Every finding on record at Martinsville Health and Rehab

Based on observations and staff interview, the facility staff failed to store and prepare food in a sanitary manner. The findings included:During an initial tour of the kitchen on 01/12/26 at 11:50 am, surveyor observed a box of ground meat with a handwritten note that read, Out to thaw 01/05/26, use by 01/11/26. Surveyor pointed this out to dietary manager. Dietary manager stated they would discard the meat. Surveyor observed the dishwasher to have a dried, crusty substance on the top corners. Dietary manager stated they clean this substance off every day, and it's back the next morning. Surveyor observed the oven in the kitchen to have dried food substance on the front outside of the oven doors. Surveyor asked the dietary manager how often the ovens are cleaned, and dietary manager stated, Weekly.On a follow-up visit to the kitchen on 01/12/26 at 1:05 pm, surveyor observed certified nurse's aide (CNA) #1 standing in the kitchen prep area. Surveyor observed that CNA #1 did not have a hair covering over her hair. Surveyor asked dietary manager if CNA #1 should be wearing a hair covering, and dietary manager stated that she should, and stated, I honestly didn't notice if she had a hair net on or not.Surveyor spoke with CNA #1 on 01/23/26 at 1:20 pm. Surveyor asked CNA #1 if they had put on a hair covering prior to entering the kitchen, and CNA #1 stated they had not.Dietary manager provided surveyor with an inservice form on 01/15/25 which read in part, Labeling and Dating Inservice. Items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from the freezer and an appropriate 'use by' date as outlined in the Retention Guide attached (Example: A tube of ground beef). The Food Storage and Retention Guide attached to the inservice form read in part, Raw Meat/Poultry/Seafood: Fish, seafood, ground meat and all poultry (Once Thawed) 1-2 days.The concern of not storing and preparing food in a sanitary manner was discussed with the administrator, director of nursing, and regional director of clinical services on 01/15/26 at 2:00 pm.No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, facility staff failed to ensure the consultant pharmacist documented their findings in the clinical records after completing drug regimen reviews for (5) five of (5) five sampled residents reviewed for unnecessary medications, Resident #2, Resident #5, Resident #6, Resident #9, and Resident #55. The findings included: The consultant pharmacist failed to document their findings regarding drug regimen reviews in the resident's clinical records. During clinical record reviews the survey team were unable to determine if the consultant pharmacist had made recommendations during their monthly drug regimen reviews. The pharmacist had only documented, chart review completed by consultant pharmacist. There was no reference regarding a recommendation being made or not made. On 01/13/2026 at 4:30 p.m., during an end of the day meeting with the Administrator, Director of Nursing (DON) and Regional Nurse Consultant the issue with the incomplete records regarding drug regimen reviews was reviewed. The DON was able to provide the survey team with a list of residents that did not have recommendations after the pharmacist review(s). This list was not part of the resident's clinical record(s). On 01/15/26 the DON provided the survey team with a copy of their policy titled, Medication Monitoring Medication Regimen Review and Reporting. This policy read in part, .Resident-specific MRR [medication regimen review] recommendations and findings are documented.A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable format.within 48 hours of MRR completion. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to periodically review resident's advance directive information for (1) one of (28) twenty-eight sampled residents, Resident #50. The findings included:The facility staff failed to periodically review Resident #50's advance directive information with the resident and/or resident representative.Resident #50's diagnoses included chronic obstructive pulmonary disease, anxiety disorder, hypertension, and dementia.Section C of Resident #50's quarterly minimum data set (MDS) assessment with and assessment reference date (ARD) of 12/13/25 was coded 00. Per the MDS manual a score of 00=severe impairment in cognitive skills for daily decision making.During the clinical record review, the surveyor was unable to locate any information to indicate Resident #50's advance directive information had been reviewed since 01/17/24. On 01/14/2026 at 9:00 a.m., during an interview with the Social Worker (SW) this staff stated they had not reviewed advance directive information with this resident due to their cognitive status and the resident's family did not attend care plan meetings. On 01/14/2026 at 12:35 p.m., the SW provided the surveyor with evidence that they had reviewed the residents advance directive information with the residents' legal representative today (01/14/26) via phone. On 01/14/2026 at 5:05 p.m., during an end of the day meeting with the Administrator, Director of Nursing and Regional Nurse Consultant the issue with Resident #50's advance directive information not being reviewed was discussed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure the comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team, for (1) one of (28) twenty-eight sampled residents, Resident #9. The findings included:For Resident #9, the facility staff failed to reassess the effectiveness of the interventions and review and revise the resident's comprehensive person-centered activity care plan to meet the resident's needs. Resident #9's diagnosis list indicated diagnoses that included, but were not limited to, cerebrovascular disease, spastic hemiplegia affecting right dominant side, schizophrenia, depressive disorder, and cognitive communication disorder. The most recent annual minimum data set (MDS) with an assessment reference date (ARD) of 12/20/25, was coded for the resident being rarely/never understood with short and long-term memory problems, and moderate impairment in decision-making. A review of the current comprehensive person-centered activity care plan disclosed an initiated date of 4/6/25 and the last revision date of 4/6/25 with no changes identified for the focus, goal or interventions. A review of the clinical record did not disclose any evidence of activity progress notes. Further review disclosed a Recreation Services Assessment for an annual review dated 12/30/24 and a Recreation Services Assessment dated 12/19/25 that was blank and noted as incomplete. A review of the completed MDS schedule revealed the following MDS assessments were completed on the following dates with no evidence of a completed activity assessment, activity care plan review, and/or activity progress notes:12/20/25-annual9/29/25-quarterly 6/29/25-quarterly On 1/14/26 at 11:22 AM, this surveyor interviewed other staff #5 (OS#5) and reviewed Resident #9's activity care plan, activity assessments, and activity progress notes. OS#5 informed this surveyor the care plan is supposed to be updated quarterly, annually, and with the MDS. OS#5 reviewed the annual activity assessment dated [DATE] with surveyor and agreed it was not completed and stated she must have gotten side-tracked and did not complete it and agreed she is supposed to complete a quarterly review/quarterly progress note for activities. OS#5 and this surveyor reviewed the interventions on Resident #9's activity care plan, and OS#5 agreed the resident had improved in group activity participation and was more social and agreed the activity plan of care should have been updated to reflect the resident's improvement and interests. OS#5 informed this surveyor that Resident #9's activity care plan would be updated. On 1/14/2026 at 12:04 PM, this surveyor was provided with an updated activity care plan for Resident #9. This concern was discussed at the end of day meeting on 1/14/26 at 5:05 PM with the administrator, director of nursing, and regional nurse consultant. Surveyor requested and received a facility policy titled, Activity Care Plan with an effective date of 11/2020 which read in part, .It is the policy of this facility's activity department to develop and maintain individualized care plans as needed for each resident.3. As a part of the care plan, activity plans are reviewed quarterly.4. A care plan is an ongoing process and should be updated as needed.5. Development/review/revision of the activity care plan is a result of the prior completed assessment. Surveyor requested and received a facility policy titled, Progress Notes with an effective date of 11/2020 which read in part, .It is the policy of this facility to complete a progress note in the following situations.2. No less than quarterly.4. Annually. No further information regarding this concern was presented to the survey team prior to the exit on 1/15/26.

Based on resident interview, family interview, staff interview, ombudsman interview, clinical record review, and facility document review, the facility staff failed to treat residents with dignity and respect for (1) one of (28) twenty-eight sampled residents, Resident #55. The findings included:For Resident #55 the facility staff failed to treat the resident with dignity and respect as evidenced by discussing her personal information with her roommate's family member.Resident #55's clinical record listed diagnoses which included but not limited to morbid (severe) obesity due to excess calories.Resident #55's most recent minimum data set with an assessment reference date of 11/30/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact.Resident #55's comprehensive care plan was reviewed and contained plans for Overweight/Obesity as related: Depression, Obese with BMI (body mass index) >30, (BMI 73.4) history of weight fluctuations with desire to lose weight. Resident desires to lose weight of 100 lb. and I am on a special diet-cause: morbid obesity. Resident expresses desire to lose weight.Surveyor spoke with Resident #55 on 01/13/26 at 11:40 am. Resident #55 stated, . (facility social worker [SW]) called her . (resident's roommate) mother and told her to stop bringing me food. She (SW) told her (roommate's mother) that I have gained 20 lbs, and if she doesn't stop bringing me stuff, they will move my roommate. It's none of her (resident's roommate) business. I felt like I was being stepped on, and I never got an apology. I was humiliated.Surveyor spoke with Resident #55's roommate's mother on 01/13/26 at 1:00 pm. Surveyor asked roommate's mother if the SW had called her to discuss Resident #55, and roommate's mother stated, She called me about bringing . (Resident #55) food and something about the floor and her (Resident #55) weight. I just thought that was . (Resident #55) personal stuff and she (SW) shouldn't be telling me about it. She (SW) said she (Resident #55) had gained a lot of weight. I only bring her iced tea, hot coffee, fresh fruits and salads. They had a meeting a couple of weeks later with the administrator, SW, doctor, and ombudsman. (Resident #55) asked me to come.Surveyor spoke with the SW on 01/13/26 at 1:20 pm regarding Resident #55. SW stated they did talk with Resident #55's roommate's mother but did not discuss resident's weight. SW stated, It was more along the lines of 'you need to talk to staff before you bring food to residents.'Surveyor spoke with the local long-term care ombudsman on 01/15/26 at 10:30 am regarding Resident #55. Ombudsman stated that Resident #55 called me, bawling her eyes out, and was very upset that the SW had called roommate's mother. Ombudsman stated they had a care plan meeting after this, and resident invited her roommate's mother to attend. Ombudsman stated that roommate's mother was upset that the SW said they would move her daughter to another room if she continued to bring Resident #55 food and felt as if was retaliation against her.Surveyor requested and was provided with a facility policy entitled Your Rights and Protections as a Nursing Home Resident which read in part, At a minimum, Federal specifies that nursing homes must protect and promote the following right of each resident. You have the right to Be Treated with Respect: You have the right to be treated with dignity and respect.The concern on not treating Resident #55 with dignity and respect was discussed with the administrator, director of nursing and regional director of clinical services on 01/15/26 at 2:00 pm.No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer a pneumococcal vaccine in accordance with nationally recognized standards for (1) one of (5) five sampled residents, Resident #14. The findings included:The facility staff failed to offer the resident a pneumococcal conjugate vaccine 15 (PCV15), 20 (PCV20), or 21 (PCV21) after their admission to the facility.The Centers for Disease Control and Prevention (CDC) website updated 10/07/25 recommends for individuals greater than 50 years or older that have only previously received only PPSV23: 1 dose of PCV15 or 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PPSV23 dose.Resident #14's age was greater than 50 and their diagnoses included diabetes and dementia.Section C (cognitive patterns) of Resident #14's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/12/25 included a brief interview for mental status (BIMS) score of 13 out of a possible 15 points. Indicating this resident was cognitively intact.On 01/13/26 the surveyor requested of the Infection Preventionist (IP) evidence of Resident #14's pneumococcal vaccines.On 01/13/2026 at 11:18 a.m., the surveyor and the IP reviewed Resident #14's vaccination status. On 04/05/23 Resident #14 had received the pneumovax 23 vaccine. The IP did not provide any further evidence to indicate this resident had received or had been offered any further pneumococcal vaccines.The facility policy titled, Pneumococcal Vaccinations with a revision date of 02/2022 read in part, The admitting nurse will research the medical record and resident history to determine if pneumococcal has ever been given. After determining vaccine status the admitting nurse determine what vaccine, if any, is recommended per current CDC guidance.Dosing Schedule.Adults with previous PPSV23 only may receive either PCV20 or PCV15 [greater than or equal to] 1 year after their last PPSV23 dose.On 01/14/2026 at 5:05 p.m., during an end of the day meeting with the Administrator, Director of Nursing, and Regional Nurse Consultant the issue with Resident #14's vaccine status was reviewed.On 01/15/26 at 12:15 p.m., during a phone interview with a staff from a local medical office this staff confirmed Resident #14 had been administered two pneumonia vaccines at their office. Vaccine #1 on 06/11/14 name of pneumococcal vaccine was unspecified. Vaccine #2 on 08/22/16 vaccine name was listed as pneumococcal polysaccharide PPV23. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observations, staff interviews, clinical record reviews, and facility document review, the facility staff failed to follow an established infection control program for (3) three of (28) twenty-eight sampled residents, Resident #4, Resident #32, and Resident #73. The findings included: 1. For resident #4, the facility staff failed to ensure the foley catheter drainage bag was not resting on the floor. Resident #4's diagnoses included but were not limited to, a history of stroke with hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness affecting one side of the body) as well as dysphagia (difficulty swallowing), type II diabetes, schizophrenia, bipolar disorder, anxiety disorder and epilepsy. The annual minimum data set (MDS) assessment with an assessment reference date of 12/16/25 assigned the resident a brief interview for mental status score of 10 out 15 indicating a moderate cognitive impairment. On 1/14/26 at 11:38 AM, this surveyor entered resident #4's room with the infection preventionist (IP) to observe wound care. This surveyor noted the foley catheter drainage bag was resting on the floor, the bed was in the low position. The IP began readying the resident for a dressing change. This surveyor asked the IP if the foley catheter drainage bag should be resting on the floor. They stated, No, it should not. The IP raised the bed enough to get the foley off the floor and hung it on the bed frame. On 1/14/26 at 11:50 AM the Director of Nursing (DON) was notified of this concern and asked for a policy on foley catheter care. The DON provided a policy entitled, Competencies with an effective date of 2/2017. The policy read in part, The nursing department will utilize the most current edition of Lippincott's Nursing Procedures and Lippincott's Manual of Nursing Practice for clinical standards of care in the facility. The DON pointed out a passage in the Nursing Procedures manual that read in part, Don't place the drainage bag on the floor, to reduce the risk of contamination and subsequent CAUTI (catheter associated urinary tract infection). This concern was discussed at the pre-exit meeting on 1/15/26 at 1:57 PM with the administrator, director of nursing, regional vice president of operations, and regional nurse consultant. No further information was provided to the survey team prior to the exit conference. 2. For Resident #32 the facility staff failed to ensure that gloves were not placed inappropriately on resident care equipment and on the floor. Resident #32's diagnosis list indicated diagnoses that included, but were not limited to, peripheral vascular disease, anxiety disorder, cognitive communication deficit, dementia, and dependence on supplemental oxygen. The most recent significant change minimum data set (MDS) with an assessment reference date (ARD) of 12/22/25, assigned the resident a brief interview for mental status (BIMS) summary score of 7 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. During a tour of the facility on 1/12/26 at 12:50 PM, this surveyor observed (2) two gloves hanging on oxygen (O2) tubing near floor on right side of resident near O2 concentrator. On 1/13/26 at 9:07AM, this surveyor observed no gloves on O2 tubing. This surveyor observed 2 gloves near Resident #32's oxygen concentrator on the floor under the resident's bed. This concern was discussed at the end of day meeting on 1/14/26 at 5:05 PM with the administrator, director of nursing, and regional nurse consultant. On 1/15/26 at 1:57 PM, the director of nursing informed this surveyor, this issue had been corrected. Surveyor requested and received a facility policy titled, Guidelines for Disposable Resident Care Items with a revision date of 10/2020 which read in part, .Disposable items are discarded after the intended use for an individual resident.4. Single-use disposable items are discarded after each use. A. Examples of single-use items are gloves. No further information was provided to the survey team prior to exit on 1/15/26. 3. For Resident #73 the facility staff failed to follow established infection control procedures. Resident #73's clinical record listed diagnoses which included but not limited to acute cystitis without hematuria. Resident #73's most recent minimum data set with an assessment reference date of 12/05/25 assigned the resident a brief interview for mental status score of 4 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #73's comprehensive care plan was reviewed and contained a plan for I have a diagnosis of MRSA (methicillin resistant staphylococcus aureus) infection. Interventions for this care plan include Transmission based precautions per order. Resident #73's clinical record was reviewed and contained a physician's order summary which read in part, Transmission Based Precautions Contact Precautions every day and night shift for MRSA. On 01/13/25 at 8:15 am, surveyor observed certified nurse's aide (CNA) #1 in Resident #73's room. CNA #1 was not wearing any PPE (personal protective equipment) at this time. Surveyor returned to Resident #73's room at 8:20 am. Resident's door was closed; there was signage on the door that read STOP. Report to nurse before entering room and a cart containing PPE located outside door. Surveyor knocked on the door and heard someone say, Come in. Surveyor opened the door and observed CNA #1 seated on side of Resident #73's bed, assisting him with drinking fluids. CNA #1 was not wearing any PPE. Surveyor asked CNA #1 if they should be wearing PPE, and CNA #1 stated, I don't know, should I? Surveyor responded by saying, You should ask someone. Surveyor spoke with director of nursing (DON) on 01/15/26 at 8:40 am regarding CNA #1 not wearing PPE and sitting on resident's bed. DON stated that CNA should have been wearing PPE and should not have been sitting on resident's bed. Surveyor requested and was provided with a facility policy entitled, Transmission Based Precautions: Contact Precautions which read in part, Contact precautions are used to prevent the spread of microorganisms by direct or indirect contact with the patient or the patient's environment. Effective contact precautions require a single room, if possible, and the use of gloves and gowns by anyone having contact with the patient, the support equipment, or items that have come in contact with the patient or the patient's environment. The concern of not following established infection control procedures was discussed with the administrator, DON, and regional director of clinical services on 01/15/26 at 2:00 pm No further information was provided prior to exit.

