Every finding on record at Martinsburg Healthcare Center

Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents in six (6) rooms. Room identifiers: #136, #143, #147, #149, #151, and #160. This was a random opportunity for discovery. Facility census: 117. Findings included: a) Upon survey entrance on 06/16/25 at 1:58PM, it was observed the following issues in Resident room numbers: room [ROOM NUMBER]: - wallpaper loose with air bubbles on the wall beside the bathroom door approximately 3 feet from the floor - wallpaper loose with air bubbles on the window wall beside bed B, approximately 2 feet from the floor - scuffs and black marks on the inside of the bathroom door - A Large circular hole in the bathroom wall behind the toilet approximate size 6 inches wide room [ROOM NUMBER]: - scrapes and tears in the wallpaper on the wall next to the sink - black scuff marks and loose trim inside bathroom door - A Large circular hole in the bathroom wall behind the toilet approximate size 6 inches wide room [ROOM NUMBER]: - paint chips approximately 1/2inch wide in the wooden trim around the air conditioner/heating unit room [ROOM NUMBER]: - black scuff marks and scrapes on wall next to the bathroom door - black scuff marks and scrapes on both sides of the bathroom door - cracks in paint under the grab bar handle on the bathroom wall room [ROOM NUMBER]: - black scuff marks and scrapes across the bottom of the wall next to the bathroom door - black scuff marks and scrapes inside on the bottom of the bathroom door room [ROOM NUMBER]: - wallpaper loose with air bubbles on the wall beside bathroom door approximately 3 feet high from the floor - wallpaper loose with air bubbles inside Resident's room door to the right of bed A approximately 3 feet high from the floor - A Large circular hole in the bathroom wall behind the toilet approximate size 6 inches wide On 06/17/25 at 1:30 PM, during a walk through with the administrator regarding environment issues in room [ROOM NUMBER], #143, #147, #149, #151, and #160. She acknowledged the environmental issues in these resident rooms and stated she will start a facility wide repair list for the maintenance department.

Based on record review and staff interviews, the facility failed to perform an accurate discharge process for two (2) of 3 residents reviewed during the survey process for hospitalization. Resident identifiers: #30, and #279. Facility census: 115 Findings included: a) Resident #30 Resident has capacity to make her own medical decision. The resident was on hospital leave from 03/23/25 until 03/26/25. There was no documentation to support the ombudsman was notified of the transfer. The facility was unable to provide a Bed Hold Notice for this hospital leave. This form was requested from the DON on 06/18/25 at 11:57 AM. On 06/18/25, late afternoon, the DON stated she was unable to find one. On 06/24/25 at 2:05 PM, discussion was held with the DON and NHA about the transfer process for this hospitalization. At this time the surveyor asked if they had any additional information to provide. NHA stated no. b) Resident #279 Resident #279 sustained a fall with injury in the facility on 02/24/25 and was transported to an acute care facility Emergency Department (ED) for evaluation. Resident did not return to the facility. DON stated on 06/18/25 at 3:47 PM that she could not locate a bed hold notice. On 06/24/25 at 2:05 PM, discussion was held with the DON and NHA about the transfer process for this hospitalization. At this time, the surveyor asked if they had any additional information to provide. NHA stated no.

Based on observation, interview and policy review the facility failed to properly store and serve food in accordance with professional standards for food service safety. This had the potential to affect all residents in the facility. Facility census: 117. Findings included: a) On 06/16/25 11:35 AM, during the Initial Brief Tour of Kitchen, with Assistant Dietary Manager #182 acknowledged the following: In the Freezer it was observed that a bag of frozen Hamburger patties were left opened and exposed. On 06/17/25 at 1:00 PM a review facility policy labeled HCSG Policy 019, Food Storage: Cold Foods. Procedures, number 5 stated All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. A bag of macaroni was observed left open and exposed in the pantry On 06/17/25 at 1:00 PM a review facility policy labeled HCSG Policy 018, Food Storage: Dry Goods. Procedures, number 5 stated All packaged and canned food items will be kept cleam, dry, and properly sealed. The temperature inside the kitchen refrigerator was 45 degrees verified by two different thermometers and witnessed by the Assistant Dietary Manager employee #182 . During the initial brief kitchen walk through and interview with the Assistant Dietary Manager employee #182, she acknowledged the bag of open macaroni in the pantry, the box of frozen burgers left open and exposed in the freezer, and the fridge temperatures at 45 degrees and stated she would take care of them and would report the refrigerator temps to the Kitchen manager to have the refrigerator checked for repair. In an interview on 06/16/25 at 1:10pm with the Dietary Manager (DM) #181, she stated she was aware of the previous mentioned issues in the pantry, freezer, and the temperature in the refrigerator. Observations made on 06/17/25 at 12:015 PM while preparing resident food trays on the tray line, It was observed that Employee #175 walked over to the freezer, touched the freezer door stepped inside and took out a chocolate ice cream cup and then walked back to the tray line and began to prep resident food trays without changing gloves or washing her hands. At 12:20PM, she pulled the delivery cart up to the prep line and opened the cart doors in preparation to load resident trays and then began preparing resident food trays again without changing gloves or washing her hands. In an interview with DM #181 on 06/17/25 at 12:20 PM, she acknowledged Employee #181 had not changed her gloves after leaving the tray line both times, touching the freezer door handle, then again touching the floor delivery cart and returning to tray prep without changing her gloves nor washing her hands.

Based on record review and staff interview, the facility failed to provide the resident or resident's representative of the risks and benefits of an anti-psychotic medication. This was found to be true for 1 (one) of six (6) residents reviewed. Resident identifier: #95. Facility census: 115. Findings included: a) Resident #95 Resident #95 had a diagnosis of depressive disorder on 05/10/24 and was prescribed Sertraline HCI tablet 50 mg on 05/10/24. The facility failed to inform the resident's medical representative of the risks and benefits of the medication, other treatment options or alternatives. The resident did not have capacity to make her own medical decisions. During the survey process, on 06/18/25 at 0:38 AM, the surveyor requested to see an informed consent for Sertraline. On 06/18/25 at 02:01 PM, the DON stated she was not able to locate the consent form. The DON did present a note from the medical record where the facility had tried to call the resident's representative, but the representative never returned the call. On 06/24/25 at 2:02 PM, surveyor met with DON and NHA to re-verify lack of informed consent and reviewed the potential deficiency with them.

Based on record review and interview, the facility failed to ensure that incontinence care was provided to dependent residents. Namely, dependent residents were not aided with toileting, cleaning themselves, and changing absorbent pads or briefs in a timely manner. This was true for one (1) of four (4) residents surveyed. Resident Identifiers: Resident identifier: #50. Facility Census: 116. Findings Include: a) Resident #50 Record review on 06/18/25 at approximately 10:00 AM revealed that Resident #50 does not have capacity. The record review revealed the following: The facility had submitted an initial report of an allegation of neglect in the area of incontinence care for Resident #50 on 03/26/25 at 1:49 PM. The facility had submitted the five-day follow-up report on 03/28/25 at 1:53 PM. The report stated that the alleged perpetrator, Nursing Assistant (NA) #15 was suspended pending the completion of the investigation. The five-day follow-up report stated that 'After thorough investigation, the allegation of incontinence care not provided timely has been unsubstantiated.' Record review of the investigative notes revealed a phone statement obtained by the Director of Nursing (DON) from NA #15 stated: I worked on South Unit last pm. I had 150-156. The following residents are incontinent 150 A&B, 151 A, 152 A7B, 153 A7B, 155 A&B, 156 A&B will ring. I have always been told we do not do anything for him, he is independent and will use his urinal and will ring for anything else. My last rounds were started before 5:20 AM. At approximately 5:20, I started with the four rooms on stretch. I am 85% I started with them. It was around or not very long after that for I did not have to change many of my incontinent. [NAME] was dry, I changed 151 A, 152 A, B was dry, 153 A dry all night and B bed was changed. Both residents 153 A&B changed.I washed up 150 B and 150 B and NA #104 and I completed their baths. I did not have anyone to complete walking rounds with, but did write the reports with booth of their names on it. I left floor 6:36 AM. I wrote report with their names on it. I spoke with Registered Nurse (RN) #36 and NA #93 was standing there and I asked if they would make sure if NA #70 and NA #58 would get their report. A written statement by NA #58 reviewed on 06/18/25 at approximately 10:11 AM, stated the following: I went in to check my section. I went into [Room]. NA # 85 and NA #93 were in the middle of stripping Resident #50's bed. The sheets were soaked with brown ring from the middle of the sheets to almost the bottom. Further review revealed written statements by NA #93 and NA #85: NA #93 stated: Around 6:40 me and NA #83 went into Resident #50's room to get him up for breakfast, when we pulled the blankets back, he was soaked, and shirt and sheets were wet. We went ahead and gave him a full head to toe bed bath. When we got done, we let his aide know. When I came out there was a report paper on the desk. When I opened it, it said he was changed and washed and dressed. NA #85 stated the following: Around 6:40 AM on 03/26/25 NA #93 and I were helping get residents up for breakfast. When we went to get Resident #50 up he was soaked up to his shirt and bed with bed with urine. We bathed him, and got him up and informed his aide of the situation. The night shift aide left a paper report stating he was changed and bathed already. During an interview on 06/18/25 at approximately 1:15 PM, NA #58 confirmed that when she went into Resident #50's room on 03/26/25, she had observed a brown ring on Resident #50's sheets.

