the staff is to be free from signs and symptoms of [CONDITION(S)] thru the next review date of 02/26/22. Some of the interventions/approaches the staff would use to accomplish this goal is to administer oxygen as ordered (2 liters via nasal cannula) to maintain oxygen saturation greater than 92% and to assess, monitor and educate resident on sign/symptoms of distress, increased heart rate, restlessness, lethargy, confusion, blood in the sputum, use of accessory muscles and change in skin color. A debriefing was conducted with the Administrator, Director of Nursing and Cooperate support on 01/17/22 at approximately 4:05 p.m. The Administration team were informed of the above findings; no further information was provided prior to exit. Definition: [CONDITION(S)] is a group of lung diseases ([CONDITION(S)] and Chronic [CONDITION(S)]) that make it hard to breathe and get worse over time. Normally, the airways and air sacs in your lungs are elastic or stretchy. When you breathe in, the airways bring air to the air sacs. The air sacs fill up with air, like a small balloon. When you breathe out, the air sacs deflate, and the air goes out (https://medlineplus.gov/[CONDITION(S)].htmlIf). Hypoxemia is a below-normal level of oxygen in your blood, specifically in the arteries. Hypoxemia is a sign of a problem related to breathing or circulation, and may result in various symptoms, such as shortness of breath (mayoclinic.org).

Based on observation, resident interview, staff interviews, and clinical record review, the facility staff failed to ensure a Resident dependent in activities of daily living received good grooming, personal hygiene and dressing care for 1 of 37 residents (Resident #281), in the survey sample. The findings included: Resident #281 was originally admitted to the facility 01/7/22 and had not been discharged . The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment had not been completed therefore; information was gained from Licensed Practical Nurse (LPN) #3 on 1/13/22 at approximately 10:30 a.m. LPN #3 stated the resident was alert and oriented to person, family, situation and place but required assistance to make daily decisions. LPN #3 also stated the resident required total care with all care including eating and she required use of an indwelling catheter. On 1/12/22 at approximately 10:15 a.m., Resident #281 was observed sitting across from the nursing station. The resident's head was lowered and her nose was draining a large amount of thick light yellow [MEDICATION(S)] which the Resident wiped away with the back of her hand. The Resident appeared very pale, had facial bruising and spoke very softly. She was wearing an untied hospital gown, had a blanket over her lap, her hair was severely matted and the catheter drainage bag was very full, containing approximately 800 milliliter of light but cloudy urine. The Resident stated she had a stroke and was found on the floor by her daughter and she had come to the facility to regain her strength after hospitalization . Review othe Resident's baseline care plan dated 1/9/22 was a problem which read; Resident has self-care deficit. The goal read; Resident needs will be met through 4/9/22. The interventions included; Assist with activities of daily living, dressing, grooming, toileting, and feeding, oral care. Promote independence, provide positive reinforcement for all activities attempted. On 1/13/22 at approximately 9:40 a.m., the Resident stated she wanted to shower but she didn't feel she was strong enough to shower herself. She stated if someone would help her she would take a shower and wash her hair. An interview was conducted with Certified Nursing Assistant (CNA) #1 on 1/13/22 at approximately 9:50 a.m. CNA #1 stated the resident rejected a shower therefore she would give her a bed bath. CNA #1 also stated she would try to get the tangles out of the Resident's hair but her hair likely needs to be cut for when the Resident arrived to the facility it was tangled and matted just as we saw it that day. During the interview with LPN #3 on 1/13/22 at approximately 10:30 a.m., she stated the Resident's daughter was telephoned about the condition of her hair and she stated on 1/15/22 the Resident would go to the beauty parlor to have it done. LPN #3 also stated the daughter wouldn't bring the resident clothing to wear therefore she only had the gowns provided by the facility. Resident #281 was visited again on 1/13/22 at approximately 12:30 p.m. The Resident stated she felt so much better after having a shower but she was tired. Her hair remained matted at the bun but soft and brush able at the scalp, her skin appeared clean and moisturized. She was still dressed in a hospital gown but it was tired at the back of her neck. On 1/14/22 at approximately 1:30 p.m., the above information was shared with the Administrator, Director of Nursing and Corporate Consultant. The facility's staff provided a progress note on 1/18/22 at approximately 9:00 in a folder. The progress note dated 1/14/22 at 15:23 which read; spoke with daughter and asked if she could bring in some personal clothing for resident. Daughter states her mother is comfortable in the gowns and is expected to have a decline. She felt hospital gowns may be more comfortable for her mother. This nurse encouraged the daughter to bring in comfortable clothing and informed her that we would continue to provide clean gowns per her request until personal clothing were provided if she wishes.