Based on observation, family interview, staff interview, clinical record review, and facility document review, facility staff failed to provide food that is prepared to conserve nutritive value, flavor, and appearance for (1) one of (28) twenty-eight sampled residents, Resident # 21. The findings included:For Resident #21 the facility staff failed to provide food that was palatable and attractive.Resident #21's clinical record listed diagnoses which included but not limited to dysphagia following cerebral infarction.Resident #21's most recent minimum data set with an assessment reference date of 11/16/25 assigned the resident a brief interview for mental status score of 9 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired.Resident #21's comprehensive care plan was reviewed and contained a plan for Potential for swallowing difficulty as related to: dysphagia. Interventions for this plan include diet as ordered.On 01/13/25 at 1 pm, surveyor spoke with Resident #21's mother. Resident #21's mother was visiting resident at this time. When surveyor began talking with Resident #21's mother, she stated, You're not here about her meal tray, I thought you were coming to talk about that. Surveyor asked Resident #21's mother what was wrong with the meal tray and resident's mother lifted the cover from the meal tray and stated, This is what she got. Surveyor observed a hamburger bun and what appeared to be breadcrumbs on the tray. Resident's mother reached into the tray and picked up the breadcrumbs and let them fall from her fingers, and stated, That is supposed to be a ground, breaded chicken patty. I don't know how she is supposed to eat that on a bun, if it was ever on the bun. It's dry as sawdust. Surveyor observed Resident #21's meal tray ticket and it read in part, Ground Breaded Chicken Patty for Bun, Hamburger Bun, Mayonnaise, Parmesan & Herb Roasted Cauliflower, chop, Oven Browned Potatoes, Sliced Peaches & Pears Resident #21's mother stated, Her ticket says she is supposed to have peaches, but they weren't on her tray. Surveyor did not observe any peaches/pears or a dish that would have contained them on the resident's tray.The concern of not providing food that is palatable and attractive was discussed with the administrator, director of nursing, and regional director of clinical services on 01/15/26 at 2:00 pm.No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, facility staff failed to provide required documentation to receiving entity at time of transfer/discharge for (3) three of (28) twenty-eight sampled residents, Resident #4, Resident #80, and Resident #91. The findings included:1. For resident #4, the facility staff failed to provide documentation that the required information was provided to the receiving healthcare institution for a transfer that occurred on 9/1/2025 and a transfer that occurred 11/26/25. Resident #4's diagnoses included but were not limited to, a history of stroke with hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness affecting one side of the body) as well as dysphagia (difficulty swallowing), type II diabetes, schizophrenia, bipolar disorder, anxiety disorder and epilepsy. The annual minimum data set (MDS) assessment with an assessment reference date of 12/16/25 assigned the resident a brief interview for mental status score of 10 out 15 indicating a moderate cognitive impairment. During an interview resident #4 would only smile and nod to surveyor and was not interviewable. The progress notes were reviewed. On 9/1/25 at 9:40 AM a change in condition note read, BP (blood pressure) 73/49 RR (respiratory rate) 30, T (temperature) 101.6 rhonchi bilateral lungs. Resident is diaphoretic. Only opens eyes when spoken to. Notified on call. Order given to send to ER (emergency room) for evaluation and treatment. There was no documentation to indicate what information the facility staff sent with the resident to the hospital. There was a note stating that a verbal report had been called in to the emergency room. A progress note dated 11/26/25 at 2:06 PM read in part, .received an order to send pt (patient) out to ER for eval/treatment There was no note to indicate what information if any was sent with the resident to the hospital. On 1/14/26 at 12:06 PM this surveyor asked the social worker to provide a copy of documents sent to the hospital with resident #4 on 9/1/25 and 11/26/25. The social worker returned with forms entitled, Notice of Involuntary Transfer or Discharge and Bed Hold Authorization for each hospitalization. On 1/14/2026 at 12:34 PM, the director of nursing informed the survey team that the facility staff was not sending required documentation with the residents upon transfer/discharge. The Director of Nursing (DON) provided documentation of education that had been done with the nursing staff on two separate occasions to show that it was an issue she had been addressing. On 1/15/26 at 10:50 AM this surveyor met with the DON and Regional [NAME] President of Operations. The DON explained that they had discovered a glitch in their software that was deleting the discharge packets from the system. My nurses have been doing them, but for some reason they are getting deleted and we don't know why. This surveyor asked for some sort of proof that resident #4's packets had been in the system at some point, but they were not able to produce any evidence. This surveyor requested and received a copy of the policy entitled, Transfer a Resident to the Hospital which read in part, 4. Print the resident's face sheet, current medication list, pertinent labs/radiology reports, and any other clinical information pertaining to transfer reason. This concern was discussed at the pre-exit meeting on 1/15/26 at 1:57 PM with the administrator, director of nursing, regional vice president of operations, and regional nurse consultant. No further information was provided to the survey team prior to the exit conference. 2. For Resident #80, the facility staff failed to ensure the appropriate information was provided to the receiving healthcare institution for a transfer/discharge on [DATE]. Resident #80's diagnosis list indicated diagnoses that included, but were not limited to, volume depletion, atherosclerotic heart disease, schizoaffective disorder, kidney failure, and acute or chronic malnutrition. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 1/10/26, assigned the resident a brief interview for mental status (BIMS) summary score of 4 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A review of the clinical record indicated Resident #20 was transferred to the hospital on [DATE]. No evidence that appropriate information was provided to the receiving healthcare institution for the transfer/discharge on [DATE] could be located. This surveyor requested evidence that appropriate information was provided to the receiving healthcare institution for the transfer/discharge on [DATE]. On 1/14/2026 at 12:34 PM, the director of nursing informed this surveyor that she agreed the facility staff is not sending required documentation with the residents upon transfer/discharge. This concern was discussed at the pre-exit meeting on 1/15/26 at 1:57 PM with the administrator, director of nursing, regional vice president of operations, and regional nurse consultant. Surveyor requested and received a facility policy titled, Transfer a Resident to a Hospital with an effective date of 3/2021, which read in part, .Emergency Transfer.3. Complete the Transfer Out (emergency) Assessment. 4. Print resident's face sheet, current medication list, pertinent labs/radiology reports, and any other clinical information pertaining to transfer reason. 5. Place printed content into transfer envelope.9. Send copy of.Involuntary Transfer form with the resident. No other information was provided to the survey team prior to exit on 1/15/26. 3. For Resident #91, the facility staff failed to provide documentation that the required information was provided to the receiving acute care hospital for a transfer that occurred on 12/30/25. Resident #91's diagnosis list indicated diagnoses, which included, but were not limited to adult failure to thrive, cerebral infarction, and polyneuropathy. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 12/11/25 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #91's clinical record included a nursing progress note dated 12/30/25 at 10:16 AM which revealed the resident had been complaining of shortness of breath, appeared to be in distress, and had an oxygen saturation level of 64% following increased oxygen administration. A provider order was received to send Resident #91 to the emergency department. A review of Resident #91's clinical record failed to reveal documentation of required resident information being provided to the acute care hospital. A facility policy titled, Transfer a Resident to a Hospital, dated 3/2021 indicated for an emergency transfer 4. Print resident's face sheet, current medication list, pertinent labs/radiology reports, and any other clinical information pertaining to transfer reason. 5. Place printed content into transfer envelope. This concern was discussed at a pre-exit meeting on 1/15/26 at 1:57 PM with the administrator, director of nursing, regional vice president of operations, and the regional nurse consultant. No further information regarding this concern was presented to the survey team prior to the exit conference on 1/15/26.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to honor resident's choices for (1) one of (28) twenty-eight sampled residents, resident #10. The findings included:For Resident #10 the facility staff failed to honor the resident's choice to have a shower in the morning instead of evening.Resident #10's clinical record listed diagnoses which included but not limited to Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side.Resident #10's most recent minimum data set with an assessment reference date of 11/21/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section GG, functional abilities, coded the resident as needing partial/moderate assistance with bathing.Resident #10's comprehensive care plan was reviewed and contained a plan for Potential for Self-Care Deficit r/t (related to): Requires staff assistance with ADL's (activities of daily living) d/t (due to) physical functioning deficit, mobility, impairment, HX (history) of CVA (cerebrovascular accident) w(ith) Left Hemiplegia, Hx of Compression Fracture at the L2 Vertebral Body. Interventions for this care plan include Encourage choices with care.Surveyor spoke with Resident #10 on 01/13/26 at 8:45 am. Surveyor asked resident if she has any concerns with her care, and Resident #10 stated, The only problem I have is not getting my showers. I am supposed to get a shower on Mondays, Thursdays, and Saturdays, but I haven't had a shower in a week. The CNA (certified nurse's aide) came in yesterday and asked me if I wanted a shower and I told her yes. She told me someone else would come and take me. No one ever came. A CNA came in and washed me off this morning because I told her I was itching. Surveyor asked Resident #10 what time of day they take their shower, and Resident #10 stated, They give them in the evenings, but I would prefer to take mine in the morning. Surveyor asked Resident #10 if they have ever refused to take a shower and Resident #10 stated, Yeah, I have, when they come in here after I've gone to sleep.Resident #10's ADL's sheets were reviewed and read in part, Shower Monday/Thursday/Saturday night shift. Prefers to take shower between the hours of 4:30 am-6:30 am. Prefers shower over bed bath.Surveyor requested and was provided with a facility document entitled Resident Rights which read in part, The Resident has the right to choose activities schedules and health care consistent with his or her interests, assessment, and plans of care.The concern of not honoring Resident #10's choice to have a shower in the morning, and rather than a bed bath was discussed with the administrator, director of nursing and regional director of clinical services on 01/15/26 at 2:00 pm.No further information was provided prior to exit.

Based on staff interview and facility document review, the facility staff failed to provide Notice of Medicare Non-Coverage at least two days prior to the end of a Medicare covered Part A stay for (1) one of (3) three sampled residents, Resident #20. The findings included: For Resident #20, the facility staff failed to provide Notice of Medicare Non-Coverage at least two days prior to the end of the resident's Medicare covered Part A stay. Resident #20's diagnosis list indicated diagnoses, which included, but not limited to metabolic encephalopathy, muscle weakness, chronic kidney disease-stage 3, and atherosclerotic heart disease of native coronary artery. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of [DATE] assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. Resident #20's last covered day of Medicare Part A services was [DATE]. A Notice of Medicare Non-Coverage (NOMNC) was issued and signed by the resident's representative on [DATE]. On [DATE] at 8:49 AM, this surveyor spoke with the facility administrator and he informed surveyor that the NOMNC was not issued on time and by the time it was issued, they had not realized the resident's covered days had already expired. This concern was discussed on [DATE] at 4:30 PM at the end of day meeting with the administrator, director of nursing, and regional nurse consultant. Surveyor requested and received a facility policy titled Advance Beneficiary Notice-ABN with an effective date of 11/2020, which read in part, .The facility will give a completed copy of the ABN far enough in advance of an event about which a decision must be made by the beneficiary.so that the beneficiary can make a rational, informed consumer decision without undue pressure. Last minute notification can be coercive, and a coercive notice is a defective notice of skilled services. No further information regarding this concern was presented to the survey team prior to the exit conference on [DATE].