Based on observation, interview and record review, the facility failed to ensure that a physician's order for oxygen administration was followed. This was a random opportunity for discovery. Resident Identifier: #6. Facility Census: 116. Findings include: a) Resident #6 During an observation on 06/16/25 at approximately 3:47 PM, the resident was observed asleep. The oxygen concentrator was noted to be set at three (3) liters per minute. A review of Resident #6's medical record revealed that the resident was diagnosed with Acute and Chronic Respiratory failure with Hypoxia. A review of Resident #6's care plan revealed a note that stated: 'Resident takes off O2 at times. Encourage the resident to allow the staff to replace the O2. Date Initiated: 02/27/2025 During the survey period, there were no observations of the resident with her nasal cannula removed. Physicians' orders prescribed Oxygen at two (2) liters per minute. Follow-up observations over the next few days revealed the following: 6/17/25 at 11:15 AM - Resident observed asleep with oxygen concentrator set at 3 liters per minute. 06/17/25 at 3:42 PM - Resident observed asleep with oxygen concentrator set at 3 liters per minute. 06/18/25 at 8:55 AM - Resident observed asleep with oxygen concentrator set at 2.5 liters per minute. 06/18/25 at 1:19 PM - Resident observed asleep with oxygen concentrator set at 2.5 liters per minute. On 06/18/25 at 1:21 PM, Licensed Practical Nurse (LPN) #17 was notified of the incorrect oxygen dose. LPN #17 stated that she would check the physician's orders, and confirmed that the resident's prescribed oxygen delivery rate should be 2 liters per minute. LPN #17 adjusted the oxygen concentrator to deliver the prescribed dose and stated that she would monitor the concentrator to ensure it was not malfunctioning.

Based on observation, interview and record review, the consulting pharmacist failed to identify and notify the physician of potential Adverse Drug Reactions (ADR's) related to the concurrent administration of opioids, benzodiazepines. Further, the pharmacist failed to identify that a medication had been prescribed to a resident with a documented allergy to it. Resident identifier: #6. Facility Census: 116. Findings Include: a) Resident #6 Record review on 06/16/25 at approximately 12:25 PM revealed that Resident #6 was an [AGE] year-old female. Resident #6 did not have capacity and a Brief Interview for Mental Status (BIMS) assessment on 05/07/25 revealed a BIMS of 02. The resident has been diagnosed with the following: Acute and Chronic Respiratory Failure with Hypoxia. Paroxysmal Atrial Fibrillation Chronic Obstructive Pulmonary Disease Alzheimer's Disease Major Depressive Disorder Atherosclerotic Heart Disease of Native Coronary Artery without angina pectoris Following the record review, Resident #6 was observed at frequent intervals throughout the survey and the following was noted: 06/16/25 at 1:55 PM - Resident observed asleep 06/16/25 at 3:47 PM - Resident observed asleep 6/17/25 at 11:15 AM - Resident observed asleep 06/17/25 at 2:21 PM - Resident observed asleep 06/17/25 at 3:42 PM - Resident observed asleep 06/18/25 at 8:55 AM - Resident observed asleep 06/18/25 at 1:19 PM - Resident observed asleep 06/18/25 at 4:05 PM - Resident observed asleep 06/19/25 at 8:59 AM - resident observed awake and in Geri chair - very vocal, loud, and making unintelligible statements. 06/19/25 at 11:15 AM - resident observed asleep 06/24/25 at 2:32 PM - resident observed asleep 06/24/25 at 4:10 PM - resident observed asleep 06/25/25 at 9:15 AM - Resident observed asleep 06/25/25 at 11:21 AM - Resident observed asleep 06/25/25 at 1:49 PM - resident observed asleep During an Interview with Registered Nurse (RN) #36 on 06/19/25 at approximately 10:30 AM, RN stated that Resident #6 usually preferred to sleep in her room for most of the day. RN #36 stated that the physician had prescribed Tramadol a few months back due to resident's behaviors. RN #36 further stated that resident's husband visits every evening, and that he would try to wake her up and talk to her. Further record review on 06/16/25 at 2:10 PM revealed that the resident was prescribed the following medications: Lorazepam Oral Tablet 1 MG (Lorazepam) Give one tablet every 8 hours as needed for anxiety. Tramadol Tablet 50 MG *Controlled Drug* Give 1/2 tablet = 25 MG by mouth daily Trazodone HCl Oral Tablet 50 MG (Trazodone HCl) - Give 50 mg by mouth at bedtime for Insomnia Both lorazepam (a benzodiazepine) and tramadol (an opioid) are CNS depressants. FDA guidance states that providers should take precautions when prescribing Tramadol (an opioid) and Lorazepam (a benzodiazepine), as concurrent use of these drug classes can result in excessive drowsiness, respiratory depression, overdose and death. The guidance also stated that physicians should reserve concurrent use of prescribing of opioid analgesics with benzodiazepines or other CNS depressants for use in patients for whom alternative treatment options are inadequate. . Record review further revealed that Resident #6 had a documented allergy to Tramadol. The allergic reaction to Tramadol was documented as 'Hallucinations'. During an interview with the Director of Nursing (DON) and Regional Clinical Nurse (RCN) #300 on 06/19/25 at 11:43 AM, they confirmed that no physicians note was available acknowledging the use of Tramadol even though the resident was allergic to it. After a comprehensive review of the resident's medical record, it was observed that there were no nursing notes or other documentation related to the resident's sleep patterns during the day or her overall quality of life. Additionally, no documentation was provided showing that the drug-to-drug interactions and possible adverse reactions were considered. Further, none of the completed Monthly Monitoring Reports (MMRs) or Gradual Dose Reductions (GDRs) addressed the concurrent use of opioids and benzodiazepines. During an interview on 06/25/25 at approximately 1:20 PM, Pharmacist #301 and RCN #300 attempted to explain the documentation provided. The pharmacist did not provide a reason for failing to identify and notify the physician about the potential adverse reactions associated with the concurrent use of benzodiazepines, and opioids. RCN #300 noted that the physician had already put orders in place for monitoring the side effects of antianxiety medications, mood stabilizers, and antipsychotics. As a result, RCN #300 did not believe it was necessary to inform the physician about the potential dangerous adverse reactions of using these medications concurrently.

Based on observation and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to the residents and unsanitary practices. This failed practice was a random opportunity of discovery. Facility Census: 117. Findings included: a) During a facility walk through on 06/16/25 at 3:34 PM, an opened box of tissues, an opened box of gloves and an opened package of wipes, was found on the middle shelf sitting on top of the clean linen of the linen cart in the South Hall. On 06/17/25 at 9:56 AM, during a facility walk through, an opened box exam gloves, a small roll of clear garbage bags, and an opened package of wipes was found on top of the clean linen on the top shelf of the linen cart in the South Hall . On 06/16/25 at 3:45 PM, in an interview with Licensed Practical Nurse (LPN) #107, she acknowledged the items on the linen cart and stated nothing should be on the linen cart with the clean linen and removed the package of wipes, box of gloves and tissues, immediately. In an interview, on 06/17/25 at 10:05 AM with Nurses Aid (NA) #117, she acknowledged the items on the linen cart and immediately removed them.

Based on observation and interview the facility failed to monitor the expiration dates of medical supplies. Further, the facility failed to ensure that expired medical supplies were disposed of and not left accessible for use by staff for resident care. Facility Census: 116. Findings Include: a) North Medication Room During an inspection of the North Medication Room on [DATE] at approximately 9:16 AM, accompanied by Licensed Practical Nurse (LPN) #17, the storage bins holding medical supplies revealed the following: 31 - BD 1 ML Syringes - expiration date [DATE] 7 - Insyte 24 GA x 0.75 in injection syringes - expiration date [DATE] LPN #17 counted and confirmed the expiration dates on the syringes. LPN #17 further stated that she would notify the DON of the finding, and dispose of the expired syringes.