Based on clinical record review, staff interviews and facility documentation, the facility staff failed to develop a baseline care plan and/or ensure the indwelling catheter was addressed in the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: 1. Resident #281 was originally admitted to the facility 01/7/22 and had not been discharged . The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment had not been completed therefore; information was gained from Licensed Practical Nurse (LPN) #3. LPN #3 stated the resident was alert and oriented to person, family, situation and place but required assistance to make daily decisions. LPN #3 also stated the resident required total care with all care including eating and she required use of an indwelling catheter. On 1/12/22 at approximately 10:15 a.m., Resident #281 was observed sitting across from the nursing station. The resident's head was lowered and her nose was draining a large amount of thick light yellow [MEDICATION(S)] which the Resident wiped away with the back of her hand. The Resident appeared very pale, had facial bruising and spoke very softly. She was wearing an untied hospital gown, had a blanket over her lap, her hair was severely matted and the catheter drainage bag was very full, containing approximately 800 milliliter of light but cloudy urine. The Resident stated she had a stroke and was found on the floor by her daughter and she had come to the facility to regain her strength after hospitalization . On 1/13/22 at approximately 9:50 a.m., Resident #281 was observed in bed. The floor near the catheter drainage bag had a large amount of fluid on the floor. Certified Nursing Assistant (CNA)#1 stated she saw what was wrong the drainage bag and proceeded to clean the fluid off of the floor. Review of the Admission assessment completed 1/7/22 was coded to indicate Resident #281 had bladder incontinence and the box for urinary catheter was not coded. Review of the hospital's discharge summary dated 1/7/22 revealed the resident had [CONDITION(S)] requiring placement of a Foley. Review of a progress note dated 1/8/22 at 13:53 which read; Urinary Elimination: Resident has voided this shift: within normal limits, Resident has urinary catheter. Urinary catheter was noted to be patent. A progress note on 1/10/22 read; Urinary Elimination: Resident has voided this shift: yellow Resident has urinary catheter. Urinary catheter was noted to be patent. Urinary catheter is draining. Urinary catheter is anchored. A progress note on 1/10/22 read; Urinary Elimination: Resident has voided this shift: within normal limits. Resident has urinary catheter. Urinary catheter was noted to be patent. Urinary catheter is draining. Urinary catheter is anchored. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Document Foley output every shift. Foley catheter care every shift and as needed. Further review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the baseline care plan dated 01/09/22 which read; Resident is incontinent of bladder. The goal read; Resident will receive assistance with toileting, maintain comfortable, clean and dry, and free from skin breakdown. The interventions included; Assess resident pattern of urination and episodes of incontinence. Provide incontinence care as needed. Monitor peri-area for redness, irritation, skin excoriation/breakdown. The baseline care plan didn't address requiring the use of an indwelling catheter. On 1/13/22 at approximately 10:25 a.m., an observation was made of the indwelling catheter currently inserted in Resident #281 with LPN #2. It revealed a 16 french with a 30 cubic centimeter balloon. An interview was conducted with LPN #2. LPN #2 stated there wasn't an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #2 obtained an order on 1/13/22 for the indwelling catheter use of an indwelling catheter 16 french with a 30 cc balloon secondary to [CONDITION(S)]. On 1/14/22 at approximately 1:30 p.m., the above information was shared with the Administrator, Director of Nursing and Corporate Consultant. The facility's staff was offered the opportunity to provide additional information but they did not. 2. The facility staff failed to complete and implement a baseline care plan within 48 hours of admission. Resident #47 was originally admitted to the facility 12/10/21 then readmitted [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/14/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible. This indicated Resident #47 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded as requiring Extensive assistance of one person with bed mobility, dressing and personal hygiene. Total dependence of one person with eating, toilet use and bathing. The current Minimum Data Set (MDS) an admission assessment MDS with an Assessment Reference Date (ARD) of 12/14/21 coded the resident with a 13 of a total possible 15. A Review of the MDS (Minimum Data Set) Section A, A1600-Entry Date of 12/10/21. Section A, A1700 Reads: Type of Entry: Admission. A review of resident's clinical records reveals that resident was admitted on [DATE]. According to the clinical record Resident's Baseline Care Plan Checklist completed on 12/15/2021. A pre-exit interview was conducted on 1/18/22 at approximately 5:45 PM., the above findings were shared with the Administrator, The Corporate Consultant and the DON (Director of Nursing). The DON stated, The nurses should complete the care plan.