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to accommodate the resident's needs and preferences to get out of bed for (1) one of (28) twenty-eight sampled residents, Resident #55. The findings included:For Resident #55 the facility staff failed to accommodate the resident's preference to get out of bed.Resident #55's clinical record listed diagnoses which included but not limited to morbid (severe) obesity due to excess calories and bed confinement status.Resident #55's most recent minimum data set with an assessment reference date of 11/30/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact.Resident #55's comprehensive care plan was reviewed and contained plans for Overweight/Obesity as related: Depression, Obese with BMI (body mass index) >30, (BMI 73.4) history of weight fluctuations with desire to lose weight. Resident desires to lose weight of 100 lb., I am on a special diet-cause: morbid obesity. Resident expresses desire to lose weight, At risk for fall related to . (Resident #55) needs assistance of staff to transfer with a hoyer lift due to bilateral lower extremity weakness due to history of Guillain Barre Syndrome and Dx (diagnosis) of Morbid Obesity and Self-Care Deficit related to . (Resident #55) needs mostly extensive to total dependence assistance of staff to complete ADL's (activities of daily living). Interventions for these care plans include Transfer assistance (Transfer using the Hoyer Lift w(with)/staff assistance of at least 2), bed bath daily, encourage choices with care, Refer to therapy PRN (as needed) and Transfers: Transfer using the Hoyer Lift w/at least 2-staff persons assisting.Surveyor spoke with Resident #55 on 01/13/26 at 11:40 am. Resident #55 stated to surveyor, I have been in this bed for almost 3 years. This came from . (facility company name omitted) that I'm too wide to get in the Hoyer lift. I would like to get out of this bed. The lift will hold my weight. Last time they tried to get me up, the lift tipped, but that was because someone was behind and pulled on it. How would you like to lay in bed all the time? I would like to take therapy, but they have told the insurance company I have plateaued.During an end of day meeting on 01/13/26 at 4:30 pm, surveyor asked if staff ever attempt to assist Resident #55 to get out of bed and if they have a Hoyer lift that will accommodate her, and administrator stated, It's not a lift weight problem, but last time they tried to use the lift, it started shimmying and seemed unsafe to use with resident. The director of nursing (DON) stated the lift is rated for up to 600 lbs.Surveyor spoke with registered nurse (RN) #3 on 01/14/25 at 2:45 pm. Surveyor asked RN #3 if they ever attempt to get Resident #55 out of bed, and RN #3 stated, We've tried a few times and the lift almost flipped with her in it. Surveyor asked RN #3 if Resident #55 has a wheelchair, and RN #3 stated, She used to have one, but I haven't seen it in a couple of years. Surveyor asked RN #3 how Resident #55 is provided with ADL care, and RN #3 stated, She gets daily bed baths.During an end of day meeting on 01/14/26 at 5:05 pm, surveyor asked if the facility has a lift pad/sling that will accommodate Resident #55 and asked if resident has a wheelchair. Administrator stated they do have a lift pad and wheelchair for Resident #55. Surveyor asked how Resident #55 would be transferred in the event of an emergency, and DON stated, We would pull her with a sheet, if we had to.Surveyor spoke with the local long term care ombudsman on 01/15/26 at 10:30 am regarding Resident #55. Ombudsman stated the resident has expressed concerns about not getting out of bed, and that these concerns have been addressed at several care plan meetings. Ombudsman stated that resident's wheelchair was in her room until she got a roommate. Ombudsman stated, They really need to meet her needs, they are restricting her by not getting her up.Surveyor requested and was provided with a copy of the Hoyer lift user manual which read in part, DO NOT exceed maximum weight limitation of the patient lift. The weight limitation for the RPL 600-2 is 600 lbs. Surveyor observed a RPL 600-2 Hoyer lift in the facility on 01/15/26.Surveyor requested to see the lift pad/sling that is used for Resident #55, and DON provided this. The sling was observed to be rated for up to 1000 lbs.The concern of not accommodating Resident #55's desire to get out of bed was discussed with the administrator, DON and regional director of clinical services on 01/15/26 at 2:00 pm.No further information was provided prior to exit.

Based on observations, staff interview, clinical record review, and facility document review, the facility staff failed to provided ordered treatment for pressure ulcers for (1) one of (28) twenty-eight sampled residents, Resident #4. The findings included:Resident #4's diagnoses included but were not limited to, a history of stroke with hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness affecting one side of the body) as well as dysphagia (difficulty swallowing), type II diabetes, schizophrenia, bipolar disorder, anxiety disorder and epilepsy. The annual minimum data set (MDS) assessment with an assessment reference date of 12/16/25 assigned the resident a brief interview for mental status score of 10 out 15 indicating a moderate cognitive impairment. On 1/3/26 at 11:25 AM a progress note read, Stage 2 pressure injury noted to sacrum. Area was cleansed with normal saline, barrier cream and foam dressing applied. Resident repositioned every 2 hours and prn (as needed). Incontinent care provided. No s/s of infection noted at present time. On call provider and (responsible party name omitted) made aware. Resident place on MD rounds. Will continue to monitor for healing. On 1/3/26 at 3:56 PM the Nurse Practitioner (NP) documented new orders in the progress notes, Cleanse the wound: Gently cleanse the wound with sterile saline or using Derma wound cleanser Apply Santyl: Apply the ointment directly to the wound surface at a thickness of about 2 mm (the thickness of a nickel), once daily Avoid certain products: Do not use Santyl with certain products, such as some detergents, acidic or basic cleaning solutions, or dressingscontaining silver or iodine, as they can reduce its effectiveness Moisturize (if needed): If the wound is dry, add moisture using a saline-moistened gauze, compatible wound gel Cover the wound: Cover the wound with foam dressing: Allevyn, Mepilex, etc.Change dressings daily, or as directed, to remove dead tissue and advance the healing process. The treatment administration record (TAR) for January 2026 was reviewed. A new order entered 1/3/26 at 3:35 PM read, Barrier cream to sacrum q (every) shift and prn (as needed) after incontinent episodes. There was no order for a dressing entered on the TAR 1/3/26 and the order for barrier cream did not include a cleansing step as in the NP's note. A nurse progress note dated 1/8/26 at 4:13 PM read, Dr. [NAME] in to see resident pressure injury found on left buttock informed resident and called RP (name omitted) no answer left message for her to return call. A document entitled Wound Evaluation and Management Summary was dated 1/8/26 and read in part, Stage 3 pressure wound to sacrum full thickness 1.4x1.2x0.2. Under the heading Dressing Treatment Plan the document read, Collagen sheet apply once daily and as needed if saturated, soiled or dislodged for 30 days. Under the heading Secondary Dressing the document read, gauze island with border apply once daily and as needed. Under the heading Peri Wound Treatment the document read, skin prep apply once daily and as needed. The TAR was reviewed on 1/13/26 and the above wound orders had not been entered. On 1/13/26 during the end of day team meeting with the Administrator, Director of Nursing (DON) and Regional Nurse Consultant, this surveyor informed the DON that I would like to observe wound care on 1/14/26 for resident #4. On 1/14/26 at 11:38 AM, this surveyor entered resident #4's room with the infection preventionist (IP) to observe wound care. This surveyor had noted that the wound care orders documented in the wound note on 1/8/26 had been put on the TAR with a date of 1/14/26. There was a dressing already on the wound dated 1/14/26. When the IP removed the dressing, this surveyor noted intact, red skin under the dressing. The IP checked to see if the area was blanchable, it was not but the wound was not open. On 1/14/26 at 11:50 AM the DON and the Regional Nurse Consultant were notified that the orders for wound care from 1/8/26 were not entered until 1/14/26 but the wound is healing and unopen. This surveyor requested a policy for wound care; the DON provided a policy for physician orders stating there was no policy for wound care. This concern was discussed at the pre-exit meeting on 1/15/26 at 1:57 PM with the administrator, director of nursing, regional vice president of operations, and regional nurse consultant.No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide an ongoing, person-centered activity program to support resident choice, interests and physical, mental, and psychosocial well-being for (1) one of (28) twenty-eight sampled residents, Resident #80. The findings included:For Resident #80, the facility staff failed to provide an ongoing, person-centered, activity program to support resident choice, interests, and physical, mental, and psychosocial well-being. Resident #80's diagnosis list indicated diagnoses that included, but were not limited to, volume depletion, atherosclerotic heart disease, schizoaffective disorder, depression, bipolar disorder, suicidal ideations, schizoaffective disorder, acute or chronic malnutrition, and personal history of mental and behavioral disorders. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 1/10/26, assigned the resident a brief interview for mental status (BIMS) summary score of 4 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. On 1/12/26 at 6:34 PM, this surveyor spoke with Resident #80's family member #1 (FM#1) via phone conversation and FM#1 informed surveyor facility staff wanted the resident to stay in bed related to health issues and was not sure if the facility staff were doing one-to-one activities with the resident. A review of the clinical record and comprehensive person-centered care plan produced no evidence of a person-centered activity care plan or any evidence of activity progress notes for Resident #80. A review of an Activity Participation Review dated 1/9/26 was blank and noted to be in progress. A review of a Recreation Services Assessment dated 1/13/26 was blank and noted to be incomplete. A review of Resident #80's admission MDS dated [DATE] Section F (Preferences for Customary Routine and Activities) was coded as being somewhat important to the resident to listen to music, be around animals such as pets, do things with groups of people, do favorite activities, go outside in nice weather, and participate in religious services or practices. This surveyor requested and received activity participation records for December 2025 and January 2026. A review of the hand-written activity participation records for December 2025 indicated Resident #80 was a passive participant for a sensory activity on the following dates:12/8/2512/13/2512/17/2512/22/2512/27/25 A review of the hand-written activity participation records for January 2026 indicated Resident #80 was a passive participant for a sensory activity on the following dates:1/4/261/7/261/9/26 A review of Resident #80's census listing disclosed the resident was transferred to the hospital on [DATE] and was re-admitted to the facility on [DATE]. On 1/14/26 at 2:11 PM, this surveyor interviewed other staff #5 (OS#5) and reviewed the hand-written activity participation records for 1/4/26 and 1/7/26. OS #5 confirmed the activities on those dates were completed with Resident #80. This surveyor informed OS#5 that Resident #80 was in the hospital during those dates, OS#5 then agreed the activities documented on 1/4/26 and 1/7/26 were marked in error and struck the entries out and hand-wrote error beside the 1/4/26, 1/7/26, and 1/9/26 entries on the activity participation record. OS#5 also agreed Resident #80 only received (5) five activities from 12/5/25 through 12/31/25. This surveyor and OS#5 reviewed the Activity Participation Review dated 1/9/26 and reviewed the Recreation Services Assessment dated 1/13/26. OS#5 agreed the assessments were not completed and agreed a comprehensive person-centered activity care plan was not completed for Resident #80. This concern was discussed on 1/14/26 at 5:05 PM at the end of day meeting with the administrator, director of nursing, and regional nurse consultant. Surveyor requested and received a facility policy titled, Activity Assessment with an effective date of 11/2020, which read in part, .It is the policy of this facility to utilize an activity interest assessment on each resident within 5 days of their admission.The assessment will reflect the resident's interests both current and past, and/or need for sensory or environmental stimulation.A progress note should be written after the initial assessment is completed to include resident status i.e.: cognition level; interest areas; potential areas of concern for activities to address; and areas other than activity interests that may better develop a plan and individualizes pertinent information of resident needs.The Resident's activity plan must be developed in conjunction with the comprehensive assessment. Surveyor requested and received a facility policy titled, Participation in Activities with an effective date of 11/2020, which read in part, .Residents have the right to attend and participate in activities of their choice . No further information was provided to the survey team prior to exit on 1/15/26.