Based on observations and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to resident handwashing. This practice had the potential to affect more than an isolated number of residents. Facility census: 116. Findings included: a) Meal tray pass An observation during dining observation on 09/19/23, at 11:45 PM revealed the residents in the north dining room, did not receive hand hygiene prior to or during the lunch meal tray pass. An observation on the 106 - 115 north hall on 09/19/23 at 12:15 PM found the residents were not offered to wash their hands prior to the lunch meal. During an interview, on 09/19/23 at 12:22 PM, with Unit Manager (RN) #106 the Unit Manager verified no hand hygiene was completed prior to the meal service in the dining room or the halls. She stated they usually use hand wipes for the residents. She stated that they used to have hand wipes put on the trays. Dining observation, on 09/19/23, at 12:45 PM, revealed the residents in the South dining room, did not receive hand hygiene prior to or during the lunch meal tray pass. During an interview, on 09/19/23 at 12:48 PM, Nurse Aide (NA) #27 verified no hand hygiene was completed prior to the meal service in the dining room.

Based on review of the concern/grievance forms, review of the facility documentation of reportable occurrences, and staff interview, the facility failed to ensure that all alleged violations of abuse, were reported immediately, to all officials (including to the State Survey Agency and Adult Protective Services (APS), where state law provides for jurisdiction in long-term care facilities) in accordance with State law, through established procedures. This deficient practice was found true for two (2) of four (4) residents reviewed. An allegation of abuse, the staff had knowledge of, was not reported in a timely manner involving Residents #20 and #119. Resident identifiers: Residents #20 and #119. Facility census: 116. Findings included: a) Policy Review A review of the Policy and Procedure, titled: WV Abuse, Neglect and Misappropriation, Policy #NS1018-03, approval date of 05/25/23, noted on page 15 of the policy, under 1. B., if the allegation did not cause serious bodily injury or abuse, the report must be made immediately, but not later than 24 hours after the discovery. b) Concern/Grievance Review A review of the facility grievance/concern file showed two (2) residents had complained of incontinence care not being provided in a timely manner involving Resident #20 and Resident #119. The grievance/concern was dated as received by facility staff on 07/03/23. c) Reportable Occurrences Review A review of the Reportable Occurrences maintained by the facility was reviewed and showed an allegation of Neglect, dated 07/03/23 for Resident #20 and Resident #119. Further review of the reportable occurrence file showed the facility failed to notify all state agencies in accordance with state law and facility policy. The facility documentation showed the allegation of neglect for both Resident #20 and Resident #119 was not reported until 07/05/23 when the allegation was received on 07/03/23 at 6:30 AM. d) Staff Interviews An interview, with the Social Worker, on 09/19/23 at 11:50 AM, revealed the reporting of the allegations made by Resident #20 and Resident #119 had not been reported in accordance with the 24-hour window of reporting the allegation. The Social Worker confirmed the allegation should have been reported no later than 07/04/23. An interview, with the Director of Nursing (DON), on 09/19/23 at 1:30 PM, verified after review of the reportable documentation, the facility failed to report the allegation in a timely manner. The DON confirmed the allegation was made known to the facility on [DATE] and was not reported until 07/05/23, which would not have met the requirements of reporting an allegation of abuse of neglect. An interview, with the Administrator, on 09/19/23 at 4:30 PM, revealed there was no additional evidence to provide because the facility had failed to meet the reporting timeline on Resident #20 and Resident #119's reported allegation.

Based on record review and staff interview the facility failed to notify the physician of a significant weight loss to evaluate and manage causes of the resident's nutritional risks and impaired nutritional status. This is true for one (1) of three (3) residents reviewed for weight loss. Resident identifier: # 51. Facility census: 116. Findings included: a) Resident #51 On 09/19/23 during a complaint survey for weight loss and physician notification a record review for Resident #51 revealed a significant weight loss on 09/01/23. Registered Dietician Notes: 9/1/2023 14:27 Weight Change Note Note Text: WEIGHT WARNING: Value: 180.8 -5.0% change over 30 day(s) [ 6.7%, 13.0] -3.0% change over 30 day(s) [ 3.8%, 7.2] -5.0% change [ 6.8% 13.2 ] (Transcribed as Written) 9/18/2023 15:50 Weight Change Note Note Text: WEIGHT WARNING: Value: 179.2 -3.0% change over 30 day(s) [ 4.0%, 7.4] -7.5% change [ 7.6%, 14.8] -10.0% change [ 10.6%, 21.2] (Transcribed as Written) Continued Medical record review found no notification of the Physician for Resident #51's significant weight changes. On 09/19/23 at approximately 1:54 PM during an interview the Director of Nursing verified the physician was not notified Resident #51's significant weight change.

Based on record review and staff interview, the facility failed to administer pain medication as ordered by the physician. This was true for one (1) of five (5) records reviewed for pain management. This failed practice has the potential to affect a limited number of resdents. Resident identifier: #424 Facility census: #115. Findings included: a) Resident #424 On 05/24/23 at 4:08 PM, it was noted the facility did not follow physicians orders for administering pain medication for Resident #424. The physicians order with a revision date of 11/19/22 was for Oxycodone HCL tablet 5 mg give 1.5 tablet by mouth every 6 hours for pain. For the review period of 11/01/22 through 12/31/22 there were nine (9) doses of Oxycodone not administered. Resident #424 was under Hospice care for end of life care during this time period. Further review of the Medication Administration Record (MAR) shows the following: On 11/17/22 at 6:00 AM the medication was signed out of the narcotic count log by Registered Nurse #129 but not documented as being administered. On 11/22/22 at 6:00 PM the medication was signed out of the narcotic count log by Licensed Practical Nurse (LPN) #103 but not documented as being administered. On 11/25/22 at 6:00 AM the medication was signed out of the narcotic count log by LPN #191 but not documented as being administered. On 11/28/22 at 12:00 Noon the medication was not documented as being administered and according to the Director of Nursing (DON) there is no narcotic sign out sheet available for this date and time. On 12/07/22 at 12:00 midnight the medication was signed out of the narcotic count log by RN #129 but not documented as being administered. On 12/07/22 at 6:00 AM the medication was signed out of the narcotic count log by RN #129 but not documented as being administered. On 12/13/22 at 6:00 AM the medication was signed out of the narcotic count log by LPN #141 but not documented as being administered. On 12/27/22 at 12:00 midnight the medication was signed out of the narcotic count log by LPN #141 but not documented as being administered. On 12/27/22 at 6:00 AM the medication was signed out of the narcotic count log by LPN #41 but not documented as being administered. The above information was confirmed by the DON on 05/24/23 at 3:50 PM.

Based on resident interviews during resident council, and staff interview, the facility failed to ensure a substantial/nourishing snack was provided as ordered and/or offered if of ordered between the evening meal and breakfast. This had the ability to affect all residents who did not have a dietary order to receive an evening snack. Resident identifiers: #61, #30, #54, #36, and #9. Facility Census: 115. Findings included: a) Resident Council Meeting During the resident council meeting on 05/23/23 at 1:00 PM, all residents in attendance stated the facility did not offer an evening snack to residents. They went on to say they would like an evening snack and felt the majority of facility residents would enjoy a bedtime snack. One (1) resident stated, They used to do that, but they don't do it anymore. Another resident reported being told by staff that the new ownership doesn't like to provide the snacks and the individual should probably have family bring them. When asked if all residents in the facility had ever been told they could request an evening snack, resident council members did not recall ever being told that was an option. b) Record Review A brief medical record review, completed on 05/23/23 at 8:05 PM, involved review of the resident council members' Brief Interview for Mental Status (BIMS) scores. The Brief Interview for Mental Status (BIMS) is a structured evaluation aimed at evaluating aspects of cognition in elderly patients. The three parts of the assessment look at patient attention, level of orientation, and the ability to recall information. A score ranging between 13-15 indicates a resident is cognitively intact and has a high level of cognitive function. Five (5) out of the six (6) resident council members in attendance were cognitively intact as indicated by their BIMS score: -Section C Cognitive Patterns of the Quarterly Minimum Data Set, with an assessment reference date of 03/17/23, identified Resident #61 had a Brief Interview for Mental Status score of 13. -Section C Cognitive Patterns of the Quarterly Minimum Data Set, with an assessment reference date of 03/02/23, identified Resident #30 had a Brief Interview for Mental Status score of 15. -Section C Cognitive Patterns of the Annual Minimum Data Set, with an assessment reference date of 04/11/23, identified Resident #54 had a Brief Interview for Mental Status score of 15. -Section C Cognitive Patterns of the Quarterly Minimum Data Set, with an assessment reference date of 03/08/23, identified Resident #5 had a Brief Interview for Mental Status score of 15. -Section C Cognitive Patterns of the Quarterly Minimum Data Set, with an assessment reference date of 04/25/23, identified Resident #9 had a Brief Interview for Mental Status score of 15. c) Interview with Culinary Director The aforementioned details were reviewed with the facility's Culinary Director on 03/24/23 at 3:30 PM. When asked to explain the facility's protocol for delivering evening snacks to the floor, the Culinary Director explained that all physician ordered snacks are taken to the floor at 8:00 PM and are labeled by resident. The Culinary Director also stated that any resident with a diagnosis of diabetes would have a snack like graham crackers that would be labeled with their name. When asked if residents without a physician order for a snack or a diagnosis for diabetes wanted an evening snack what the protocol would be, the Culinary Director stated the floor has a pantry where nursing staff could access snacks, upon request. The Culinary Director reported it was not facility protocol to ask each resident if he or she would like an evening snack, that it would be up to each individual resident to understand they needed to make the request.