Based on observations, resident interview, staff interviews, clinical record review, and facility document review the facility staff failed to reassess resident for self-administration of medication for 1 of 37 residents (Resident #46) in the survey sample. The findings included: The facility staff failed to reassess Resident #46 for self-administration of medication [MEDICATION(S)] HFA ([MEDICATION(S)]) inhaler. Resident #46 was originally admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #46's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 12/13/21 coded the resident's Brief Interview for Mental Status (BIMS) score 15 of a possible 15 with no cognitive impairment for daily decision-making. In section G (Physical functioning) the MDS coded Resident #46 requiring total dependence of one with bathing, limited assistance of one with dressing, hygiene, bed mobility and toilet use and supervision with one assist with transfer and eating for Activities of Daily Living (ADL) care. The care plan with a created on 01/20/16 and a revision date of 01/04/20 identified Resident #46 with altered respiratory status, difficulty breathing related to (r/t) chronic respiratory failure and [CONDITION(S)]. The goal set for the resident by the staff to maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date of 03/27/2022. Some of the interventions/approaches the staff would use to accomplish this goal is administer medication/puffers as ordered, monitor for effectiveness and side effects, assess /document changes in orientation, increased restlessness, anxiety, and air hungry. During the initial tour of the facility on 01/11/22 at approximately 1:30 p.m., observed on Resident #46's overbed table was an open inhaler (also known as a puffer, pump or allergy spray). On 01/12/22 at approximately 10:35 a.m., the open inhaler remains on Resident #46's overbed table. On the same day at approximately 11:55 a.m., an interview was conducted with Resident #46 who stated, I try not to use the inhaler no more once or than twice a day. When asked if she informed her nurse when she self-administers her inhaler, she replied, No, I don't say anything and they don't ask. Review of Resident #46's January Order Summary Report revealed the following as needed inhaler: [MEDICATION(S)] HFA Aerosol Solution 180 - give 2 puffs inhale orally every 4 hours as needed for [CONDITION(S)] with a start date of 01/19/21. A nurse's note entered by License Practical Nurse (LPN) #6 on 01/12/22 at approximately 5:14 p.m., revealed the following: This writer noticed that resident's [MEDICATION(S)] inhaler was in her room. Resident stated that she uses it when she needs it, and she needed it today per resident. This writer then went to check the order of the inhaler and the inhaler is not self-administered. The medicine is now in the med cart and will be given to resident as scheduled. A nurses' note entered by the corporate nurse on 01/13/22 at approximately 8:52 a.m., revealed the following Spoke with Resident #46 this morning regarding if she had a desire to be able to self-administer as needed inhaler. Resident educated on the assessment process, securing medication in lock box, informing staff when used so administration can be documented, and the need to obtain approval and order from MD, She voiced interest in being able to start that process. Resident reported the nurse secured the inhaler in med cart yesterday was one that she had received from community pharmacy. Informed resident that this nurse would return after breakfast to perform assessment. A nurses' note entered by the corporate nurse on 1/13/22 at approximately 11:06 p.m., revealed the following: A self-administration assessment performed. Assessment results indicate resident is not a candidate for self-administration. The results of the assessment findings were discussed with resident who voiced understanding. Resident #46 was re-educated on not bringing outside medications into the center who voiced understanding. A debriefing was conducted with the Administrator, Director of Nursing and corporate nurse on 01/17/22 at approximately 4:12 p.m. Corporate said on 01/13/22, a self-administer assessment was completed on Resident #46 01/13/22, which she did not pass because she