Based on observations, staff interview, resident interview, clinical record review, and facility document review, facility staff failed to provide activities of daily living care for (2) two of (28) twenty-eight dependent residents, Resident #10 and Resident #64. The findings included:1.For Resident #10 the facility staff failed to provide showers or daily bed baths. Resident #10's clinical record listed diagnoses which included but not limited to hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side and contracture, left hand. Resident #10's most recent minimum data set with an assessment reference date of 11/21/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section GG, functional abilities, coded the resident as needing partial/moderate assistance with showering/bathing. Resident #10's comprehensive care plan was reviewed and contained a plan for Potential for Self Care Deficit r/t (related to): Requires staff assistance with ADL's d/t (due to) physical functioning deficit, mobility impairment, Hx (history) of CVA (cerebrovascular accident) w/Left Hemiplegia, Hx of Compression Fracture at the L2 Vertebral Body. Interventions for this plan include Encourage choices with care and provide all needed assistance w/ADLs and mobility. Surveyor spoke with Resident #10 on 01/13/26 at 8:45 am. Resident #10 stated to surveyor the only concern they have with their care is not getting showers like they should. Resident #10 stated to surveyor that they are supposed to get a shower on Mondays, Thursdays and Saturdays, but they have not had a shower in a week. Resident #10 stated The CNA (certified nurse's aide) came in yesterday and asked me if I wanted a shower and I told her yes. She told me someone else would come and take me. No one ever came. They go tell the nurse I refuse, so they don't have to do their job. The CNA this morning came and washed me off because I told her I was itching. Surveyor asked Resident #10 what time of day they take their shower, and Resident #10 stated, They give them in the evenings, but I would prefer to take mine in the morning. Surveyor asked Resident #10 if they have ever refused to take a shower and Resident #10 stated, Yeah, I have, when they come in here after I've gone to sleep. Resident #10's ADL's sheets were reviewed and read in part, Shower Monday/Thursday/Saturday night shift. Prefers to take shower between the hours of 4:30 am-6:30 am. Prefers shower over bed bath. Resident #10's daily shower/bath sheets were reviewed and indicated that from 08/12/25 through 08/20/25 (8 days) resident received or was offered neither a shower nor a bed bath. Resident was neither offered nor received either a shower or bed bath between 08/26/25 and 08/31/25 (5 days). Surveyor requested and was provided with a facility policy entitled AM Care which read in part, Clinical services personnel will offer AM care each day to ensure resident's overall comfort, cleanliness, good grooming, and general well-being. Residents who are capable of performing their own personal care are encouraged to do so. Showers, baths, and shampoos are scheduled at least weekly and more often as needed. The concern of not providing ADL care for Resident #10 was discussed with the administrator, director of nursing, and regional director of clinical services on 01/15/26 at 2:00 pm. No further information was provided prior to exit. 2. For resident #64 the facility staff failed to perform nail care for a dependent resident. Resident #64's diagnoses included but were not limited to: a history of stroke, peripheral vascular disease, muscle weakness, protein calorie malnutrition, major depressive disorder, and anxiety. The quarterly minimum data set (MDS) assessment with an assessment reference date of 1/6/26 assigned the resident a brief interview for mental status (BIMS) score of 14/15 indicating intact cognition. According to the MDS, resident #64 is dependent on staff for all activities of daily living such as bathing and dressing, as well as all mobility. On 1/12/26 at 3:40 PM During initial tour, this surveyor interviewed resident #64. During the conversation, this surveyor noted that the residents fingernails were long and jagged with brownish/black material caked under each one. This surveyor asked resident #64 if he liked his nails that long and he shook his head no. When asked if he would like for the staff to trim his nails he stated he shook his head yes. When asked when the last time someone had trimmed and cleaned his nails, he shrugged his shoulders. On 1/13/26 at 4:15 PM this surveyor entered resident #64's room. His nails were still long and dirty. When the resident saw this surveyor looking at his fingernails he stated, Mama will do it. This surveyor met with the Director of Nursing (DON) on 1/13/26 at 4:40 PM and asked what the policy for nail care is. The DON stated, It's done as needed. The DON was informed of this surveyors' observations of resident #64. On 1/14/26 at 11:45 AM this surveyor went to visit with resident. His nails were clean and had been trimmed. No further information was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, facility staff failed to ensure an accurate minimum data set assessment for (1) one of (28) twenty-eight sampled residents, Resident #58. The findings included:The facility staff had coded Resident #58's annual MDS assessment to indicate the resident had been administered insulin. Resident #58 did not have a provider order for insulin and had not received insulin during the look back period of this MDS assessment.Resident #58's diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease, and hypertension.Section C (cognitive patterns) of Resident #58's annual MDS assessment with an assessment reference date (ARD) of 09/30/25 included a brief interview for mental status (BIMS) score of 9 out of 15 points. Per the MDS manual a 9=moderately impaired in cognitive skills for daily decision making. Section N (medications) had been coded to indicate this resident received insulin injections.During the clinical record review, the surveyor was unable to find a current or discontinued provider order for insulin.On 01/14/2026 at 9:12 a.m., Registered Nurse (RN) #1was interviewed regarding the coding of insulin on the MDS. On 01/14/2026 at 9:40 a.m., RN #1 confirmed the MDS had been coded incorrectly and stated a modification MDS had been completed. On 01/14/2026 at 5:05 p.m., during an end of the day meeting with the Administrator, Director of Nursing, and Regional Nurse Consultant the issue with the incorrect coding of the MDS was reviewed.No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review and facility document review, facility staff failed to complete (PASARR) for (1) one of (28) twenty-eight sampled residents, Resident #18. The findings included:Resident #18's diagnoses included but were not limited to chronic obstructive pulmonary disease, heart failure, dementia, psychosis, mood disorder, and major depressive disorder.Resident #18's quarterly minimum data set (MDS) assessment with an assessment reference date of 12/22/25 assigned the resident a brief interview for mental status score of 00 out of 15 indicating severe cognitive impairment.Resident #18's care plan included a focus that read in part, (resident name omitted) has a history of behaviors which include refusing showers or baths at times, refuses to allow staff to assist her. Physically striking others. Refuses room change; delusions-states we are being watched through the cameras. Refuses to see Dentist, Optometrist.This surveyor was unable to locate a Level I Preadmission Screening and Resident Review (PASRR) in the clinical record.On 1/13/26 at approximately 2:20 PM this surveyor asked the social worker if resident #18 had a PASRR. The social worker was unable to locate at PASARR in the clinical record and stated, She has an old UAI (Uniform Assessment Instrument) but there is no PASARR with it.On 1/13/26 at 4:46 PM the survey team met with the Administrator, Director of Nursing (DON) and the Regional Nurse Consultant. This concern was discussed at that time. The DON stated, She came before that was a requirement I thought. This surveyor stated that the resident was admitted to the facility in 2014.On 1/15/26 the social worker brought this surveyor a Level I PASARR with resident #18's name written on it and stated, She refused to do it. The form was blank except for the resident demographic information, and the social worker signature, date and facility address and phone number. A handwritten note at the bottom of the form read, RSD. (resident) refused to participate stating I'm doing that junk I've done it before.This surveyor requested and received a copy of the policy entitled Preadmission Screening and Resident Review (PASSR) Policy which read in part, It is the Facility's policy that a PASSR be obtained for every new admission to the Facility. This PASSR should be obtained prior to admission to the Facility.Prior to the admission to the Facility and as part of the referral review, the Facility Admissions Director (or designated admissions back-up) will verify that the PASSR has been completed, and the Facility has received a copy of the PASSR before the patient is admitted to the Facility. For long-term care residents already in the Facility without a Level I screening (admitted prior to July 1, 2019), a designated Facility staff member with medical knowledge of the resident and knowledge of the medical terminology in the Level I screening process will complete the screening.According to the dmas.virginia.gov website, All persons, regardless of payment status or reason for admission to a nursing facility, must be screened for mental illness (MI), intellectual disability (ID), and related conditions (RC). This screening is called a Level I Screening. If the nursing facility (NF) is processing admission of a non-Medicaid member, or anyone who does not have a Medicaid LTSS Screening, which includes the Level I Screening, the NF must complete or arrange for the completion of the Level I Screening. If a resident refuses or cannot participate, the facility must still complete the screening, and if a potential condition is identified, follow state procedures.This concern was reviewed with the administrative team during a meeting on 1/16/26. No further information was provided prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, facility staff failed to develop a baseline care plan for (3) three of (38) thirty-eight sampled residents, Resident #4, Resident #64, and Resident #94. The findings included:1. For resident #4 the facility staff failed to complete a baseline care plan upon admission. Resident #4's diagnoses included but were not limited to, a history of stroke with hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness affecting one side of the body) as well as dysphagia (difficulty swallowing), type II diabetes, schizophrenia, bipolar disorder, anxiety disorder and epilepsy. The annual minimum data set (MDS) assessment with an assessment reference date of 12/16/25 assigned the resident a brief interview for mental status score of 10 out 15 indicating a moderate cognitive impairment. Resident #4 was initially admitted to the facility in April of 2024. The baseline care plan was initiated but only question #2 for primary language and question #4 for allergies had been answered. The rest of the form was blank including the section where the care plan was reviewed with the resident or family member. In December 2025 resident #4 returned from a lengthy hospital stay. A baseline care plan was generated but was incomplete and not reviewed with the resident or the family. On 01/14/26 the DON provided the survey team with a copy of their policy titled, Baseline Care Plan and Summary. This policy read in part, .Upon admission the admitting clinical team will develop an initial plan of care based on information upon admission.2. Communication with resident and family or responsible party A. Within 48 hours the resident and family or responsible party will be given a summary review of the baseline care plan. A member of the clinical team or IDT (interdisciplinary team) will review in person or via phone the summary of the baseline care plan. A copy will be provided to the resident, family and or responsible party. This concern was discussed at the pre-exit meeting on 1/15/26 at 1:57 PM with the administrator, director of nursing, regional vice president of operations, and regional nurse consultant. No further information was provided to the survey team prior to the exit conference. 2. For resident #64, the facility staff failed to complete the baseline care plan upon admission to the facility. Resident #64's diagnoses included but were not limited to: a history of stroke, peripheral vascular disease, muscle weakness, protein calorie malnutrition, major depressive disorder, and anxiety. The quarterly minimum data set (MDS) assessment with an assessment reference date of 1/6/26 assigned the resident a brief interview for mental status (BIMS) score of 14/15 indicating intact cognition. According to the MDS, resident #64 was dependent on staff for all activities of daily living such as bathing and dressing, as well as all mobility and was fed via tube with orders to have nothing by mouth (NPO). On 9/30/25 a baseline care plan was initiated for resident #64. The form was mostly blank including the section indicating who the baseline care plan was reviewed with. On 1/13/26 at 1:20 PM this surveyor interviewed resident #64's responsible party. When asked if they had received a baseline care plan shortly after admission to the facility they stated, No, I don't believe I did. On 01/14/26 the DON provided the survey team with a copy of their policy titled, Baseline Care Plan and Summary. This policy read in part, .Upon admission the admitting clinical team will develop an initial plan of care based on information upon admission.2. Communication with resident and family or responsible party A. Within 48 hours the resident and family or responsible party will be given a summary review of the baseline care plan. A member of the clinical team or IDT (interdisciplinary team) will review in person or via phone the summary of the baseline care plan. A copy will be provided to the resident, family and or responsible party. This concern was discussed at the pre-exit meeting on 1/15/26 at 1:57 PM with the administrator, director of nursing, regional vice president of operations, and regional nurse consultant. No further information was provided to the survey team prior to the exit conference. 3. For Resident #94, the facility staff failed to develop a baseline care plan. This was a closed record review. Resident #94's diagnoses included cerebral infarction, adult failure to thrive, diabetes, quadriplegia, and muscle weakness. Section C (cognitive patterns) of Resident #94's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 06/16/23 was coded 1/1/2 to indicate this resident had problems with long and short-term memory and was moderately impaired in cognitive skills for daily decision making. During the clinical record review, the surveyor was unable to find evidence that a baseline care plan had been developed. On 01/14/2026 at 11:30 a.m., during an interview with the Director of Nursing (DON) this staff stated they were unable to find a baseline care plan for this resident. On 01/14/2026 at 5:05 p.m., during an end of the day meeting with the Administrator, DON, and Regional Nurse Consultant the issue with the missing baseline care plan was reviewed. On 01/14/26 the DON provided the survey team with a copy of their policy titled, Baseline Care Plan and Summary. This policy read in part, .Upon admission the admitting clinical team will develop an initial plan of care based on information upon admission. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to develop and/or implement a person-centered, comprehensive, activity care plan for (1) one of (28) twenty-eight sampled residents, Resident #80. The findings included:For Resident #80 the facility staff failed to develop and implement a comprehensive person-centered activity care plan to include measurable objectives and timeframes to meet the resident's mental and psychosocial needs and include the resident's goals, desired outcomes, and preferences for activities. Resident #80's diagnosis list indicated diagnoses that included, but were not limited to, volume depletion, atherosclerotic heart disease, schizoaffective disorder, depression, bipolar disorder, suicidal ideations, schizoaffective disorder, acute or chronic malnutrition, and personal history of mental and behavioral disorders. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 1/10/26, assigned the resident a brief interview for mental status (BIMS) summary score of 4 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A review of Resident #80's clinical record and comprehensive care plan produced no evidence of a person-centered, activity care plan. On 1/14/2026 at 2:11 PM, this surveyor interviewed other staff #5 (OS#5) and reviewed Resident #80's care plan. OS#5 agreed that an activity care plan was not completed for the resident. This concern was discussed at the end of day meeting on 1/14/26 at 5:05 PM with the administrator, director of nursing, and regional nurse consultant. On 1/15/26, this surveyor reviewed Resident #80's person-centered comprehensive care plan with a focus which read in part, I have a short attention span exhibited by: Not being able to focus on anything for long.Date Initiated: 01/14/2026. A review of the goal and interventions read in part, .I will be able to Hold an object for 5 minutes at least three times a week by my next review.Date Initiated: 01/14/2026.I need encouragement to participate in activities at times, and like compliments for my attempts to participate.If I become less involved in group activities, please do 1:1 activities with me that I'll enjoy.Offer me shorter duration activities if I need them.Please give me help as I need it, giving easier instructions, cuing, and breaking the things I'm doing down into smaller steps. Surveyor requested and received a facility policy titled, Activity Care Plan with an effective date of 11/2020 which read in part, .It is the policy of this facility's activity department to develop and maintain individualized care plans as needed for each resident.an activity care plan will be developed which will reflect and meet the needs of a newly admitted resident.individualized activity care plans are integrated into the resident's total care plan. No further information regarding this concern was presented to the survey team prior to the exit conference on 1/15/26.

Based on staff interview and clinical record review the facility staff failed to ensue medications were available for administration for 1 of 13 residents, Resident #1. The findings included: For Resident #1 the facility staff failed to ensure the medication SPS Oral solution (Sodium Polystyrene Sulfonate [Kayexalate]) was available for administration. Resident #1's most recent minimum data set with an assessment reference date of 01/04/24 assigned the resident a brief interview for mental status score of 7 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #1's clinical record was reviewed and contained a physician's order summary which read in part, SPS Oral suspension 15 GM/60 ML (Sodium Polystyrene Sulfonate). Give 60 ml by mouth one time a day for hyperkalemia. Order Date: 01/03/2024. Start Date: 01/04/2024. Discontinue: 01/15/2024, Sodium Polystyrene Sulfonate Oral Suspension 15 GM/60 ML (Sodium Polystyrene Sulfonate). Give 30 ml by mouth one time only for supplement for 1 day. Order Date: 01/15/2024. Start Date: 01/15/2024. End Date: 01/16/2024, and Sodium Polystyrene Sulfonate Oral Suspension 15 GM/60 ML (Sodium Polystyrene Sulfonate). Give 15 gram by mouth one time a day for hyperkalemia. Order Date: 01/15/2024. Start Date: 01/15/2024. Resident #1's electronic medication administration record was reviewed and contained entries as above. These entries were coded 7 on 01/08, 01/09, 01/15, 01/20, 01/22, and 01/23/24 and coded 3 on 01/21 and 01/25/24. Chart code 7 is equivalent to Other/See Nurses Notes. Chart code 3 is equivalent to Hold/See Nurses Notes. Resident #1's clinical record was reviewed and contained nurse's notes which read in part, 01/08/2024 17:20 Note Text: SPS Oral Sustention GM/60 ML. Give 60 ml by mouth one time a day for hyperkalemia waiting to arrive from pharmacy, 01/09/2024 09:39 Note Text: SPS Oral Suspention15 GM/60 ML. Give 60 ml by mouth one time a day for hyperkalemia waiting to arrive from pharmacy, 01/14/2024 09:41 Note Text: SPS Oral Suspention15 GM/60 ML. Give 60 ml by mouth one time a day for hyperkalemia waiting for pharmacy to deliver, 01/20/2024 21:56 Note Text: SPS Oral Suspention15 GM/60 ML. Give 60 ml by mouth one time a day for hyperkalemia on order spoke with pharmacy waiting on confirmation, 01/21/2024 21:07 Note Text: SPS Oral Suspention15 GM/60 ML. Give 60 ml by mouth one time a day for hyperkalemia on order waiting on pharmacy confirmation, 01/22/2024 21:46 Note Text: SPS Oral Suspention15 GM/60 ML. Give 60 ml by mouth one time a day for hyperkalemia Waiting for medication from Pharmacy, 01/23/2024 21:39 Note Text: SPS Oral Suspention15 GM/60 ML. Give 60 ml by mouth one time a day for hyperkalemia Waiting for medication from Pharmacy, and 01/24/2024 21:10 Note Text: SPS Oral Suspention15 GM/60 ML. Give 60 ml by mouth one time a day for hyperkalemia on order waiting on pharmacy md aware. Surveyor requested and was provided with a facility policy entitled Medication Shortages which read in part, The facility nurse must make every effort to ensure that a medication ordered for the resident is available to meet the needs their needs. The concern of not ensuring medications were available for administration was discussed with the administrator, director of nursing, unit manager #1, unit manager #2, and regional vice president of operations on 01/31/24 at 1:45 pm. No further information was provided prior to exit.