Based on observation and staff interview, the facility failed to complete labeling and dates on refrigerator and freezer items in accordance with professional standards for food service safety related to storage. This has the ability to affect all Residents that receive their nutrition from the kitchen and pantries. Facility census: 115. Findings included: Record review of the facility's policy titled, Food Storage with revision date 09/2017, showed that All food will be stored wrapped or covered containers, labeled, and dated, and arranged in a manner to prevent cross contamination. a) Kitchen During the initial kitchen tour on 05/22/23 at 9:15 AM, an observation found: --Walk-in Freezer- pork Butcher Box, 2 hamburger patties, large package of hot dogs, chicken crumbles, were not labeled or dated. Walk-in Freezer- Box of sausage patties, Chicken pieces and a pork roast, not closed, open to air. During an interview on 05/22/23 at 9:22 AM, the Dietary Director confirmed the items were not labeled and stated that all food items should be labeled and dated. b) Resident North Pantry's --2 bowls of cereal, and a piece of cake, not labeled or dated. --Two old brown boiled eggs in a bowl in the upper cabinet. During an interview on 05/22/23 at 9:34 AM., Dietary Director confirmed the items were not labeled and stated that all food items should be labeled and dated.

Based on observation and staff interview, the facility failed to store garbage and refuse in a proper manner. One (1) dumpster did not have a lid, the area was polluted with garbage and used medical supplies. This has the potential to affect all residents that reside in the facility. Facility census: 115. Findings included: a) Dumpster area An observation on 05/24/23 found on the ground around the dumpster area was polluted with garbage, bags full of trash, and used medical supplies. On 05/24/23 at 1:57 PM during an interview the Maintenance Director verified the garbage was not disposed of correctly. He stated that the lid to the dumpster has been gone for a while.

45171 Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for four (4) of thirty-two (32) records reviewed. Resident identifiers: #88, #421, #91 and #91. Facility census: 115. Findings included: a) Resident #88 On 05/22/23 at 2:32 PM it was noted that there was a transmission based precaution (TBP) donning/doffing station outside of Resident #88's room. There was however, no signage on the door to instruct what kind of precautions or Personal Protective Equipment (PPE) was needed. According to Licensed Practical Nurse (LPN) #4 the resident had nebulizer treatments ordered and the PPE is for treatments. The order states: Albuterol Sulfate inhalation Neulization Solution 2.5 MG/0.5 ML (Albuterol Sulfate) 1 vial inhale orally via nebulizer every 4 hours as needed for COPD. and DuoNeb Solution 0.5-2.5 (3) MG/3 ML (Ipratropium-Albuterol 1 application via mask every 6 hours as needed for COPD. According to the Director of Nursing (DON) on 05/24/23 at 2:00 PM, there should be an order reading: Aerosol Droplet Precautions during nebulizer treatments: Please close door, pull privacy curtain, DON PPE during treatment, display Aerosol Droplet Precaution sign and remove once treatment is completed. Disinfect equipment and surrounding areas once treatment is completed. b) Resident #421 On 05/22/23 at 1:33 PM it was noted on the facility matrix Resident #421 was under Hospice services. A record review shows there was no order for hospice care. On 05/23/23 at 1:51 PM, it was confirmed with the DON that Resident #421 was on Hospice at this time and there should be a physicians order for Hospice. c) Resident #91 During a medical record review on 05/23/23, it revealed there was an incomplete physician's orders for aerosol treatments, which did not include droplet precautions for Resident #91. In an interview on 05/23/23 at 1:42 PM with the DON, verified the order was incomplete and did not include droplet precautions for aerosol treatments. d) Resident #91 - Incorrect date for last covered day of skilled service On 05/23/23 at 11:00 AM, a review was completed regarding the beneficiary protection notification liability notice given for the following resident who remained in the facility following the last covered day of Medicare Part A services: -Resident #91's last covered day of Medicare Part A Services was on 04/06/23. -Resident #91 was issued a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) on 04/04/23 which listed her last covered day of Medicare Part A Services as 04/05/23. The SNFABN read, Beginning on 04/05/23, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. During an interview, on 05/23/23 at 12:40 PM, the Social Worker #105 reported the 04/05/23 date was listed in error and the correct last covered date of Medicare Part A Services was 04/06/23.

Based on observation, record review, staff interview and policy review, the facility failed to have signage on the door and/or a donning/doffing station available at the door of a resident's room designated as a transmission-based precaution (TBP) room. Resident Identifiers: #88, #114, #111 and #101 Facility census: 115. Findings included: a) Policy review According to the Guidance for Aerosol Generating Procedures dated 02/03/22, An N95 mask, and full PPE must be worn with all aerosol generating procedures.close the door to the resident room before performing treatment. Keep door closed throughout treatment and for one hour post treatment if it is safe to do so . b) Resident #88 On 05/22/23 at 2:32 PM it was noted that there was a donning/doffing transmission based precaution (TBP) station outside of Resident #88's room. There were however, no signage on the door to instruct what kind of precautions or Personal Protective Equipment (PPE) was needed. According to Licensed Practical Nurse (LPN) #4 the resident has nebulizer treatments ordered and the PPE is for treatments. The order states: Albuterol Sulfate inhalation Nebulization Solution 2.5 MG/0.5 ML (Albuterol Sulfate) 1 vial inhale orally via nebulizer every 4 hours as needed for COPD. and DuoNeb Solution 0.5-2.5 (3) MG/3 ML (Ipratropium-Albuterol 1 application via mask every 6 hours as needed for COPD. On 05/23/23 at 12:35 PM during an interview with LPN #8 stated that if a resident has a nebulizer treatment ordered and is in a semi private room, the only special procedure she would have to do would be to pull the curtain around the room mates bed. She would not have to wear any PPE unless the resident had a multidrug-resistant organism (MDRO) or COVID, she would not have to place any signs on the door reflecting that they are receiving a nebulizer treatment. According to the DON on 05/24/23 at 2:00 PM, there were Aerosol-Generating Procedure in Progress signs available which indicates what PPE is required to enter the room along with instructions to KEEP DOOR CLOSED DURING USE AND 1 HOUR POST TREATMENT (See nurse for time frames). She also confirmed that such a sign should be on each door that has nebulizer treatments ordered. c) Resident #114 On 05/22/23 at 2:40 PM it was noted that there was a donning/doffing TBP station outside of Resident #88's room. There were however, no signage on the door to instruct what kind of precautions or PPE were needed. According to LPN #4 the resident had nebulizer treatments ordered and the PPE was for treatments. The order states: Albuterol Sulfate inhalation Nebulization Solution 2.5 MG/0.5 ML (Albuterol Sulfate) 1 inhalation inhale orally via nebulizer four times a day for COPD. There is also an order that reads Aerosol Droplet Precautions during nebulizer treatments: Please close door, pull privacy curtain, DON PPE during treatment, display Aerosol Droplet Precaution sign and remove once treatment is completed. Disinfect equipment and surrounding areas once treatment is completed. Four(4) times a day. On 05/23/23 at 12:35 PM during an interview with LPN #8 she states if a resident has a nebulizer treatment ordered and is in a semi private room, the only special procedure she would have to do would be to pull the curtain around the room mates bed. She would not have to wear any PPE unless the resident had a multidrug-resistant organism (MDRO) or COVID, she would not have to place any signs on the door reflecting that they are having a nebulizer treatment. According to the DON on 05/24/23 at 2:00 PM, there were Aerosol-Generating Procedure in Progress signs available which indicates what PPE is required to enter the room along with instructions to KEEP DOOR CLOSED DURING USE AND 1 HOUR POST TREATMENT (See nurse for time frames). She also confirmed that such a sign should be on each door that has nebulizer treatments ordered. d) Resident #111 On 05/22/23 at 2:50 PM it was noted that there was a donning/doffing transmission based precaution station outside of Resident #88's room. There was however, no signage on the door to instruct what kind of precautions or PPE were needed. According to LPN #4 the resident had nebulizer treatments ordered and the PPE was for treatments. The order states: DuoNeb Solution 0.5-2.5 (3) MG/3 ML (Ipratropium-Albuterol 1 unit inhale orally via nebulizer every 4 hours as needed for COPD: cough. There is also an order that reads Aerosol Droplet Precautions during nebulizer treatments: Please close door, pull privacy curtain, DON PPE during treatment, display Aerosol Droplet Precaution sign and remove once treatment is completed. Disinfect equipment and surrounding areas once treatment is completed. Four times a day. On 05/23/23 at 12:35 PM during an interview with LPN #8 stated that if a resident has a nebulizer treatment ordered and is in a semi private room, the only special procedure she would have to do would be to pull the curtain around the room mates bed. She would not have to wear any PPE unless the resident had a multidrug-resistant organism (MDRO) or COVID, she would not have to place any signs on the door reflecting that they are having a nebulizer treatment. According to the DON on 05/24/23 at 2:00 PM, there were Aerosol-Generating Procedure in Progress signs available which indicates what PPE is required to enter the room along with instructions to KEEP DOOR CLOSED DURING USE AND 1 HOUR POST TREATMENT (See nurse for time frames). She also confirmed that such a sign should be on each door that had nebulizer treatments ordered. e) Resident #101 An observation on 05/22/23 at 10:08 AM of Resident #101's room found an aerosol nebulizer machine with no signage on the door or personal protective supplies available. A medical record review of Resident #101's Physician Orders revealed an order: --Levalbuterol HCl Inhalation Nebulization Solution 0.63 MG/3 ML (Levalbuterol HCl) One (1) vial inhale orally via nebulizer every 4 hours as needed for shortness of breath or wheezing. During an interview on 05/22/23 at 12:55 PM the DON verified Resident 101's Nebulizer order and confirmed the EBP signage or PPE was not available in proximity. She stated that Resident #101 had moved rooms and the signage and PPE cart were not moved.