has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On the self-administer medications assessment, the 2nd question ask if the resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated, Resident #46 failed the self-administer medication assessment due to having a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility policy titled Self-Administration of Medication with a revision date of 02/09/21. Residents who have the desire to, and who have been assessed to be capable and safe to, may self-administer medications. Procedure read in part: 4. If the Interdisciplinary Team (IDT) has determined the resident safe to administer medications (s), administration of medication(s) will be Care Planned for approved self-administered medications. 5. Self-administration of medications must be reviewed by the (IDT) with each quarterly review. 6. When a resident is unable to self-administer medications, the medication will be held by the nurse until the resident can be reassessed by the (IDT). 7. The MAR must identity medications that are self-administered, and the medication nurse will need to follow-up with the resident as the documentation and storage of medications during each medication pass. Medication(s) kept at the bedside must be kept in a locked drawer. Definitions: -[CONDITION(S)] is a group of lung diseases ([CONDITION(S)] and Chronic [CONDITION(S)]) that make it hard to breathe and get worse over time. Normally, the airways and air sacs in your lungs are elastic or stretchy. When you breathe in, the airways bring air to the air sacs. The air sacs fill up with air, like a small balloon. When you breathe out, the air sacs deflate, and the air goes out (https://medlineplus.gov/[CONDITION(S)].htmlIf). [CONDITION(S)] is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time. It also changes how your body works (https://medlineplus.gov/ency/article/ 5.htm).

Based on clinical record review, staff interviews and facility documentation review, the facility staff failed to ensure residents were afforded the opportunity to formulate an advance directive for 3 of 37 residents (#15, 281, and 45), in the survey sample The findings included: 1. The facility staff failed to afford Resident #15 and/or her representative to formulate an advanced directive. Resident #15 was originally admitted to the facility 03/29/2021 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Malnutrition, Cirrhosis, Heart failure and Anemia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/30/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #15's cognitive abilities for daily decision making were moderately impaired. A review of the Resident #15's clinical record didn't reveal a written Advance Directive which would have included what to do if the resident becomes incapacitated, a designated health care surrogate, medical/surgical treatments, feeding restrictions, organ donation, autopsy request or other but; the Physician's Order Summary revealed an order written 10/6/21 reading Full Code and it was documented on the physician's progress dated 11/24/21, Code Status: Full Code. An interview was conducted with Licensed Practical Nurse (LPN) #2 on 1/13/22 at approximately 10:10 a.m. LPN #2 she would look in the chart to obtain Advanced Directive information to convey to the receiving facility but LPN #2 was only able to locate information on the Physician's Order Summary not the Advanced Directive. On 1/13/22 at approximately 10:45 a.m., an interview was conducted with the Social Worker. The Social Worker stated he reviewed the previous Advanced Care Tracking Form upon the resident's readmission to the facility from a hospital and the resident was to remain a Full Code. In the documents provided by the facility staff on 1/18/22 at approximately 9:00 a.m., an Advanced Care Tracking Form dated 10/7/22 read; reviewed existing Advanced Care Plan upon readmission. The discussion was held with the resident and resident representative, confirmed code status Full and preference to be sent to the hospital if deemed medically necessary. It was handwritten and not viewable in the clinical record and no information was provided on how the direct care staff would be able to obtain it when needed. On 1/14/22 at approximately 1:30 p.m., the above information was shared with the Administrator, Director of Nursing and Corporate Consultant. They provided additional documents on 1/18/22 at approximately 9:00 a.m., for consideration regarding the above information. That information is reflected in this report. 