Based on clinical record review, staff interview, resident interview and facility document review, the facility staff failed to prevent accident hazards for 7 of 30 residents and in (1) oxygen storage room in the nursing facility (Resident #29, #9, #63, #68, #314, #13 and #97). The findings included: 1. The facility staff failed to ensure that Resident # 9 was positioned properly while in the lift, which resulted in Resident # 9 sliding out of the lift onto the floor and hitting her head on the foot rest of the lift. As a result of the fall, Resident # 9 experienced pain to the head and back and was transferred to the emergency room and was diagnosed with [REDACTED]. This is harm. Resident # 9 was a [AGE] year-old-female who was originally admitted to the facility on [DATE], and had a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 9 was reviewed on [DATE] at 11:10 am. The most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of [DATE]. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 9 had a BIMS score (brief interview for mental status) of 11 out of 15, which indicated that Resident # 9's cognitive status was moderately impaired. Section G of the MDS assesses functional status. In Section G0110, the facility staff documented that Resident was totally dependent on staff requiring two or more persons to assist with transfers. The plan of care for Resident # 9 was reviewed and revised on [DATE]. The facility staff documented a focus area for Resident # 9 as At risk for falls related to: Use of medication, history of falls, decreased mobility, bladder/bowel incontinence, requires maxi lift w(with)/staff assistance for transfers. Interventions included but were not limited to, Transfer using the Maxie Move lift with two person assistance at all times. The surveyor observed a SBAR-Change of Condition note that was documented on [DATE] at 11:55 pm. The note included documentation that included but was not limited to .Situation: Called to room by aid, resident was laying on floor, resident slide out of Hoyer lift during transfer. Assessment: resident c/o (complained of) mid and lower back pain and a headache, notice resident head was laying on foot rest of lift. The surveyor reviewed emergency department discharge instructions for Resident # 9 dated [DATE]. The surveyor observed documentation on the discharge instructions that included but was not limited to .Diagnosis: [REDACTED]. On [DATE] at, 12.10 pm, the surveyor reviewed the Fall Investigation from Resident # 9's fall on [DATE]. The surveyor reviewed documentation on the fall investigation that included but was not limited to .10. Was a Hoyer lift used? (Surveyor observed a handwritten check mark next to Yes) Was resident positioned correctly? (Surveyor observed a handwritten check mark next to No) Were ,[DATE] assists used? (Surveyor observed a handwritten check mark next to No) Were legs of Hoyer lift in correct position? (Surveyor observed a handwritten check mark next to No). On [DATE] at 2:51 pm, the surveyor interviewed LPN # 2 (licensed practical nurse). The surveyor asked LPN # 2 if she had documented the SBAR-Change of Condition note and fall investigation that was documented on [DATE] for Resident #9. LPN # 2 stated, Yes. The surveyor asked LPN # 2 to explain the events that happened with Resident # 9 on [DATE]. LPN # 2 informed the surveyor that a CNA (certified nursing assistant) had gotten Resident # 9 up with the lift and the lift pad was not criss crossed at the bottom, which caused Resident # 9 to slide out of the lift pad onto the floor. LPN # 2 stated, She hit her head on the lift. She complained of back and head pain, and we sent her out. The surveyor asked LPN # 2 if two staff members had assisted with the lift transfer for Resident # 9 on [DATE]. LPN #2 informed the surveyor that the CNA was working alone during the transfer on [DATE] when Resident # 9 slid from the lift. On [DATE] at 9:19 am, the surveyor interviewed CNA # 4. The surveyor asked CNA # 4 if she provided care for Resident # 9 on [DATE]. CNA # 4 stated, Yes. The surveyor asked CNA # 4 to describe the events that led to Resident # 9's fall from the lift on [DATE]. CNA #4 stated, That morning they had a different lift pad. I had never used that before. I asked for assistance, but the girl didn't come back. The lift I usually use was different. I was unaware that you had to criss cross. I started to get her up, and she slid out. On [DATE] at 4:52 am, the administrator, the director of nursing, and the regional director of clinical services were made aware of the findings as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on [DATE]. 2. The facility staff failed to implement appropriate interventions for fall prevention for Resident # 314, which led to continued falls leading up to a fall on [DATE] in which Resident # 314 was transferred to the hospital and diagnosed with [REDACTED]. This is harm. Resident # 314 was a [AGE] year-old-male who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 314 was reviewed on [DATE] at 9:54 am. The most recent MDS (minimum data set) assessment for Resident # 314 was a discharge assessment with an ARD (assessment reference date) of [DATE]. Section C of the MDS assesses cognitive status. In Section C1000, the facility staff documented that Resident # 314's cognitive status was severely impaired. On [DATE] at 9:54 am, the surveyor observed a general note for Resident # 314 that had been documented on [DATE] at 6:56 pm. The general note contained documentation that included but was not limited to .Resident is alert and oriented to person only, resident is not oriented to place or time. Resident is a high fall risk. Resident is a heavy wetter due to [MEDICATION NAME]. The surveyor observed a general note for Resident # 314 that was documented on [DATE] at 12:35 pm. The note was documented as, Resident was found sitting on the floor by the CNA assigned to him. He sustained a large skin tear on the right elbow and a smaller skin tear on the right upper arm. Areas were cleaned with normal saline, triple antibiotic ointment applied, followed by a [MEDICATION NAME]. Resident tolerated procedure well. VSS (vital signs) T (temperature) 97.6 P (pulse) 52 R (respirations) 18 B/P (blood pressure) ,[DATE]. The surveyor reviewed the plan of care for Resident # 314. The surveyor observed a focus area for Resident # 314 was initiated by facility staff on [DATE]. The focus area was documented as, At risk for falls related to: new environment, use of medication. Interventions initiated on [DATE] were as follows: Assess for pain, Assess that wheelchair is of appropriate size, assess need for foot rests, assess for need to have wheelchair locked/unlocked for safety, anti-tippers, Call light or personal items available and in reach or private reacher, Keep environment well lit and free of clutter, Observe for side effects of medications, and Orientation to new room and roommate. The surveyor reviewed the facility Fall Investigation from Resident # 314's fall on [DATE] that was completed on [DATE]. The fall investigation contained documentation that included but was not limited to, .3. What is the resident's cognition? (The surveyor observed handwritten documentation) A&O x1 (alert and oriented times one), confused. (Indicate what may have caused the incident (The surveyor observed handwritten documentation) Confused and got out of the bed without assistance. The surveyor observed an intervention of Fall matt beside bed was initiated on [DATE]. The surveyor observed a general note for Resident # 314 that had been documented on [DATE] at 11:04 am. The general note was documented as, MDS (minimum data set) assessment for ARD (assessment reference date)/14 day: Resident is alert and oriented at times. However, he experiences episodes of confusion at times as well. Resident needs assistance with transfer and completed ADLs (activities of daily living). He has problems with short and long term memory. He is able to express his needs to the staff. Resident stated that in the last two weeks he has experienced depression, feeling bad about himself, and trouble concentration on watching television. The total severity score is 06. BIMS (brief interview for mental status) score is 02. The surveyor observed a general note for Resident # 314 that was documented on [DATE] at 10:35 am. The note was documented as, MDS assessment for ARD/Medicare 60 day: Resident was in bed resting when SW (social worker) entered the room. Resident was alert and oriented. He is able to express his needs to the staff. Resident has short term and long term memory problems. Resident agreed to do the interview. During the mood interview, resident sated that he has experienced in the last two weeks depression, trouble falling asleep, tiredness, feeling bad about himself, and trouble concentrating on reading/watching television. Total severity score is 05. Resident received a BIMS of 05. The surveyor observed a nurse's note for Resident # 314 that was documented on [DATE] at 11:28 am, the note was documented as, Resident has a fall this am (morning) @ (at) 7:30 am. He was attempting to toilet himself unattended and fell in the bathroom, skin tear noted to right elbow and c/o pain, notified MD (medical doctor) orders given for xray of right elbow, neuro checks in place due to unsupervised fall. RP (responsible party) (name withheld) notified of incident. The surveyor reviewed the facility Fall Investigation from Resident # 314's fall on [DATE] that was completed on [DATE]. The fall investigation contained documentation that included but was not limited to, .3. What is the resident's cognition? (Handwritten) Alert with confusion 7. When was the resident's last toileting time? (Handwritten) Toileting himself at the time of the incident 9. Is assistance required to transfer/ambulate? (Handwritten) Yes continuous reminders to call for assistance What intervention was implemented after the fall? (Handwritten) correct footwear Indicate what may have caused the incident (handwritten) Resident states he doesn't know he had one shoe on and one shoe off attempting to toilet self unattended. The surveyor noted that an intervention was added to the plan of care for Resident # 314 on [DATE] as Ensure Resident has on both shoes when he is up ambulating. The surveyor observed a nurse's note that for Resident # 314 that was documented on [DATE] at 9:22 am. The note was documented as, Resident calling out for help and staff rushed to resident's room. Resident was found sitting upright on his buttocks with his feet up against the wall near the door. Scant amount of blood noted on the fitted sheet to his bed and on his right elbow. A nickel size skin tear was noted to his outer left wrist and a scabbed area about the size of a nickel was noted to have a scant amount of blood on it. Rsd (resident) stated he fell out of the bed but he has memory loss and he was far away from his bed. ROM WNL (range of motion within normal limits) vitals ,[DATE]-[DATE]% RA (room air). Daughter of resident (daughter's name withheld) was called and a message was left for her to call the facility in regards to a non-urgent matter. Tx (treatment) rendered per standing order to left wrist and wright elbow and tol (tolerated) well. Resident assisted by two staff to his chair. No c/o (complaints of) pain at this time. Resident's MD was notified. Will continue to monitor. The surveyor reviewed the facility Fall Investigation from Resident # 314's fall on [DATE] that was completed on [DATE]. The fall investigation contained documentation that included but was not limited to, .3. What is the resident's cognition? (Handwritten) Alert with confusion 12. Was the call bell in place (handwritten check mark beside) YES Can resident use it? (Handwritten check mark beside) NO (handwritten) Resident confused What intervention was implemented after the fall? (Handwritten) nonskid footwear given to prevent slipping Indicate what may have caused the incident (handwritten) ambulating unassisted. The surveyor noted that an intervention was added to the plan of care for Resident # 314 on [DATE] as Footwear to prevent slipping, and Encourage resident to call for assistance when needed on [DATE]. The surveyor observed a nurse's note that was documented on [DATE] at 11:23 pm. The nurse's note was documented as, Resident is alert with confusion noted, had ears washed out today. Resident states he can hear some better. Resident was noted sitting on the floor at bedroom door, stated he fell in the bathroom and scooted to the door, denies hitting his head, c/o pain to left back, notified MD, family MD ordered x-ray to back. Encourage resident to ask for assistance when he needs to go to the bathroom, reminded resident of urinal at his bedside. The surveyor reviewed the facility Fall Investigation from Resident # 314's fall on [DATE] that was completed on [DATE]. The fall investigation contained documentation that included but was not limited to, .3. What is the resident's cognition? (Handwritten) Alert, confusion What intervention was implemented after the fall? (Handwritten) encourage resident to use call light -assessed and placed back to bed Indicate what may have caused the incident (handwritten) tired and was ambulating by himself. The surveyor noted that an intervention was added to the plan of care for Resident # 314 on [DATE] as Encourage resident to utilize call bell. The surveyor observed a nurse's note for Resident # 314 that was documented on [DATE] at 11:17 am. The note was documented as, Resident was found by nursing staff in the bath tub in resident's bathroom. Resident was attempting to use the bathroom and fell backwards. Resident had small blanchable area to the back of head. No c/o pain from resident. Neuro checks in place. ND notified. Called and spoke with (daughter's name withheld) about fall. Resident resting in bed at this time. VS WNL. Call light in reach. Will continue to monitor. The surveyor reviewed the facility Fall Investigation from Resident # 314's fall on [DATE] that was completed on [DATE]. The fall investigation contained documentation that included but was not limited to, .3. What is the resident's cognition? (Handwritten) confused What intervention was implemented after the fall? (Handwritten) medication review ([MEDICATION NAME]) assessed, placed in bed neuros started Indicate what may have caused the incident (handwritten) unsteady. The surveyor noted that an intervention was added to the plan of care for Resident # 314 on [DATE] as Med review. The surveyor observed a SBAR-Change of Condition note for Resident # 314 that was documented on [DATE] at 6:59 am. The note was documented as, Situation: Resident fell in bathroom and hit head on wall Background: History of falls, hard of hearing Assessment: Resident has skinned up head on back and skin tear on right hand, resident is awake and alert Response: Sending resident to ER (emergency room ) for test to make sure everything is ok. MD and RP notified 911 called. The surveyor reviewed the facility Fall Investigation from Resident # 314's fall on [DATE]/18 that was completed on [DATE]. The fall investigation contained documentation that included but was not limited to, .3. What is the resident's cognition? (Handwritten) confused/alert What intervention was implemented after the fall? (Handwritten) education Indicate what may have caused the incident (handwritten) ambulating unassisted while sleepy. The surveyor noted that an intervention was added to the plan of care for Resident # 314 on [DATE] as Educate resident to ask for assist with toileting during early morning hours. The surveyor observed a SBAR-Change of Condition note for Resident # 314 that was documented on [DATE] at 9:50 pm. The note was documented as, Situation: Found resident on floor in room Background: unspecified combined systolic and diastolic [MEDICAL CONDITION], unsteadiness on feet, [MEDICAL CONDITION] without lower urinary tract symptoms, [MEDICAL CONDITIONS] without behavioral disturbance, essential hypertension, [MEDICAL CONDITION] Assessment: Resident alert, yelling out. Resident is very hard of hearing. Skin warm and dry. Noted to have small hematoma above left eyebrow, laceration to right forehead, skin tear to right elbow. Also c/o right hip/leg pain, right leg rotated outward and shortened. C/O pain upon movement and touch. VS 97.4, 57, 20, ,[DATE], PEARL (pupils equal and reactive to light) Response: (Physician's name withheld) new order to send to ER for eval. RP (daughter's name withheld) notified. EMS (emergency medical services) notified. The surveyor observed a nurse's not for Resident # 314 that was documented on [DATE] at 3:03 am. The note was documented as, Called ER spoke to (name withheld) resident is being transferred to (facility name withheld) with DX (diagnosis) right [MEDICAL CONDITION] and brain bleed. DON (director of nursing) notified. The surveyor reviewed the facility Fall Investigation from Resident # 314's fall on [DATE] that was completed on [DATE]. The fall investigation contained documentation that included but was not limited to, .3. What is the resident's cognition? (Handwritten) alert normally confused What intervention was implemented after the fall? (handwritten) sent to ER Indicate what may have caused the incident (handwritten) resident was ambulating while tired and sleepy and lost balance. On [DATE] at 1:15 pm, the surveyor and the MDS coordinator reviewed the clinical record for specifically nurse's notes, MDS, and plan of care for Resident # 314. The surveyor reviewed each of the falls and interventions put in place after the falls with the MDS coordinator. The surveyor and the MDS coordinator also reviewed documentation that Resident # 314's cognitive status was severely impaired; Resident # 314 often ambulated unassisted with an unsteady gait. After review of the documentation in the clinical record the MDS coordinator agreed that the interventions implemented for Resident # 314 following falls were not appropriate due to his cognitive status and level of confusion. On [DATE] at 4:54 pm, the administrator, director of nursing, and regional director of clinical services were informed of the incident as stated above. The administrative team was provided the opportunity to ask questions and provide additional information. No further information regarding this issue was presented to the survey team prior to the exit conference on [DATE]. This is a complaint deficiency 3. The facility staff failed to ensure that Resident # 63 was appropriately positioned in the lift during a transfer, which resulted in the lift tilting and Resident # 63 being lowered to the floor. Resident # 63 was a [AGE] year-old-female that was originally admitted to the facility on [DATE], and had a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 63 was reviewed on [DATE] at 9:46 am. The most recent MDS (minimum data set) assessment for Resident # 63 was a quarterly assessment with an ARD (assessment reference date) of [DATE]. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 63 had a BIMS (brief interview for mental status) score of 15 out of 15, which indicated that Resident #63 was cognitively intact. Section G of the MDS assesses functional status. In Section G0110, line B assessed transfer status. The facility staff documented that Resident # 63 was totally dependent requiring the assistance of two or more persons for transfers. The plan of care for Resident # 63 was reviewed and revised on [DATE]. The facility staff documented a focus area for Resident # 63 as, At risk for falls related to: Use of medication, Dx's (diagnoses) of chronic [MEDICAL CONDITION] demyelinating [MEDICAL CONDITIONS], and due to fear of falling. Interventions included but were not limited to, Transfer using the Hoyer lift w/at least 2-staff persons assisting, and Education provided after fall [DATE]. The surveyor observed a nurse's note for Resident # 63 that had been documented on [DATE] at 3:06 pm. The nurse's note was documented as, Resident was lowered to the floor during transportation to chair due to it overturning. She was not hurt during the incident. There were 3 CNAs present at the time I entered the room. Resident was still on part of the bed while the CNAs were holding her. DON (director of nursing) and unit manager came to witness the incident. Statements will be written in regards to the situation. On [DATE] at 3:30 pm, the surveyor requested to see the facility investigation of the incident on [DATE], which led to Resident # 63 being lowered to the floor. On [DATE] at 11:04 am, the surveyor reviewed a hand written statement that was written by the director of nursing on [DATE]. The statement was documented as, Had (Three employee's name's withheld) concerning lowering Resident # 63 to the floor. Had CNAs re-inact the transfer with therapy, administration, and myself. CNAs stated that as they went to move Resident # 63 the lift tilted and they has to lower her to the floor. The re-inactment revealed that the CNAs did not have Resident # 63's weight balanced in the sling but had her feet on one side and her upper body on the other side which caused the lift to tilt to the side that had her upper body on it. On [DATE] at 10:32 am, the surveyor interviewed CNA # 2. The surveyor asked CNA # 2 if she was providing care to Resident # 63 on [DATE] when she was lowered to the floor. CNA # 2 stated, Yes. The surveyor asked CNA # 2 to describe the events that led to Resident # 63 being lowered to the floor. CNA # 2 stated, We were getting her out of bed and putting her in the chair. They didn't have her positioned properly, and the lift tilted, so we lowered her to the floor. On [DATE] at 4:54 pm, the surveyor reviewed the investigative findings of Resident # 63's fall on [DATE] with the administrator, director of nursing, and regional director of clinical services. No further information was provided to the survey team prior to the exit conference to [DATE]. 4. The facility staff failed to ensure that a portable oxygen cylinder was properly secured on Resident # 68's wheelchair. Resident # 68 was a [AGE] year-old-male who was originally admitted to the facility on [DATE], and had a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 68 was reviewed on [DATE] at 2:52 pm. The most recent MDS (minimum data set) assessment for Resident # 68 was a quarterly review assessment with an ARD (assessment reference date) of [DATE]. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 68 had a BIMS score (Brief interview for mental status) of 15 out of 15, which indicated that Resident # 68 was cognitively intact. Section O of the MDS assesses special treatments, procedures, and programs. In Section O0100, the facility staff documented that Resident # 68 had received oxygen therapy during the last 14 days during the look back period for the [DATE] ARD. Resident # 68 had orders that included but were not limited to, Oxygen at 3L/min (liters per minute) via NC (nasal cannula) continuous, which was initiated by the physician on [DATE]. On [DATE] at 11:25 am, the surveyor observed Resident # 68 sitting in the hallway in his wheelchair. The surveyor observed a portable oxygen cylinder that was in a nylon holder on the back of Resident # 68's wheelchair. The surveyor observed that the bottom straps of the nylon holder that held the oxygen cylinder were not secured to the wheelchair frame. On [DATE] at 2:52 pm, the surveyor observed Resident # 68 sitting in his wheelchair in his room. The surveyor observed a portable oxygen cylinder held in a black nylon holder on the back of Resident # 68's wheelchair. The surveyor observed that the bottom straps of the nylon holder were not secured to the wheelchair frame. The manufacturer's instructions for W/C (wheelchair) Oxygen Tank Holder contained documentation that included but was not limited to, .Application Instructions: 1. Place the oxygen cylinder in the sleeve. 2. With the cylinder facing away from the backrest, hang the top straps on the push handles and secure the bottom straps to the wheelchair frame. 3. To secure and position the oxygen tank holder, tighten all four straps as desired. On [DATE] at 4:52 pm, the administrator, director of nursing, and regional director of clinical services were made aware of the findings as stated above. On [DATE] at 12:02 pm, the director of nursing informed the surveyor that the administrative team had reviewed the oxygen tank holder for Resident # 68 and agreed that the straps were not properly secured to the wheelchair for Resident # 68. No further information regarding this issue was presented to the survey team prior to the exit conference on [DATE]. 5. The facility staff failed to ensure that Resident #29 was free from abuse from another resident that resided in the nursing facility. Resident #29 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE], the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #29 was also coded as requiring supervision of 1 staff member for dressing and personal hygiene and requiring physical help in part of the bathing activity from 1 staff member. During the clinical record review from [DATE] through [DATE], the surveyor noted the following documentation in the nursing notes dated and timed for: XXX[DATE] 19:33 (7:33 pm) Situation: Writer called into dining room by aide; resident sitting in front of wheelchair. Aide states resident had an altercation with another resident. Background: [MEDICAL CONDITION], Anxiety Disorder Assessment: Upon assessment ______ (name of Resident #29) scalp is reddened and missing hair. No other injuries noted. Response: On call MD (medical doctor) made aware, Own R.P. (responsible party), DNS (director of nursing services) and Administrator made aware. Police notified. Deputy ______ (name of deputy) returned call stating that he doesn't have to come out, whom ever is harmed needs to go to the magistrates office to file charges, This information given to _______ (name of resident). She got in touch with her daughter and she came and signed her mom out to go to the Office . [DATE] 16:27 (4:27 pm) Resident stated her head was sore from where the other resident pulling her hair out. Resident reported she is doing ok and has filed charges against the other resident . The surveyor reviewed the care plan for Resident #29 and the following was documented in the care plan: .Focus: I sometimes have behaviors which include: demanding my showers at shift change and to be the first resident showered. Demanding staff to stay with for hour long intervals during the showers. Making false accusations against staff. Reporting missing objects that are not missing. Trying to sneak and take showers unassisted . Interventions: Attempt interventions before my behaviors begin. Explained to resident she cannot always be first, but will try to get her showered ASAP (as soon as possible) Give me my medications as my doctor has ordered Help me to avoid situations or people that are upsetting to me Let my physician know if I my behaviors are interfering with my daily living Make sure I am not in pain or uncomfortable Offer me something I like as diversion Please refer to my psychologist/psychiatrist as needed Please tell me what you are going to do before you begin Speak to me unhurriedly and in a calm voice . The surveyor noted the date documented for the focus and interventions were initiated on [DATE] with a revision date of [DATE]. There were no interventions noted by the surveyor after the resident-to-resident altercation that had occurred on [DATE]. The surveyor also noted an Emergency Protective Order dated for [DATE] at 8:10 pm in which named Resident #29 as being the alleged victim was to have no contact with the other resident involved in the altercation. The order expired on [DATE] at 11:59 pm. The survey team interviewed Resident #29 in the conference room on [DATE] at 11:20 am. The surveyor asked Resident #29 if she could tell the surveyor what had happened with another resident on [DATE] that resulted in this resident obtaining an Emergency Protective Order against another resident that was involved in an altercation that had occurred on [DATE]. Resident #29 stated, _____ (name of the resident involved in the altercation on [DATE]) came over while we were in the dining room and pulled a lot of my hair out of my head. It was a handful of hair and pulled out by the roots. ____ (Name of resident involved in altercation) and I were friends and we set together in the dining room for our meals. But one day she started saying things to me that were not nice and then she accused me of saying things about her son. I really don't know how it started. But after she pulled my hair and called me names, the staff called the police and they were told that I would have to go to the Magistrate's office to press charges against her. So I called my daughter and she took me down there. I got a Protective Order for her to keep away from me but I still saw her coming down the hallway where my room is and she would say things to me as she passed my room, but they stopped and told her that she could not come down that hallway where I was without a staff member being with her. I still saw her down the hallway from time to time without anyone with her. The surveyor asked the resident if she felt safe in the facility. The resident stated, I really don't. She (referring to resident involved in altercation) could come in my room, she is a big woman, and she could smother me by sitting on my face or putting a pillow over it. But I feel better now because since Friday, she has had a staff person sitting with her all the time. Did you hear what happened on Friday at supper time? The surveyor stated that she had read the documentation in the nurses' notes for Friday about the details of another altercation. The resident stated, I had asked an aide for some vanilla ice cream. Then ____ (name of other resident involved in altercation) said, Why don't you get it your damn self. She came full force toward me and an aide stopped her and the wheelchair before she could get to me. Since then she has had to have a sitter be with her all the time and she has had to eat her meals in her room. The surveyor noted the following documentation in the nurses' notes timed and dated

Based on staff interview, clinical record review and facility document review, the facility staff failed to follow physician's orders for 4 of 30 residents (Resident #40, #103, #47 and #316 and failed to assess and monitor for 2 of 25 residents (Resident #77 and #63) in the survey sample. The findings included: 1. The facility staff failed to assess and monitor Resident # 63 for excessive vaginal bleeding, which lead to Resident # 63 having a critical hemoglobin and hematocrit and was subsequently admitted to the hospital with [REDACTED]. Resident # 63 was originally admitted to the facility on [DATE], and had a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 63 was reviewed on 10/10/19 at 9:46 am. The most recent MDS (minimum data set) assessment for Resident # 63 was a quarterly assessment with an ARD (assessment reference date) of 8/21/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 63 had a BIMS (brief interview for mental status) score of 15 out of 15, which indicated that Resident #63 was cognitively intact. Section G of the MDS assesses functional status. In Section G0110, line I assessed toilet use. Toilet use assessment included but was not limited to, how the Resident #63 used the toilet room, commode, or bedpan; cleansed self after elimination, and changed pad. The facility staff documented that Resident # 63 was totally dependent requiring the assistance of two or more persons for toilet use. Section G0120 assessed bathing. The facility staff documented that Resident # 63 was totally dependent, requiring the assistance of two or more persons for bathing. On 10/10/19 at 1:28 pm, the surveyor was in Resident # 63's room conducting a Resident interview. The surveyor asked Resident # 63 if she had been readmitted to the hospital since her admission to the facility. Resident # 63 informed the surveyor that she had lost a lot of blood and was admitted to the hospital. Resident # 63 stated, I was as white as that sheet. The surveyor reviewed the progress notes for Resident # 63. The surveyor observed a SBAR-Change in Condition note that had been documented on 12/23/18 at 9:47 am. The note contained documentation that included but was not limited to .Situation: Resident is bleeding from vaginal area Assessment: Resident is bleeding from vaginal area with heavy bright blood with clots present. Resident states she feels weak Response: MD (medical doctor) notifies. New orders to send to ER (emergency room ) ED (emergency department) notified of transfer). The surveyor observed a nurse's note that had been documented on 6/27/19 at 10:59 am. The nurse's note contained documentation that included but was not limited to .Resident alert and oriented, complained of menstrual was on for a month. She appears to be pale and states she felt weak. VS (vital signs) 96.5, 122/70, 73, 16, 98%. MD (medical doctor) notified of concern. The surveyor reviewed a SBAR- Change of Condition note for Resident # 63 that was documented on 6/27/19 at 2:42 pm. The note was documented as, Situation: Lab drawn today and had critical low HGB (hemoglobin) 5.0 and HCT (hematocrit) 16.0, [MEDICATION NAME] 2.9 Background: Resident stated her period was on for longer than a month and this was not the 1st time she experienced this. Assessment: VS 122/70, 96.5, 73, 16, 98%, MD notified to have CBC (complete blood count) which was already in place due to neurology appointment being schedule after results. Response: MD (physician's name withheld) stated send resident to hospital. The surveyor reviewed a nurse's note that had been documented on 6/27/19 at 10:18 pm. The nurse's note was documented as, Contacted (Facility name withheld) ER (emergency room ) to check on rsd (resident) condition, Rsd admitted with menorrhea with [MEDICAL CONDITION]. The surveyor reviewed the clinical record for Resident # 63 further, specifically the progress notes, physician's orders, and consultations, and did not locate any documentation that reflected that Resident # 63 had vaginal bleeding for a month or more, or that the physician had been notified of the vaginal bleeding. On 10/16/19 at 10:05 am, the surveyor interviewed Cna # 2 (certified nursing assistant). The surveyor asked Cna #2 if Resident # 3 had excessive vaginal bleeding. Cna # 2 stated, Yes and she has blood clots. The surveyor asked Cna # 2 if she informed the nursing staff when Resident # 63 had excessive vaginal bleeding with blood clots. Cna # 2 stated, Yes. On 10/16/19 at 10:33 am, the surveyor interviewed the unit manager RN # 1 (registered nurse) and asked if she was aware that Resident # 63 had episodes of excessive vaginal bleeding. RN # 1 informed the surveyor that she had been unaware that Resident # 63 had episodes of excessive vaginal bleeding until the nurse had informed her in (MONTH) of 2019 that Resident # 63 was pale. RN # 1 stated that she instructed the nurse to inform the physician. The surveyor asked RN # 1 if she would expect the certified nursing assistants to inform the nurses if they noticed that Resident # 63 was having excessive vaginal bleeding. RN # 1 stated, Yes. The surveyor asked RN # 1 if she expected the nursing staff to document episodes of excessive bleeding in the clinical record and notify the physician. RN # 1 stated, Yes. The surveyor informed RN # 1 that there was no documentation in the clinical record for Resident # 63 that reflected that Resident # 63 had vaginal bleeding for a month or more prior to 6/27/19. On 10/17/19 at 3:35 pm, the surveyor interviewed LPN # 1 (licensed practical nurse) the surveyor asked LPN # 1 if she was aware that Resident # 63 had episodes of excessive vaginal bleeding. LPN # 1 stated, Yes. The surveyor asked LPN # 1 if the certified nursing assistants informed her when Resident # 63 had episodes of excessive vaginal bleeding. LPN # 1 stated, Yes. The surveyor asked LPN # 1 if information that Resident # 63 was having episodes of excessive vaginal bleeding should be documented in the clinical record and the physician be notified. LPN # 1 stated, Yes it should be. On 10/17/19 at 4:52 am, the administrator, the director of nursing, and the regional director of clinical services were made aware of the findings as stated above. The surveyor asked the administrative team if they would expect the nursing staff to document abnormal vaginal bleeding in the clinical record and notify the physician at the time the abnormality was noted. All three administrative team members agreed that abnormal vaginal bleeding should have been documented in the clinical record and the physician should have been notified at the time the abnormality was noted. The facility staff presented the following information to the survey team as the standard of practice for documentation. Information included but was not limited to .5. A deviation from protocol should be documented in the patient's chart with, clear, concise statements of the nurse's decisions, actions, and reasons for care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to less than accurate recollection of the specific events. Reference Nettina, S.M. (2013) Lippincott manual of nursing practice. 