Based on staff interview, medical record review, and policy review, the facility failed to ensure monthly medication regimen reviews (MRR) were completed by a pharmacist and the physician responded to the pharmacy recommendations in a timely manner. This is true for four (4) of five (5) reviewed for unnecessary medications. Resident identifiers: #7, #34, #8, #22. Facility census: 115. Findings include: a) Policy The facility policy titled Medication Regimen Review with a review date of 02/28/23, states non-urgent medication irregularities will be addressed with the attending physician no later than the next routine visit. The attending physician must document in the medical record the identified irregularity reviewed, any action taken to address rational for declining the recommendation. b) Resident (R) #7 Review of the medical record on 05/23/23 revealed there were no MRR for October 2022, November 2022 and February 2023. In addition, the medical record lacks a physician response to the MRR dated 08/27/22. The MRR date 08/27/22 requests a gradual dose reduction for R#7's medications to treat depression and anxiety. Current medications include Trintellix (antidepressant) 20 milligrams (mg) daily, Ativan (antianxiety) 0.5 mg three (3) times a day and Buspar (antianxiety) 5 mg twice a day. During an interview on 05/24/23 at 8:00 AM, the Director of Nursing (DON) reported the facility changed pharmacists and there were no monthly MRR completed for R#34 for October and November 2022. During a follow up interview on 05/24/23, the DON acknowledged she was unable to find the physician response for the MRR dated 08/27/22. c) Resident (R) #34 A review of the medical record on 05/23/23 revealed there were no MRR's for October 2022, November 2022, December 2022, and February 2023. In addition, there is no physician response to the MRR completed on 04/29/23. The MRR dated 04/29/23 identifies a polypharmacy concern noting 26 active medication orders. The pharmacist requested the physician evaluate the following medications for possible discontinuation: Senokot S (laxative) one daily, Miralax (laxative) 17 grams daily, vitamin D3 5000 international units daily, Melatonin (alternative therapy sleep aide) 6 milligrams (mg) at bedtime which is being given with Trazadone (antidepressant they may help with sleep) 50 mg at bedtime. The pharmacist also noted the order for Singulair 10 mg daily for chronic obstructive pulmonary disease (COPD), stating this is not indicated for use in COPD. In addition, the pharmacist recommended the Lidocaine patch order be amended to state the patch is to be warn 12 hours daily and a notation should be made when the patch is removed. The Medication Administration Record (MAR) for May 2023 note the above medications are still active, the Singulair order is not corrected, and the Lidocaine patch order is not amended to include a sign off when the patch is removed after 12 hours. During an interview on 05/24/23 at 8:00 AM, the Director of Nursing (DON) reported the facility changed pharmacists and there were no monthly MRR completed for R#34 for October 2022, November 2022, December 2022 and February 2023. The DON noted the MRR dated 04/29/23 is still in the physician's folder waiting to be reviewed. When asked how often he visits the facility, the DON stated he is in the building every Monday and Wednesday and every other Friday. The DON added she has been struggling with getting the physician to review the MRR and respond. At 8:10 AM on 05/24/23, Registered Nurse #23 acknowledged R#34's MAR has not changed and the medication orders were not updated since the pharmacy recommendations were made on 04/29/23. d) Resident #8 During a medical record review on 05/23/23, it was discovered the Pharmacist had not completed the MRR for 10/22 and 11/22. Also the MRR completed on 08/27/22 for a recommended dose reduction for Trazodone 50 milligrams (mg) had no response from the physician and or designee. In an interview with the DON on 05/24/23 at 10:00 AM, verified she was unable to locate the MRR's for 10/22 and 11/22 and the Pharmacy MRR recommendation to review Trazodone on 08/27/22 had no response from the physician and or designee. e) Resident #22 A record review, completed on 05/23/23 at 8:00 PM, revealed there were no medication regimen reviews on file for the months of October 2022, November 2022, and February 2023. During an interview on 05/24/23 at 11:15 AM, the DON reported the facility could not provide evidence monthly mediation reviews were completed for October 2022 and November 2022 noting that was during the timeframe the facility was switching pharmacists. At that time, the DON stated she would have to check on the month of February 2023. On 05/24/23 at 1:26 PM, the DON reported the facility could not produce evidence a monthly medication review had been completed by the pharmacist in February 2023. 43340

Based on resident interview, record review, and staff interview, the facility failed to protect and promote the rights of Resident #50. The facility failed to issue Resident #50 an invitation to attend two (2) appeals hearings regarding the discharge for nonpayment. This was a random opportunity for discovery. Resident identifier: #50. Facility census: 115. Findings included: a) Resident #50 During an interview on 05/23/23 at 8:11 AM, Resident #50 reported she had been given a discharge notice for nonpayment. Record review, completed on 05/23/23 at 7:10 PM, identified the following details: -A Physician Determination of Capacity, dated 04/21/21, which stated Resident #50 had capacity to make decisions. -A Durable Power of Attorney (DPOA) on file listing resident's family member as DPOA. (A durable power of attorney is a legal document that gives another person the authority to make financial decisions for someone.) -A Social Service Note, dated 02/17/23 at 9:03 AM, stated that the social worker had received notification from the Business Office Manager of a telephone hearing for the resident's appeal, regarding the notice of discharge for nonpayment, scheduled for 03/14/23 at 10:00 AM. There was no other information in the electronic medical record regarding this appeal hearing. -A Social Service Note, dated 04/14/23 at 8:18 AM, stated that the Social Worker (SW) received a confirmation letter from Resident #50's family of the appeal hearing scheduled on 05/16/23 at 9:00 AM. The SW also documented the Business Office Manager confirmed the information to be accurate. -A Social Service Note, dated 05/16/23 at 12:02 PM, stated that the telephone appeals hearing was held with the Business Office Manager, the SW, the DPOA, and the DPOA's granddaughter all present on the call. The SW also documented she was later approached by Resident #50 to inquire about the upcoming telephone hearing. Resident #50 was with the understanding that it was scheduled for 05/18/23. During an interview on 05/24/23 at 8:13 AM, the SW confirmed Resident #50 had mental capacity. The SW reported she was not present for the 03/14/23 appeal hearing because she was off sick. The SW then stated that Resident #50 had not been present at the second appeal hearing on 05/16/23 because the facility had deferred to the resident's DPOA to participate on resident's behalf. No invitation was extended to Resident #50 to attend either hearing. The SW agreed the facility had failed to promote the rights of Resident #50 to participate in the two (2) appeal hearings. During an interview on 05/24/23 at 10:40 AM, the Business Office Manager confirmed Resident #50 was not in attendance at the 03/14/23 appeals hearing. The Business Office Manager stated it was typically a social service function to identify if a resident should be in attendance at such meetings.