2. The facility staff failed to afford Resident #281 and/or her representative to formulate an advanced directive. Resident #281 was originally admitted to the facility 01/7/22 and had not been discharged . The current diagnoses included; new stroke with left side weakness and dysphasia. The Minimum Data Set (MDS) assessment had not been completed therefore; information was gained from Licensed Practical Nurse (LPN) #3. LPN #3 stated the resident was alert and oriented to person, family, situation and place but required assistance to make daily decisions. LPN #3 also stated the resident required total care with all care including eating and she required use of an indwelling catheter because of urinary retention. A review of Resident #281's clinical record didn't reveal a written Advance Directive which would have included what to do if the resident becomes incapacitated, a designated health care surrogate, medical/surgical treatments, feeding restrictions, organ donation, autopsy request or other but; the Physician's Order Summary revealed an order written 1/7/21 which read; Do Not Resuscitate (DNR). Review of the baseline care plan dated 01/09/22 was a problem which read; Resident is DNR. The goals read; Resident's wishes will be followed. The interventions included; Document resident's advanced directives. Involve Physician/NP in advanced directives conversations. Review advanced directives with resident/family periodically On 1/13/22 at approximately 10:45 a.m., an interview was conducted with the Social Worker. The Social Worker stated the resident Advanced Care Tracking Form was completed but the resident and/or representative didn't make any decisions. A copy of the Advanced Care Tracking Form wasn't available on the clinical record for viewing therefore; an interview was conducted LPN #2. After looking through the clinical record LPN #2 stated she would have to contact the Social Worker to obtain documents to convey to a receiving facility for she was unable to locate any in the clinical record. On 1/14/22 at approximately 1:30 p.m., the above information was shared with the Administrator, Director of Nursing and Corporate Consultant. They provided additional documents on 1/18/22 at approximately 9:00 a.m., for consideration regarding the above information. The folder contained a copy of a Durable Do Not Resuscitate Form completed at a local hospital 12/28/21. The boxes checked read the patient is incapable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment. The document also stated the patient had not executed a written advanced directive (living will or durable power of attorney for health care). 40711 3. The facility staff failed to execute the opportunity to provide an advance directive for Resident #45. Resident #45 was originally admitted to the facility 08/03/2015 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Essential Hypertension, Paroxysmal Atrial Fibrillation. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/12/2021 coded the resident coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #45 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded as requiring extensive assistance of two person for bed mobility, transfers and dressing. The resident was coded as requiring extensive assistance of one person with personal hygiene. Supervision after set-up with eating. A review of the clinical record on 1/14/22 revealed there were no advance directives in the clinical record on the above resident. On 1/14/22 at approximately 2:08 PM., an interview was conducted with the Social Worker (Other Staff Member/OSM) #4 concerning the above resident. He stated, The resident is under hospice care and has a DNR (Do Not Resuscitate) order. We leave that up to the discretion of the family who's able to say what she needs. On 1/18/22 at approximately 5:45 PM., the above findings were shared with the Administrator, The Corporate Consultant and the DON (Director of Nursing). The administrator stated, We need to ask the question if they have one.