10th ed. Philadelphia: Wolters Kluwer Health/Lippincott[NAME] & Wilkins. On 10/18/19 at 3:45 pm, the surveyor provided the administrator, the director of nursing, and the regional director of clinical services the opportunity to ask further questions and provide additional information in response to the deficient practice as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 10/18/19. 2. For Resident #103, facility staff failed to ensure the resident received treatment and care based on the comprehensive assessment when it failed to ensure ordered pain medication [MEDICATION NAME] was available for administration. Resident #103 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On the 14 day Minimum Data Set assessment with assessment reference date 9/23/19, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of [MEDICAL CONDITIONS], or behavior affecting care. The resident was assessed as receiving scheduled pain medication and non-medication interventions for pain daily in the 5 days prior to the assessment. The resident reported being in pain almost constantly in the 5 days prior to the assessment and that the pain made it difficult to sleep. Pain intensity was assessed as 8/10. The Office of Licensure and Certification received a Facility Reported Incident (FRI) dated 6/4/19 concerning misappropriation of the resident's [MEDICATION NAME]. The FRI investigation revealed the nurse was unable to fill the order for [MEDICATION NAME] on 6/4/19. The facility was unable to discover what happened to the missing 15-16 doses of the medication. On 10/15/19 at 7:37 AM, resident said his pain is generally under control. He did state that there were several days a few months ago when [MEDICATION NAME] was unavailable. Medication administration notes for a physician order dated 9/28/18 for [MEDICATION NAME] Hcl 15 mg tablet give 1 tablet by mouth four times a day for pain *do not change dose unless Blue Ridge Pain Management Associates is contacted were as follows: 6/1/19 00:48 nursing note awaiting pharmacy arrival 6/1/19 09:43 nursing note awaiting pharmacy arrival --coded 2=refused 6/1/19 12:38 nursing note awaiting pharmacy arrival 6/1/19 17:28 nursing note awaiting pharmacy arrival 6/1/19 20:29 nursing note awaiting pharmacy arrival-- --coded 2=refused 6/2/19 08:59 nursing note awaiting pharmacy arrival 6/2/19 12:16 nursing note awaiting pharmacy arrival 6/2/19 16:40 nursing note awaiting pharmacy arrival 6/2/19 21:03 nursing note awaiting pharmacy arrival 6/3/19 16:55 nursing note awaiting pharmacy arrival 6/3/19 20:35 nursing note awaiting pharmacy arrival 6/4/19 09:34 nursing note awaiting pharmacy arrival 6/3/19 for 09:00 and 13:00 no documentation in MAR and no nursing notes concerning resident status This review indicated the resident missed 14 consecutive doses of [MEDICATION NAME]. The pain assessments associated with those 14 doses were either 'X' or blank except for the 6/2 assessment at 21:00 was documented as '0' on the medication administration record. The clinical record included no indication that the physician was notified that the [MEDICATION NAME] was missing. The surveyor discussed the concern with the director of nursing (DON) on 10/16/19 at 8:44 AM. The DON said that the doctor on call would not write a replacement prescription or a prescription to pull doses from the stat box because the doctor wanted to avoid DEA scrutiny. The Pain clinic said that they would not replace the prescription and the resident could do without the drug until time for a new prescription to start. The DON stated the resident showed no signs of withdrawal. The DON provided hand written employee statements dated 10/16/19 from two LPNs stating they had contacted physician offices concerning the medication being unavailable. Surveyors discussed the failure to make pain medication available with the administrator and DON during individual discussions on 10/16/19. 3. The facility staff failed to follow physician's order with regard to [MEDICATION NAME] administration for Resident # 47. Resident # 47 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 47 was reviewed on 10/9/19 at 2:27 pm. The most recent MDS (minimum data set) assessment for Resident # 47 was a quarterly assessment with an ARD (assessment reference date) of 8/5/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 47 had a BIMS score (brief interview for mental status) of 15 out of 15, which indicated that Resident # 47 was cognitively intact. Resident # 47 had orders that included but was not limited to, [MEDICATION NAME] tablet 0.5 mg (milligram) give 0.5 mg by mouth two times a day related to anxiety disorder give 2nd dose with dinner do not give w/n (within) 5 hours of [MEDICATION NAME], which was initiated by the physician on 9/13/19. Resident # 47 also had orders for [MEDICATION NAME] capsule 7.5 mg give 1 capsule by mouth at bedtime related to [MEDICAL CONDITION], which was initiated by the physician on 9/2/19. On 10/17/19 at 2:59 pm, the surveyor reviewed the (MONTH) 2019 medication administration record for Resident # 47. The surveyor observed that [MEDICATION NAME] 0.5 mg was scheduled to be administered at 1700 (5:00 pm) and [MEDICATION NAME] 7.5 mg was scheduled to be administered at 2100 (9:00 pm). The surveyor observed that the documented administration times did not comply with physician's orders. The physician's orders specified that [MEDICATION NAME] was not to be administered within 5 hours of [MEDICATION NAME] and the documented administration times reflected a 4-hour period between administration of [MEDICATION NAME] and [MEDICATION NAME]. On 10/17/19 at 4:54 pm, the administrator, director of nursing, and regional director of clinical services were made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 10/18/19. 4. The facility staff failed to administer [MEDICATION NAME] to Resident # 316 per physician's orders. Resident # 316 was a [AGE] year-old-male who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 316 was reviewed on 10/9/19 at 9:38 am. Resident # 316 had orders for [MEDICATION NAME] tablet 1 mg (milligram) by mouth at bedtime related to generalized anxiety, which was initiated by the physician on 9/18/18. The surveyor reviewed the (MONTH) (YEAR) medication administration record for Resident # 316. The surveyor observed a 7 documented on the medication administration record for the 2100 (9:00 pm) dose of [MEDICATION NAME] 1 mg tablet for Resident # 316. The surveyor observed documentation on the medication administration record that 7 = Other/see nurse's notes. The surveyor reviewed a nurse's note to Resident # 316 that had been documented on 9/19/18 at 8:43 pm. The nurse's note had been documented as, [MEDICATION NAME] tablet 1 mg by mouth at bedtime related to generalized anxiety awaiting arrival from pharmacy MD (medical doctor) is aware. On 10/9/19 at 10:46 am, the surveyor reviewed the facility Stat box Listing. The surveyor observed that 4 tablets of [MEDICATION NAME] 0.25 mg were available in the facility stat box and that the 4 tablets equaled the scheduled dose and could have been administered to Resident # 316 to prevent a missed dose of medication. On 10/10/19 at 3:54 pm, the administrator and director of nursing were made aware of the findings as stated above. The administrative team agreed that the [MEDICATION NAME] could have been retrieved from the stat box and administerd to Resident # 316 to prevent a missed dose of medication. No further information regarding this issue was presented to the survey team prior to the exit conference on 10/18/19. This is a complaint deficiency. 5. The facility staff failed to follow psychiatric physician recommendation for an increase in Resident #40's anxiety medication, [MEDICATION NAME]. Resident #40 was readmitted to the facility with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/24/19, coded the resident as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #40 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and being totally dependent on 1 staff member for bathing. Resident #40 asked to speak to the surveyor during the dates of 10/8/19 through 10/18/19. The surveyor interviewed the resident on 10/15/19 at 10:30 am in the resident's room. The resident reported to the surveyor that her doctor that she sees for her psychiatrist issues ordered her anxiety medication to be increased. That was supposed to be done 2 weeks ago and it has not been increased yet. The resident stated, _____ (name of nurse) comes by my room each morning and tells me that the pharmacy is having issues in getting her anxiety medication increased and as soon as they resolve the issues, it will be done. She keeps telling me this over and over but nothing gets done about this. All I can do is sit in this bed and worry about everything. I feel helpless and I feel that I cannot get anything done to help me. So I lay in here and worry about this. The staff uses me as a sounding board and talks to me about everything that is going on with all the new changes in staff that has occurred. I don't mind because everyone needs someone to talk to but then the rest of the time, I think back over what they tell me and I think well if they are not doing this like they are supposed to then what makes me think they will do what the doctor wants then to do for me. So I worry about this consistently and I get myself worked up about all of this. I just feel helpless and I need some help in getting my medication increased so I can deal with all of the worries that I am having. The surveyor verbalized to the resident that these concerns would be investigated and resident would be notified of the findings of these concerns. The resident verbalized understanding of this to the surveyor. The surveyor performed a clinical record review of Resident #40's clinical record from 10/15/19 to 10/18/19. During this review, the surveyor noted the following documentation from the nurse practitioner with the _______ (name of the psychiatric medical group) dated for the following: 8/22/19 .Pt. reports feeling overwhelmed because she is trying to get to be able to go home for Christmas this year but she is having trouble participating in therapy. She is reporting anxiety r/t (related to) this .She is reportedly only getting 3 hours of sleep at night because the doctor recently decreased her [MEDICATION NAME] .Patient reports sleep as Not as good at all. Patient reports mood as anxious . Under Assessment/Plan .Anxiety-Currently stating it is uncontrolled and wants hers [MEDICATION NAME] back. I suggested [MEDICATION NAME] 5 mg TID to start and she was agreeable to this plan . 9/13/19 .Pt (patient) is reporting that my nerves are real bad and she cannot relax. She reports that it started about a week after she met this provider for the first time. She is reporting that it is an 8/10 right now and that nothing seems to make it better. Says the only thing that has ever helped has been [MEDICATION NAME]. Patient reports sleep as Not good at all. Patient reports mood as anxious . Review of Medications .8/23/19 [MEDICATION NAME] (1) 5 mg (milligram) Tablet TID (three times a day) . Assessment/Plan .Anxiety-Pt states her anxiety has gotten much worse since she was started on [MEDICATION NAME] 2 or 3 weeks ago and that [MEDICATION NAME] has not touched it. She reports that even 1 mg of [MEDICATION NAME] was helpful for her in the past and that her anxiety worsened 3 weeks to a month after stopping it in June. She was on [MEDICATION NAME] for about 3 years d/t (due to) her nerves. Will increase [MEDICATION NAME] to 10 mg PO (by mouth) TID and if anxiety does not improve over next 2 weeks, I will consider restating low dose benzo (benzodiazepine) . Recommendations: .Increase [MEDICATION NAME] to 10 mg PO TID for anxiety . 9/25/19 .I'm not good Pt is reporting that her anxiety is really bad. She has been in bed all weekend because of her anxiety. She shakes and has a horrible time dealing with people right now, she states she is really crabby. Patient reports sleep as Not good at all. Patient reports mood as anxious . Review of medication: .8/23/19 [MEDICATION NAME] (1) 5 mg Tablet TID . Assessment/Plan .Anxiety. Pt states anxiety has gotten worse since she was started on [MEDICATION NAME]. Is not working for her. I am going to decrease [MEDICATION NAME] and then start [MEDICATION NAME] .Will continue to get anxiety under control since the patient believes that is her most pressing issue and will readdress depression to the future . Recommendation only: .Decrease [MEDICATION NAME] to 5 mg PO TID x (times) 7 days, then decrease to 5 mg PO BID (twice a day) x 7 days, and then d/c (discontinue) Start [MEDICATION NAME] 0.25 mg PO BID for anxiety . 10/9/19 .Pt was started on [MEDICATION NAME] and started it last Friday. She states it helps a little but not much and not for long. She states she feels like she is sitting on pins and needles and was wondering if the medication could be increased. Patient reports sleep as Not good at all. Patient reports mood as anxious . Review of medication . 