Based on record review, resident interview, staff interview, family interview, and hospital record review, the facility failed to ensure residents were free of neglect by failing to assess, monitor, and provide medical intervention timely for a resident who had worsening decubitus ulcers, and for two (2) dependent residents who were incontinent. Three (3) of fourteen (14) sampled residents were found to have evidence of neglect. Resident identifiers: #89, #71, and #78. Facility census: 118. Findings include: a) Resident #89 Review of a 01/02/13 nursing progress note revealed this resident was "noted to have reddened areas to bony prominences to bilateral lateral hips." The physician was made aware. Review of a 01/02/13 physician's orders [REDACTED]. Review of Section M of the Minimum Data Set (MDS), with an assessment reference date (ARD) of 01/16/13, revealed this resident had two (2) Stage I pressure ulcers. Review of the medical record found no evidence of any further assessment and monitoring of the reddened ischial tuberosities from 01/02/13, at their discovery, until after the resident was seen in the emergency roiagnom on [DATE]. Review of a nurse's progress note, dated 01/24/13 at 6:04 a.m., revealed a nursing assistant had found "blackened areas on foot" during the resident's bath. The nurse assessed "has 3 areas on right foot lateral side 1st is 1 inch below 5th toe that measures overall 4 cms (centimeters) with 2.3 x 1 cm blackened area. 2nd is 1/2 inch above that is 2 cm in length with 1/2 cm x 1 cm area that is blackened and 3rd is directly over talus lateral ankle that is red. Anterior surface of foot is slightly [MEDICAL CONDITION] . . . Prevalon boots applied. MD notified. Will have day nurse call POA (power of attorney)". Review of a nurse's progress note, dated 01/24/13 at 11:57 a.m., found an order from the attending physician to send the resident to the emergency room for evaluation and treatment of [REDACTED]. Review of the hospital's emergency room record and attending physician's assessment, dated 01/24/13, revealed this resident was assessed as having "Stage 2 decubitus ulcer ischial tuberosity on left. Larger stage 2 decubitus ulcer over the right ischial tuberosity and in the center that has black eschar". The physician also assessed areas along the lateral border of the right foot, "primarily over the base of the 5th metatarsal and along (the) metatarsal head both of which have central areas of skin necrosis". The physician recommended that this resident be referred to the wound care center for follow-up, and scheduled an appointment for 01/30/13 at 8:30 a.m. Review of a Concern Form, dated 01/25/13, revealed the family of Resident #89 had met with administrative staff. The form included, ". " (Resident ' s name) was unable to D/C (discharge) home with family on 1/25/12 due to a decline in his health and a pressure area to his R (right) hip that has gotten worse. . . . " The facility follow-up included placing Resident #89 on a flap care bed to encourage more aggressive potential for wound healing, and for the resident to be evaluated by the wound team. Review of a nurse's progress note, dated 01/25/13, revealed this resident had five (5) pressure ulcers, with three (3) of the five (5) located on the right foot. The nurse noted a "Pressure ulcer to proximal metatarsals with necrosis 2.4 x (symbol for by) 1.1 cm. R (symbol for right) lateral foot noted with necrosis .5 x (symbol for by) .5 cm. and R (symbol for right) tallus noted with increased non-blanchable reddened area .2 x .(symbol for by) .5 cms. R (symbol for right) hip noted with necrotic area 3 x (symbol for by) 6 cm, dry....L (symbol for left) hip noted with eschar and scab that measured 2.4 x (symbol for by) 6 cm. dry skin". Review of a social service note, dated 01/25/13, by a former social service intern, revealed that the resident's family member "stated she is angry about the circumstances that have come about regarding finding necrotic areas on this resident's skin". Review of a significant change MDS, with an ARD of 01/31/13, found the resident was assessed with [REDACTED]. The largest area had measurements of 3.0 by 6.0 centimeters. During an interview with a nurse, Employee #23, and the administrator, on 02/06/13 at 6:00 p.m., they were asked if they had any further information about when the reddened area on the ischial tuberosities had declined, or when they were staged or measured prior to the emergency room visit, or when those areas became necrotic or had scabs or eschar. They had no answers to these question. No evidence was produced prior to exit to indicate that ongoing monitoring and assessment had been done. During an interview with the former treatment nurse, Employee #138, on 02/07/13 at 2:20 p.m., she said in her assessment on 01/25/13 of the ischial tuberosities, the right hip had necrotic tissue and was black in color, but not open. It was 3.0 cms x 6.0 cms. During an interview with another nurse, Employee #110, at that time, she said this area was still blackened and about the same. In an interview with the Administrator, on 02/07/13 at 12:30 p.m., she said they had held another "Ad Hoc" meeting on 01/18/13 where they identified during an audit that pressure ulcers were a problem area. During a second "Ad Hoc" meeting on 02/01/13, she said they identified problem areas related to "skin". She said a skin sweep was completed on all the residents on 01/29/13 (which was verified by surveyor), and PUSH tools were completed for every skin area by 01/31/13. They had another skin sweep scheduled for 02/05/13 and 02/06/13. Also, they were transitioning to a wound team comprised of four (4) registered nurses, rather than their former method of one licensed nurse and the Director of Nursing. They were interviewing for a new wound nurse. She said they were in the process of completing staff education for the nurses and nursing assistants. Also, they had various types of mattresses, and changed out two surfaces for upgrades. b) On 02/05/13 at 8:15 a.m., a list of concerns/grievances was requested for the months of January and February, including any and all that had yet to be resolved. The administrator provided a log of concerns/grievances completed, which was dated through 02/02/13. She indicated no other concerns/grievances had been completed and no others were outstanding. 1) Resident #71 Review of Resident #71's medical record, on 02/05/13 at 2:30 p.m., revealed she had a concern with incontinence care on 02/03/13 at 09:14 a.m. A skilled progress note related the resident's husband had approached the nurse in the hallway at 8:14 a.m., stating his wife had not been cleaned from a bowel movement that had occurred prior to 6:00 a.m. It noted staff were in Resident #71's room and had advised the resident, "while trays are being passed we can not change people, however, as soon as trays are finished she will be the first one changed." The nurse indicated the resident was satisfied at that point. The nurse further added, " At 0700 (7:00 a.m.) housekeeping had approached her and advised the "patient wanted cleaned up." She noted "at 0806 (8:06 a.m.) patient was washed up by CNA (nursing assistant) on the floor. Educated pt on call bells and use of how to get help. Patient stated she told night shift nurse she needed cleaned and night shift did not come back into room. Patient's husband asked who he needed to talk to about getting resident to another facility. Advised social services will be in tomorrow a.m. and I will let them know as well they wanted to speak to social services. Pt husband asked why there were not barrels in each room like the hospital. Explained infection control and how the facility operates." Another note, dated, 02/03/13 at 10:11, related staff, "Checked with patient . . . Advised this nurse made a note on the incident that occurred and note placed on social services door for Monday morning. Patient advised, ask for nurse personally if there are any issues today." During an interview with Resident #71, on 02/05/13 at 5:15 p.m., she related, "I asked the girl to clean me up and she said she wasn't allowed. A lady, a little bit before six came in and changed me. I had a bowel movement a little bit after that. Sometimes I can tell and sometimes I can't tell If I have to have a bowel movement. It's the same way with the urine. I rang the bell at 6:15 a.m. Later, the lady brought in her breakfast (pointed to roommate). I asked her, when you get finished can you come back and change me. She didn't answer yes, or no, maybe, or anything. I kept laying and laying and laying. No one ever came. She had finished her breakfast and I still hadn't got breakfast and was still laying in a mess, so I called my husband and he came down here and raised hell. They said they would write her up. I know she has friends she works with and they might do something to me. I haven't seen her since. No one came in before my husband got here. He asked me, have you been changed yet, and I told him no." When asked if she knew the name of the staff member, she stated, "I think I would know her if I saw her." She further added, "to my knowledge, nobody came to see me. This is the first I heard about it again, since the incident. " The resident's spouse was interviewed on 02/05/13 at 6:00 p.m. He stated, "I was home and I got a call at 8:00 in the morning. She said I need you to come out here. I've been here for 2 hours waiting on someone to change my diaper. I spoke with (Employee #128's name), my wife has been here for 2 hours waiting to get her diaper changed. She told me that they don't do those services. She said breakfast started at 7:00 a.m. We have to deal with cross contamination. She said I would have to talk with (Employee #110's name). The patient advocate, she has blonde hair, (identified as Employee #79) was sitting at the nurses' station. I asked (Employee #79's name) about the concern and she said she would investigate it. She said she was going to have to instruct the staff." Resident #71's spouse added, another "incident is the bedpan. I went into the bathroom and it had fecal matter all over the bedpan. I spoke with (Employee #79's name) about this also. He further added, "when (name of Resident #71) was admitted to the facility, the hospital had just removed the catheter." He further added, "She had it for 28 days, from December 26, 2012 to January 24, 2013. The facility should know she would require bladder retraining." Upon inquiry, Resident #71's husband said he was not aware of any toileting plan, and she would wet, two or three times, before being changed. The intervention/task form, completed by nursing assistants, was reviewed on 02/06/13. It noted the resident had received care at 3:49 a.m. No further entries were completed until 2:29 p.m. The 2:30 - 10:30 shift data, on 02/03/13, provided no evidence care had been provided on that shift. During an interview with the Employee #124, on 02/06/13, she reviewed the concern form and said she had "never heard anything about that." She added, "Waiting three hours, that is on the lines of neglect, I would think. This is the first I heard about it. I've had no concerns at all with this family. The social work intern reported she was not aware, either. 2) Resident #78 The facility concern log was reviewed on 02/06/13 at 8:00 a.m. It noted Resident #78's daughter had reported a concern on 01/07/13. It indicated, on Friday 01/04/13, the resident "was soiled and patient stated he had been sitting in it all day. Evening aide cleaned him up and stated it was dried on. Family states it was running down his leg into his shoe." Review of the medical record, on 02/06/13 at 8:05 a.m., reveal an order dated 12/31/12. It read, "cleanse excoriation to scrotum et coccyx after each incontinence episode and apply z guard." The care plan was also reviewed. It noted "At risk of urinary incontinence related to history of incontinence, cognitive deficit, communication deficit, impaired mobility, physical limitations and diabetes. At risk for complications: goal maintain in as clean and dry dignified state as possible. Interventions included, "Urinal with in reach, assistance with toileting, incontinent care as needed, remind and assist as needed upon rising before and after meals activities therapy and bedtime. Additionally, a general progress note, dated 01/06/13 at 5:38 a.m., indicated the "resident is incontinent of bowel and bladder. Perineal area and scrotum macerated due to constant wetness..." During an interview with Employee #40 (nursing assistant), on 02/06/13 at 9:50 a.m., she stated, "he requires assist of one" and she had to help him when she assisted with toileting. Resident #78 was interviewed on 02/06/13 at 10:00 a.m. He said he remembered the incident and stated, "I was having a lot of problems back then." He said he still requires assistance, "sometimes." Observation of the room revealed he did not have a urinal within reach. Upon inquiry with Employee #83 (licensed practical nurse), she said they are" kept in the bathroom and the residents asks for them, because they tend to make a mess. The care plan was reviewed with the LPN. She confirmed it noted the urinal was to be within the resident's reach. The resident's room was then observed by the nurse and she verified the urinal was not within the resident's reach. She checked the bathroom and stated, "it isn't in here either." Employee #124 (social worker), reviewed the concern form regarding incontinence management. Upon inquiry, she stated, "yes, I would report it." When asked whether it had been reported, she said, "no." She further added, "I know it wasn't reported." .