Based on information gleamed during a complaint investigation, staff interview, clinical record review, and review of facility documents, the facility staff failed to resolve a grievance of missing personal items the resident and/or representative reported for 1 of 37 residents (Resident 279), in the survey sample. The findings included: Resident #279 was originally admitted to the facility 11/19/20 and was discharged return not anticipated from the facility 12/31/20. The Resident's diagnoses included; end stage renal disease, diabetes and peripheral vascular disease. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/25/20 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #279's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of two people with transfers and toileting, extensive assistance of one person with bed mobility and personal hygiene, limited assistance with dressing and supervision after set-up with eating. A complaint was filed 12/15/20 on behalf of Resident #279 by a friend. The grievance stated Resident #279 had missing personal items to include undergarments and a phone charger which were lost after the Resident was placed in isolation. An interview was conducted with the Adult Protective Services (APS) representative on 1/14/22 at approximately 9:30 a.m., who notified the Office of Licensure and Certification regarding grievances. The APS representative stated he had closed the case for Resident #279. An interview was conducted with the Administrator 1/13/22 at approximately 6:20 p.m. The Administrator stated he had no grievance on behalf of Resident #279. Interviews were attempted with several staff members during the survey but no one remembered the resident and phone calls were made to the Resident and friend but there was no answer or return call regarding messages left. On 1/18/22 a folder of papers were provided by the facility. Inside the folder was a grievance dated 12/28/20 based on an email sent to social services from Resident #279's friend. The grievance stated the Resident had missing underwear and tee shirts and a concern of not getting enough to eat on the trays. The document stated the grievance related to the dietary needs were forwarded to the dietary staff and resolved with providing the resident with double portions but the grievance forwarded to the laundry stated clothing not found. A complaint was filed 12/15/20 on behalf of Resident #279 by a friend. The grievance stated Resident #279 had missing personal items to include undergarments and a phone charger which were lost after the Resident was placed in isolation. An interview was conducted with the Adult Protective Services (APS) representative on 1/14/22 at approximately 9:30 a.m., who notified the Office of Licensure and Certification regarding grievances. The APS representative stated he had closed the case for Resident #279. An interview was conducted with the Administrator 1/13/22 at approximately 6:20 p.m. The Administrator stated he had no grievance on behalf of Resident #279. Interviews were attempted with several staff members during the survey but no one remembered the resident and phone calls were made to the Resident and friend but there was no answer or return call regarding messages left. On 1/18/22 a folder of papers were provided by the facility. Inside the folder was a grievance dated 12/28/20 based on an email sent to social services from Resident #279's friend. The grievance stated the Resident had missing underwear and tee shirts and a concern of not getting enough to eat on the trays. The document stated the grievance related to the dietary needs were forwarded to the dietary staff and resolved with providing the resident with double portions but the grievance forwarded to the laundry stated clothing not found. The facility staff provided no corrective action taken or to be taken by the facility as a result of the grievance, and there was no evidence that a written decision was issued. COMPLAINT DEFICIENCY

Based on complaint investigation, observation, staff interviews, clinical record review and facility documentation, the acuity staff failed to ensure 1 of 37 residents (Resident #277) to be free from misappropriation of the resident's narcotic medication. The findings included: The facility staff failed to ensure Resident #277's was free from the misappropriation of their narcotic medication [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]). Resident #277 was originally admitted to the nursing facility on 05/15/19. Resident #277's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #277's Minimum Data Set (an assessment protocol) a significant change assessment with an Assessment Reference Date (ARD) of 04/28/21 coded the resident's Brief Interview for Mental Status (BIMS) score 08 of a possible 15 with moderate impairment for daily decision-making. In section G (Physical functioning) the MDS coded Resident #277 requiring total dependence of one with hygiene, bathing and toilet use, extensive assistance of two with bed mobility and transfer, extensive assistance of one with dressing