Based on record review, staff interview, and hospital record review, the facility failed to assess and monitor pressure ulcers, as evidenced by failing to recognize a deterioration in a pressure ulcer from a Stage I reddened area, to a pressure ulcer with black eschar, prior to an emergency room physician assessment. This deficient practice was evident for one (1) of fourteen (14) sampled residents. Resident identifier: #89. Facility census: 118. Findings include: a) Resident #89 Review of an 01/02/13 nursing progress note revealed this resident was "noted to have reddened areas to bony prominences to bilateral lateral hips." The physician was made aware. Review of a physician's orders [REDACTED]. Section M of the Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 01/16/13, was coded to indicate this resident had two (2) Stage I pressure ulcers. Review of the medical record found no evidence of any further assessment and monitoring of the ischial tuberosities from 01/02/13, when they were first discovered, until after the resident was seen in the emergency roiagnom on [DATE]. A nursing progress note, dated 01/24/13 at 6:04 a.m., revealed that a nursing assistant found "blackened areas on foot" during the resident's bath. The nurse assessed that he "has 3 areas on right foot lateral side 1st is 1 inch below 5th toe that measures overall 4 cms (centimeters) with 2.3 x 1 cm blackened area. 2nd is 1/2 inch above that is 2 cm in length with 1/2 cm x 1 cm area that is blackened and 3rd is directly over talus lateral ankle that is red. Anterior surface of foot is slightly [MEDICAL CONDITION] . . . Prevalon boots applied. MD notified. Will have day nurse call POA (power of attorney)". Review of a nursing progress note, dated 01/24/13 at 11:57 a.m., found an order from the attending physician to send the resident to the emergency room for evaluation and treatment. Review of the hospital's emergency room record and attending physician's assessment, dated 01/24/13, revealed this resident was assessed as having "Stage 2 decubitus ulcer ischial tuberosity on left. Larger stage 2 decubitus ulcer over the right ischial tuberosity and in the center that has black eschar". The physician also assessed areas along the lateral border of the right foot, "primarily over the base of the 5th metatarsal and along (the) metatarsal head both of which have central areas of skin necrosis". The physician recommended this resident be referred to the wound care center for follow-up, and scheduled an appointment for 01/30/13 at 8:30 a.m. Review of a Concern Form, dated 01/25/13, revealed the family of Resident #89 met with administrative staff regarding a concern that the resident could not be discharged due to a decline in his condition. The facility follow-up included placing Resident #89 on a flap care bed to encourage more aggressive potential for wound healing, and for the resident to be evaluated by the wound team. Review of a nurse progress note, dated 01/25/13, revealed this resident had five (5) pressure ulcers, with three (3) of the five (5) located on the right foot. The nurse noted a "Pressure ulcer to proximal metatarsals with necrosis 2.4 x (symbol for by) 1.1 cm. R (symbol for right) lateral foot noted with necrosis .5 x (symbol for by) .5 cm. and R (symbol for right) tallus noted with increased non-blanchable reddened area .2 x .(symbol for by) .5 cms. R (symbol for right) hip noted with necrotic area 3 x (symbol for by) 6 cm, dry....L (symbol for left) hip noted with eschar and scab that measured 2.4 x (symbol for by) 6 cm. dry skin". Review of a significant change MDS, with an ARD of 01/31/13, revealed the presence of two unstageable pressure ulcers due to coverage, and three unstageable pressure ulcers due to deep tissue injury. The largest area measured 3.0 by 6.0 cms. During an interview with Employee #23 (a nurse) and the administrator, on 02/06/13 at 6:00 p.m., they were asked if they had any further information about when the reddened area on the ischial tuberosities had declined, or when they were staged or measured prior to the emergency room visit, or when those areas became necrotic or had scabs or eschar. They had no answers to these question, and no evidence was produced prior to exit to indicate that ongoing monitoring and assessment had been done. During an interview with the former treatment nurse, Employee #138, on 02/07/13 at 2:20 p.m., she said in her assessment on 01/25/13 of the ischial tuberosities, that the right hip had necrotic tissue and was black in color, but not open, 3.0 cms x 6.0 cms. During an interview with nurse Employee #110 at this time, she said this area is still blackened and about the same. (Note: necrotic tissue is dead tissue, it is not viable.) During an interview with the administrator on 02/07/13 at 12:30 p.m., she said they had held an "Ad Hoc" meeting on 01/18/13 where they identified during an audit that pressure ulcers were a problem area. During a second Ad Hoc meeting on 02/01/13, she said they identified problem areas related to "skin". She said a skin sweep was completed on all the residents on 01/29/13 (which was verified by surveyor), and PUSH tools were completed for every skin area by 01/31/13. They have another skin sweep scheduled for 02/05/13 and 02/06/13. Also, they are transitioning to a wound team comprised of four registered nurses, rather than their former method of one licensed nurse and the Director of Nursing. They are interviewing for a new wound nurse. She said they are in the process of completing staff education for the nurses and nursing assistants. Also, they have various types of mattresses, and changed out two surfaces for upgrades. .