and eating for Activities of Daily Living (ADL) care. In section J (Health Condition for Pain Management) was coded zero for pain. The care plan with a created on 09/24/20 and a revision date of 05/25/21 identified Resident #277 with the potential for pain and discomfort secondary to [CONDITION(S)]. The goal set for the resident by the staff is express pain level within satisfactory limits. One of the interventions/approaches the staff would use to accomplish this goal is administer pharmacological interventions as indicated per physician and monitor the effectiveness. Review of the Resident #277's Order Summary Report for February 2021 revealed an order with a start date of 12/08/20: -[MEDICATION(S)] tablet 5/325 mg - give 1 tablet by mouth every 4 hours as needed for pain. Review of pharmacy manifest dated 12/28/20 indicated 86 tablets of [MEDICATION(S)]-Acetaminophen 5mg/325mg tablets were delivered to the facility on [DATE]. The manifest on 01/02/21 was signed as received by License Practical Nurse (LPN) #6. An interview was conducted with the Director of Nursing and Corporate Nurse on 01/13/22 at approximately 1:47 p.m. The DON said she received a call from the previous Unit Manager on 02/04/21 stating that a card of 30 [MEDICATION(S)] belonging to Resident #277 was missing. The DON provided a copy of the facility's investigation indicated the following: The DON immediately initiated and a facility wide search performed as well as a review of all other narcotic sheets with no further issues identified and narcotic counts were verified as correct. All nurses who had access to the medication cart and keys were interviewed any all denied any knowledge of where the missing care could be. The nursing staff who had access to that cart as well as the Unit Manager completed a urine drug screen performed in house with no pertinent findings. During the interview, the DON said there was one nurse, LPN #12 who worked on the medication cart on 02/02/21 (7-3 shift) who was running late and did not count the cart upon her retrieving the keys from the Unit Manager. The DON said, LPN #12 was informed that all the staff who had access to the medication cart came in for a drug test and she was asked to come into the facility to do a urine drug test also which she decline. LPN #12 said she was would go to (name of doctor's office) to get her urine drug test done but we never heard back from LPN #12; the LPN was terminated. The DON said Adult Protective Services (APS) and the local police department were notified. A phone interview was conducted with LPN #6 on 01/12/22 at approximately 8:19 p.m. The LPN said he signed for 3 cards of [MEDICATION(S)] (86 pills) for Resident #277 on 01/02/21 (3-11 shift). He said there were 3 cards of [MEDICATION(S)] when [NAME] got off on 02/01/21 (3-11 shift). The LPN said he did not return to work until 02/04/21 (3-11 shift). LPN #6 stated, I did not realize there was a missing card until at the end of the shift on 02/04/21. The LPN stated he was the oncoming nurse on 02/04/21 (3-11 shift), so I counted the Controlled Narcotics and the off going nurse counted the Controlled Narcotic Sheets. The LPN stated, At the end of my shift, I was counting with the oncoming nurse and as I was counting the Controlled Narcotic Sheets, I realized the number on the Narcotic sheet was changed from the number 86 to 56 and instead of there being 3 cards of [MEDICATION(S)] there were only cards. The LPN stated, I only remembered there were 86 [MEDICATION(S)] for Resident #277 because I was the nurse who signed for the medications when they were delivered to the facility on [DATE]. LPN #6 said the oncoming nurse, LPN #11 reported the missing card of [MEDICATION(S)] to the Unit Manager. A phone call was placed LPN #11 on 01/15/21 at approximately 9:51 p.m. The LPN was assigned to Resident #277 on 01/31/21 and 02/01/21 (11-7 shift). The LPN stated, I can't remember back that far but I gave a statement to the DON. Review of LPN #11's statement indicated there were 86 [MEDICATION(S)] tablets at the end of her shift on 02/01/21. An interview was conducted with LPN #3 on 01/14/22 at approximately 11:05 a.m., who stated, The Controlled Narcotic are counted at the change of each shift (the off going has the narcotic book and the oncoming has the controlled narcotic and the two are counted together and the keys are not exchanged until we make sure the count is correct. When asked, what is the process for discontinued controlled narcotic, she replied, They remain on the cart and is counted until picked up by the DON. She said the DON will count the controlled narcotic and the Controlled Narcotic Sheet is signed by the DON and the nurse. An interview was conducted with LPN #10 on 01/14/22 at approximately 11:23 a.m.,who stated, The oncoming nurse and the off going nurse count the narcotic book along with the narcotic together and only after the count is correct does the oncoming nurse accept the keys. The LPN said all discontinued controlled medications are counted on each shift until they are picked up by the DON. The LPN provided a Controlled drug shift/shift count sheet that is to completed at then end and beginning of each shift. The Controlled drug shift/shift count sheet included the following information: Signing below acknowledges that you have counted the controlled drugs on hand and have found that the quality of each medication counted is in agreement with the quantity stated on the Controlled Drugs-Count Record. Any discrepancies need to be reported immediately to the supervisor and the Director of Nursing. Random Controlled drug shift/shift count sheet were reviewed with no discrepancies. During the 4 days on survey, random narcotic counts were conducted by this surveyor with all narcotics located behind a double lock located in the medication cart. There were discontinued medications in the narcotic lock box that were being counted for at the beginning and end of each shift. Nursing staff were also interviewed on the process for counting Controlled Narcotics and received the same response from all staff interviewed, The oncoming and off going nurse have to count the Controlled Narcotic cards and the Controlled Narcotic Sheets together and cannot accept the keys without receiving report and counting the Controlled Narcotics. An interview was conducted with DON and Corporate nurse on 01/17/22 at approximately 4:00 p.m., When asked what is the process for removing discontinued medications with the potential for abuse from the medication cart, the DON stated, If I remove the Controlled Narcotic from the medication cart, the narcotics are counted by the nurse as well as my self and we both sign together and if the medication are bought to my office; they are removed from the cart by 2 nurses who will signed off on the controlled sheet, bought to me and I will count the medications and sign the Controlled Narcotic sheet also to include how many medications are left on the card. A debriefing was conducted with the Administrator, Director of Nursing and Corporate on 01/17/22 at approximately 4:05 p.m. The Administration team were informed of the above finding. The surveyor requested all discontinued medications with the potential for abuse for the month of 01/22. Review of all discontinued medications with the potential for abuse were reviewed after the debriefing on 01/17/22 at 4:05 p.m. The facility provided 6 resident's Controlled Narcotic Sheets on 01/18/22 at approximately 10:38 a.m., which revealed the following: -Narcotic sheet #1 - [MEDICATION(S)] 0.5 mg last administered on 01/13/22 with 20 tabs remaining; the document indicated the [MEDICATION(S)] was removed from the medication cart on 01/07/22, prior to the last dose being administered on 01/13/22. The DON did not signed the Narcotic Controlled sheet or document how many were remaining in the section for disposition of unused drugs. -Narcotic sheet #2 - [MEDICATION(S)]-Acetainophen 5mg/325 mg last administered on 01/13/22 with 25 tablets remaining; the document revealed the medication was removed from the medication cart on 01/07/22, prior the the last dose being administered on 01/13/22. -Narcotic sheet #3 - [MEDICATION(S)] 500 mg - last administered on 01/13/22 with 4 tablets remaining; disposition on 01/07/22, the document revealed the medication was removed from the medication cart on 01/07/22, prior the the last dose being administered on 01/13/22. -Narcotic sheet #4 - Clonaepam 0.25 mg - last administered on 01/13/22 with 14 tablets remaining; disposition on 01/07/22, the document revealed the medication was removed from the medication cart on 01/07/22, prior the the last dose being administered on 01/13/22. Definitions: [MEDICATION(S)]-Acetaminophen is used to relieve pain severe enough to require opioid treatment and when other pain medicines did not work well enough or cannot be tolerated (https://www.mayoclinic.org/drugs-supplements/[MEDICATION(S)]-and-acetaminophen-oral-route/description/drg). [MEDICATION(S)] is used to treat anxiety disorders and panic disorder (sudden, unexpected attacks of extreme fear and worry about these attacks). [MEDICATION(S)] is in a class of medications called benzodiazepines. It works by decreasing abnormal excitement in the brain (https://www.drugs.com/[MEDICATION(S)].htm). [MEDICATION(S)]-Acetaminophen is a combination medicine used to relieve moderate to severe pain. [MEDICATION(S)] may be habit-forming and should be used only by the person it was prescribed for. Keep the medication in a secure place where others cannot get to it. Acetaminophen and [MEDICATION(S)] can cause side effects that may impair your thinking or reactions (https://www.drugs.com/acetaminophen-and-[MEDICATION(S)].html). [MEDICATION(S)] is used with other medications to prevent and control seizures. It is also used to relieve nerve pain (https://www.drugs.com/[MEDICATION(S)]). Clonaepam is used alone or in combination with other medications to control certain types of seizures. It is also used to relieve panic attacks (sudden, unexpected attacks of extreme fear and worry about these attacks (https://medlineplus.gov/druginfo/meds). Complaint deficiency