Based on record review and staff interview, the facility failed to provide medical intervention timely, and/or ongoing monitoring and assessments, to a resident who had a change in condition. An [AGE] year old resident with diabetes developed a change in condition to her right great toe, with no known interventions and/or assessments until six (6) days after the initial assessment. This delay in treatment had the potential to adversely affect the progression of the wound and comfort of the resident. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 This [AGE] year old resident had [DIAGNOSES REDACTED]. According to the resident's medical record, this resident had been treated for [REDACTED]. A progress note, dated 12/13/12, by Employee #126, a licensed nurse, identified the family's concern with the resident's great toe on the right foot. The nurse assessed the area, and noted a "dark purple hematoma on toe". Record review found no evidence of assessment or monitoring of the changes to the right great toe until six (6) days later on 12/19/12 at 5:47 a.m. A progress note, dated 12/19/12 at 5:47 a.m., by a registered nurse (Employee #1), revealed a change of condition note that assessed the "Resident has blackened area on right great toe and 4th great toe, her foot is [MEDICAL CONDITION] and cool. Skin of foot is red with striation . . . No dorsal or post tibia pulse appreciated with Doppler. Left foot has sore on 2nd toe . . . Will report to MD (doctor)". During an interview with Employee #126 on 01/23/13 at 8:50 a.m., she said she faxed the physician about the right great toe on 01/13/12, and verbally passed the information to the oncoming shift. She said the right great toe looked purple, it seemed to have been a sudden change, and had given the appearance of perhaps having been bumped. During an interview with Employee #82 (registered nurse) on 01/23/13 at 9:05 a.m., she said they keep copies of faxes sent to the physician in the physicians' mailboxes until they received a response. They would re-fax the physician if there was no response. All resolved faxes were filed in a book at the desk. This book was thinned on occasion when it was getting larger, and the older ones were shredded. Review of the resolved fax book, on 01/23/13 at 9:10 a.m., found the faxes in the book only went back to 12/20/12. An interview with the director of nursing (DON), on 01/23/13 at 1:45 p.m., revealed that the first time the right great toe issue was placed on the 24-hour report occurred on 12/19/12, after Employee #1 wrote the entry and noted to call the doctor. The DON said an appointment was then made with the podiatrist, who saw the resident on 12/19/12 at 4:45 p.m. She could produce no evidence that a physician had been notified, or had evaluated the toe, between 12/13/12 and 12/19/12. Review of the podiatrist's progress note, dated 12/19/12, revealed his assessment that Resident #119 had dry gangrene of the right hallux (big toe). He recommended that the resident be seen by an orthopedic physician as soon as possible. Record review revealed the resident's medical power of attorney made an appointment for 12/27/12 with an orthopedic surgeon. However, due to an increase in the resident's level of pain, she was sent to a local hospital on [DATE], where she was subsequently admitted . According to a 12/25/12 nursing progress note, the resident was transferred for pain evaluation "due to uncontrolled pain in the right lower leg". Review of the admitting hospital's medical records, revealed that upon admission she was found to have "avascular (having few or no blood vessels) right great toe with a lot of pain and color changes", and "gangrene due to secondary diabetes mellitus". An orthopedic consultation dated 12/16/12 revealed an impression of "dry gangrene, right foot", and a recommendation "for a BKA ([MEDICAL CONDITION]) right lower extremity". She underwent a right [MEDICAL CONDITION] on 12/27/12. Additionally, it was found that Resident #119 was admitted to the facility in November 2012 with a Stage II pressure ulcer to the right heel. This was the same foot on which the great toe had a blackened area. Record review found the absence of a weekly body audit on 12/11/12, with the most recent body audit having occurred on 12/04/12, and the next on 12/17/12. Record review also found the absence of a weekly measurement and assessment of the pressure ulcer to the right heel on 12/20/12, with the most recent one having occurred on 12/13/12, and no other prior to her transfer to the hospital on [DATE]. Interview with licensed nurse Employee #81, on 01/22/13 at 9:30 a.m., found that every resident is to have a skin audit done weekly. Although they are usually done by the treatment nurse, the floor nurses do them in the absence of the treatment nurse. During an interview with the Director of Nursing (DON), on 01/22/13 at 2:45 p.m., she produced weekly body audit sheets dated 12/04/12 and 12/17/12 for Resident #119. She was unable to locate a body audit sheet for 12/11/12 at this time, or prior to exit. She said that body audits were to be done weekly. .

Based on record review and staff interview, the facility failed to ensure residents were free of neglect by failing to assess, monitor, and provide medical intervention timely, for an [AGE] year old resident with diabetes and an existing pressure ulcer when she developed a blackened area on her right great toe. There was no evidence of assessments or interventions until six (6) days after the initial identification. This delay had the potential to adversely affect the progression of the wound and comfort of the resident. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 This [AGE] year old resident had [DIAGNOSES REDACTED]. She also had a had been receiving treatment for [REDACTED]. A progress note, dated 12/13/12, by Employee #126, a licensed nurse, identified the family's concern with the resident's great toe on the right foot. The nurse assessed the area, and noted a "dark purple hematoma on toe". No evidence of any additional assessment or monitoring of the changes to the right great toe were found until six (6) days later on 12/19/12 at 5:47 a.m. On 12/19/12 at 5:47 a.m., a registered nurse (Employee #1), documented "Resident has blackened area on right great toe and 4th great toe, her foot is [MEDICAL CONDITION] and cool. Skin of foot is red with striation . . . No dorsal or post tibia pulse appreciated with Doppler. Left foot has sore on 2nd toe . . . Will report to MD (doctor)". In an interview with Employee #126, on 01/23/13 at 8:50 a.m., she said she had faxed the physician about the right great toe on 01/13/12, and verbally passed the information to the oncoming shift. She said the right great toe looked purple, it seemed to have been a sudden change, and had given the appearance of perhaps having been bumped. Employee #82 (registered nurse) was interviewed on 01/23/13 at 9:05 a.m. She said they kept copies of faxes sent to the physician in the physicians' mailboxes until they received a response. They would re-fax the physician if there was no response. All resolved faxes were filed in a book at the desk. This book was thinned on occasion when it was getting larger, and the older ones were shredded. Review of the resolved fax book, on 01/23/13 at 9:10 a.m., found the faxes in the book only went back to 12/20/12. An interview with the director of nursing (DON), on 01/23/13 at 1:45 p.m., revealed the first time the condition of the resident's right great toe had been placed on the 24-hour report was on 12/19/12. This was after Employee #1 had written the entry about the condition of the resident's toe and noted to call the doctor. The DON said an appointment was then made with the podiatrist, who saw the resident on 12/19/12 at 4:45 p.m. She could find no evidence to support a physician had been notified, or had evaluated the toe, between 12/13/12 and 12/19/12. The podiatrist's progress note, dated 12/19/12, noted Resident #119 had dry gangrene of the right hallux (big toe). He recommended the resident be seen by an orthopedic physician as soon as possible. According to the resident's record, her medical power of attorney had made an appointment for 12/27/12 with an orthopedic surgeon. However, due to an increase in the resident's level of pain, she was sent to a local hospital on [DATE], at which time she was admitted . According to a 12/25/12 nursing progress note, the resident was transferred for pain evaluation "due to uncontrolled pain in the right lower leg". Review of the admitting hospital's medical records, revealed that upon admission the resident was found to have "avascular (having few or no blood vessels) right great toe with a lot of pain and color changes", and "gangrene due to secondary diabetes mellitus". An orthopedic consultation dated 12/16/12 revealed an impression of "dry gangrene, right foot", and a recommendation "for a BKA ([MEDICAL CONDITION]) right lower extremity". She underwent a right [MEDICAL CONDITION] on 12/27/12. Resident #119 had been admitted to the facility in November 2012 with a Stage II pressure ulcer to the right heel. This was the same foot on which the great toe had a blackened area. Record review found the absence of a weekly body audit on 12/11/12, with the most recent body audit having occurred on 12/04/12, and the next on 12/17/12. Neither noted the condition of the right great toe. Record review also found the absence of a weekly measurement and assessment of the pressure ulcer to the right heel on 12/20/12, with the most recent one having occurred on 12/13/12, and no other prior to her transfer to the hospital on [DATE]. Interview with licensed nurse Employee #81, on 01/22/13 at 9:30 a.m., found that every resident was to have a skin audit done weekly. Although they were usually done by the treatment nurse, the floor nurses were to do them in the absence of the treatment nurse. During an interview with the Director of Nursing (DON), on 01/22/13 at 2:45 p.m., she produced weekly body audit sheets dated 12/04/12 and 12/17/12 for Resident #119. She was unable to locate a body audit sheet for 12/11/12 at that time, or prior to exit. She said that body audits were to be done weekly. .