5/24/19 [MEDICATION NAME] 0.5 50 mg Tablet TID 8/23/19 [MEDICATION NAME] (1) 5 mg Tablet BID .9/25/19 [MEDICATION NAME] 0.5 0.5 mg Tablet BID . Assessment/Plan Anxiety - Pt states her anxiety is about the same. She says the [MEDICATION NAME] helps just a little bit but not much and not for long. She is asking for an increased dose or using it more frequently. I told her we can increase the dose to see if this helps .Will get anxiety under control since the patient believes that this is her most pressing issue and will readdress depression in the future. [MEDICAL CONDITION] - pt says she cannot sleep at all at night and wants to go back to her [MEDICATION NAME]. I explained to the patient that [MEDICATION NAME] is better for [MEDICAL CONDITION] at a lower dose but the patient was not buying this so I told her if she thinks it will make her sleep better than we can try [MEDICATION NAME] 100 mg PO WHS (at bedtime) . Recommendations only: Increase [MEDICATION NAME] back to 100 mg PO QHS (at bedtime) for [MEDICAL CONDITION]. Increase [MEDICATION NAME] to 0.5 mg PO BID for anxiety . The surveyor reviewed the physician order sheets (POS) and noted the start date for each of these medications: [MEDICATION NAME] 5 mg Give 10 mg by mouth three times a day -- start date of 9/13/19 [MEDICATION NAME] 50 mg Give 0.5 tablet by mouth at bedtime - start date of 5/24/19 The surveyor noted supplemental physician orders that were the following medications with orders dates as follows: [MEDICATION NAME] 5 mg Give 5 mg by mouth three times a day related to anxiety disorder -- The order date for this medication was 10/3/19. [MEDICATION NAME] 0.5 MG Give 0.25 mg by mouth two times a day - The order date for this medication was 10/3/19. The surveyor reviewed the MAR (medication administration record) for Resident #40 for the month of (MONTH) 2019. It was noted that [MEDICATION NAME] Tablet 0.5 mg Give 0.5 mg by mouth two times a day .Order date 10/15/19 1041 (10:41 am) . The surveyor also noted that [MEDICATION NAME] 0.5 mg tablet Give 0.25 mg by mouth two times a day .D/C Date 10/15/19 1041 . This medication with dosage of 0.5 mg ½ tablet was d/cd on 10/15/19 and the dosage of 0.5 mg two times a day was started on 10/15/19. This was noted to be discontinued and started the correct dosage of [MEDICATION NAME] after the surveyor began to investigate and ask the administrator and the director of nursing questions about the psychiatric recommendations that had occurred between 8/22/19 through 10/9/19. The surveyor notified the administrator and the director of nursing of the above documented findings on 10/15/19 at approximately 4:15 pm. The director of nursing stated that she was not the director of nursing for the facility until approximately 2 weeks before this survey had begun and that she was not aware of these incidents or recommendations for this resident. The assistant director of nursing (ADON) and regional corporate nurse and director of nursing (DON) came to the surveyor in the conference room and stated that they wanted to discuss the issue concerning the medication for _____ (name of Resident #40). This occurred on 1016/19 at 2 pm. The surveyor asked the ADON if the nurse practitioner that was in the psychiatric group ordered for a resident to start, increase, decrease or discontinue a medication could the nurses' not treat this as a regular order and order what the practitioner had ordered for the resident. The ADON stated that _____ (name of the psychiatric group that was contracted to see the residents in the nursing facility) started seeing the residents in (MONTH) 2019. The FNP (Family Nurse Practitioner) would order the medications; the nurses would treat this as a regular order and put this order into the computer. The pharmacy would receive this order and send the medication as ordered for the resident. Then around 9/13 or 9/18, the FNP called and stated that his boss only wanted him to recommend what medications the resident would be needing then let the medical director at the facility to approve or disapprove and order the medications based upon the psychiatric group's recommendations. The medical director would sign off on it and then the nurses would order the medications from the pharmacy and administer it to the residents. The surveyor asked what is an appropriate time period that this process should take to get the Medical Director to sign off this recommended order and get this to the pharmacy then the resident receives the medication that was recommended for them to have. The ADON stated, I believe that 48 hours for this to occur would be an appropriate time period for this to occur. The surveyor asked what was the time period that all of this process occurred for Resident #40 to have and get the medications recommended for her to have for the anxiety that she was verbalizing to the psychiatric nurse practitioner in the above documented findings. The ADON did not respond to the surveyor's question. The ADON responded later and stated, The recommended changes in the resident's medications were faxed to the doctor. Then he responded and asked questions that I answered and faxed back to him several times. The final response from the doctor was on 9/30/19 which he stated no new orders. The surveyor asked if she had called or faxed and asked for a clarification to this since the psychiatric nurse practitioner had recommended an increase in [MEDICATION NAME] due to the resident verbalizing increased anxiety that was to the point that she had remained in bed one whole weekend due to this anxiety she was experiencing. The ADON stated, The doctor stated no new orders. So I didn't ask him further if he wanted anything else for this resident. The surveyor again discussed the above documented findings on 10/18/19 at 4:15 pm with the administrator, director of nursing and the regional corporate nurse. No further information was provided to the surveyor prior to the exit conference on 10/18/19. 6. For Resident #77, the facility staff failed to assess and treat an area on the resident's right great toe. Resident #77's face sheet listed an admission date of [DATE] and a readmission date of [DATE]. The resident's [DIAGNOSES REDACTED]. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 9/04/19 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns. Resident #77 was also coded as being independent in bathing and requiring supervision only in dressing and personal hygiene. While interviewing Resident #77 on 10/10/19 at approximately 3:15pm, the resident stated her right big toe is sore and there is a place on it that looks like it is turning black. Resident stated she told a nurse about one month ago and no one has looked at it. Resident also stated the nurses check my skin for sores but they never look at my feet and I'm diabetic. The surveyor spoke with LPN #1 on 10/10/19 at approximately 3:20pm regarding resident's right great toe. Surveyor asked LPN #1 if Resident #77 had an area on her right foot, LPN #1 stated no, nothing had been reported but she would check it. Following the resident interview, the surveyor reviewed the medical record and did not locate any documentation related to an area on the resident's right great toe. On 10/11/19 at approximately 9:00am, the administrator provided the surveyor with a copy of a progress note for Resident #77 dated 10/10/19 15:30 written by LPN #1 stating in part, this nurse assessed pt and noted black area to R great toe 0.3 x 0.2 cm, skin cool and color wnl. Pt c/o of numbness r/t [MEDICAL CONDITION], and noted weak pedal pulses. NP notified and new order for ABI to R extremity Surveyor reviewed Resident #77's Weekly Skin Integrity Check assessment in the medical record dated 10/05/19 which is checked for the statement Skin clear, no change of condition assessed. Surveyor requested and was provided with a copy of the facility policy Skin Assessment - Weekly which stated in part, A Licensed Nurse will complete a total body assessment on each resident weekly, paying particular attention to any skin tears, bruises, stasis ulcers, rashes, pressure ulcers, [MEDICAL CONDITION], abrasions, reddened areas and skin turgor problems. The purpose of the Skin Assessment is to evaluate the condition of the resident's skin on a regular basis. The concern of the lack of assessment and treatment to the area on Resident #77's right great toe was discussed with the administrative staff (administrator, director of nursing and regional director of clinical services) on 10/17/19 at approximately 5:00pm. No further information was provided prior to exit conference on 10/18/19.

Based on, clinical record review, staff interview, family interview, and over the course of a complaint investigation, the facility staff failed to ensure that 3 of 45 Residents in the survey sample received adequate supervision and assistance to prevent accidents, Resident # 85, Resident # 82, and Resident # 101. The findings included: The facility staff failed to transfer Resident # 85 using the Hoyer Lift as determined necessary by the comprehensive plan of care, during a transfer from the wheelchair to the bed, resulting in the resident sustaining a 14 inch laceration to the lateral left leg which required that she be transferred to the emergency room where she received sutures, a Penrose drain, and required antibiotic therapy. A facility reported incident was sent into the Office of Licensure and Certification on 11/9/17. The Office of Licensure and Certification converted this facility reported incident into a complaint, which was investigated during an unannounced Medicare/Medicaid recertification survey that took place on site at the facility on 5/29/18 through 6/4/18. Resident # 85 was originally admitted to the facility on [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 85 was reviewed on 5/31/18 at 9:35 am. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 5/2/18. Section C assesses cognitive patterns. In section C1000, the facility staff coded that Resident # 85's cognitive status as severely impaired. Section G assesses functional status. In Section G0110, the facility staff documented that Resident # 85 totally dependent requiring assistance of 2 or more persons for transfers. The current plan of care for Resident #85 was reviewed and revised on 5/9/18. The focus area for At risk for falls related to: Use of medication, assistance with mobility, has interventions that included but were not limited to Transfer using the Hoyer lift with staff assistance. On 5/31/18 at 9:42 am, the surveyor observed a progress note in the clinical record written on 11/4/17 at 2:57 pm. The progress note stated, This nurse along with coworker was sitting at the nurses station and heard someone calling out for the nurse. Upon going down the hall observed patients left lower extremity bleeding with large approx. 10x10 cm (centimeter) gash. Skin flap was intact and adipose tissue exposed. Recovered gash with skin flap, applied pressure, contacted 911 for transport to ED (emergency department) elevated patient leg while applying pressure. Resident transported to ED via ambulance at 1425 (2:25 pm), resident RP (responsible party) notified at 1432 (2:32 pm) of incident and that patient was at ED. Will contact ED for update on the resident. On 5/31/18 at 9:46 am, the surveyor observed a progress note in the clinical record written on 11/4/17 at 5:57 pm. The progress note stated Returned from ER (emergency room ) with orders to not get patient up to leave in bed, left leg wrapped in Coban with Penrose drain in place, return toER on Monday to remove drainage bag, and return in 2 weeks for suture removal, 1 gram [MEDICATION NAME] given in hospital, started on [MEDICATION NAME] 100 mg (milligram) BID (twice daily) for 10 days. On 5/31/18 10:20 am, the surveyor spoke with the DON (director of nursing) about Resident # 85 sustaining an injury to her left leg on 11/4/17. The DON stated to the surveyor that the CNA (certified nursing assistant) in this situation did not use the lift and transferred the resident improperly. On 5/31/18 11:25 am, the surveyor interviewed LPN # 3(licensed practical nurse) in the presence of the survey team. The surveyor asked LPN # 3 what happened during the incident on 11/4/17 in which Resident # 85 sustained an injury to her left leg. LPN # 3 stated that she heard CNA calling for help. LPN # 3 and another nurse rushed down there and saw the extent of the wound. LPN # 3 stated that she put the skin back and applied pressure. The surveyor asked LPN # 3 to describe the wound to Resident # 85's left leg. LPN #3 stated that the wound was Very long and deep and I knew it needed medical attention that I couldn't give. LPN # # stated that she contacted the physician and got Resident # 85 sent to the ER. LPN # 3 stated that she educated the CNA because she transferred the resident improperly. LPN # 3 stated that the CNA was using a stand and pivot technique when transferring Resident # 85 and stated that Resident # 85 was assisting with standing during the transfer and then Resident # 85 stated My leg, my leg, and the CNA looked down and saw the blood and called for the nurses. On 5/31/18 at 11:55 am, the surveyor interviewed CNA # 1 in the presence of the survey team. The surveyor asked CNA # 1 to tell what happened on 11/4/17 when Resident # 85 sustained an injury to her left leg. CNA #1 stated That day I was in a hurry because I was behind. I usually use the stand up and the lift wasn't available. I think someone else was using it. I transferred her using stand and pivot. CNA # 1 stated that Resident # 85 stood and did fine and when I sat her on the bed she said oh my leg I looked down and saw the blood. CNA # 1 stated that she put Resident # 85's legs on the bed and called for the nurse. CNA # 1 stated, I am assuming that she hit it on the bed rail that was on the bed at the time. CNA # 1 stated that she had worked with Resident # 85 before and was familiar with her plan of care and knew that she was supposed to use the lift. CNA # 1 stated again that she was behind and this is the reason she transferred incorrectly. CNA # 1 stated that she was placed on suspension and when she returned she was educated on the use of the lift with the residents. On 5/31/18 at 1:43 pm, the surveyor reviewed the MDS assessment that was completed for Resident # 85 prior to the incident on 11/4/17. The MDS assessment was a quarterly assessment with an ARD of 10/4/17. In Section G 0110, the facility staff documented that Resident # 85 was totally dependent with transfers requiring the assistance of two or more persons. On 5/31/18, the administrative staff was made aware of the findings as stated above. No further information was provided to the survey team prior to the exit conference on 6/4/18. *** This is a complaint deficiency*** 2. The facility staff failed to maintain an accident free environment for Resident #82 in regards to a fall. Resident #82 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/1/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 13 out of a possible score of 15. Resident #82 was also coded as being totally dependent on 2 or more staff members for bed mobility, transfer and bathing. Then being totally dependent on 1 staff member for dressing and personal hygiene. The surveyor performed a review on Resident #82's clinical record on 5/31 and 6/1/18. It was noted that the following documentation was made in the nurses' notes dated and timed for 3/9/18 at 1607 (4:07 pm): Called to room by CNA. Upon entering room resident lying in floor on back, blood noted to head and floor. Approximately 2 in (inch) laceration noted to left eyebrow. Resident assessed. Pressure applied to laceration for approx. (approximately) 15 mins with bleeding controlled. Resident was not moved d/t (due to) fall with head injury .Resident stated he was trying to hold on but is not used to not having side rails and could not hold on .MD (medical doctor) notified new order to send to ER for evaluation . Then on 3/9/18 at 2334 (11:34 pm) the nurses' notes read in part .Resident returned to facility @ 9 pm via stretcher transported by EMS accompanied by father .Laceration to left eye with 6 stitches above eyebrow. L (left) eye swollen and purple. Sm (small) bump on right side of forehead. Abrasion to right knee. L (left) knee cap swollen and purple. Ice pack applied .Father very verbally upset that rails were removed from bed and demanded that they be put back .Supervisor talked to father about new policy concerning rails. Father stated he would be talking to Administration . The surveyor reviewed the MDS with ARD of 2/1/18, in which the resident was coded as being totally dependent on 2 or more staff members for bed mobility, transfer and bathing. The comprehensive care plan was also reviewed by the surveyor. Under the Focus section of the care plan it read in part .Mobility impairment . with the following interventions listed on the care plan: Assist to turn and reposition frequently. Assistive device: w/c (wheelchair) Call bell within reach Encourage choices with care Inspect skin with care. Report reddened areas, rashes bruising or open areas to charge nurse Nail care PRN (as needed) -refer to the Podiatrist PRN. Observe and report changes in physical functioning ability Observe and report changes in ROM (range of motion) ability Praise effort at participation Provide all needed assistance w/ADL's (activities of daily living) & mobility. Provide all needed assistance w/toileting-provide incontinence care PRN. Resident to have left hand orthotic placed in AM, removed at night, and worn no more than 12 hours per order. Therapy per order. The surveyor interviewed the director of nursing (DON) on 6/1/18 at 8:50 am in the conference room. The surveyor asked how the resident obtained a laceration above his left eyebrow on 3/9/18. The DON stated, He got the laceration by sliding off the edge of the bed when the CNA was changing him. The doctor was called and he told us to send the resident to the ER for evaluation. The surveyor asked the DON if the side rails were present on the bed at the time of the accident. The DON stated, No, they were not. The surveyor asked the DON what was the date that the side rails were removed from the resident's bed. The DON stated, I don't know the exact date but I know we looked at the most ambulatory residents first and removed those first and then we worked our way through the rest of the residents. I know we began this around the 29th of (MONTH) and ended taking the side rails off the beds the middle of March. The surveyor interviewed CNA #2 at 9:05 am in the conference room. The surveyor asked CNA #2 to tell the events leading up to and surrounding _______ (name of resident) fall from his bed on 3/9/18. CNA #2 stated, I was changing him and used the draw sheet to turn him towards the window which was away from the side of the bed that I was standing on. He began to start falling and I could see him grabbing at the sheet but he fell anyways. The surveyor asked CNA #2 if the side rails were on or off the bed at the time of this fall. CNA #2 stated, I don't remember when the side rails were taken off but they were not on there when he fell out of the bed. The surveyor asked CNA #2 how many staff members were needed to turn this resident and how would you know about this information to care for the resident. CNA #2 stated, In the past he could use the side rails to hold on if he felt like he was falling. We did only use 1 aide to turn him but since the accident we are required to have 2. There is a kardex on each unit that tells you how many aides are needed to do certain things with the resident and then we also get a report from the charge nurse. This surveyor and the team leader for the survey went into Resident #82's room at 9:25 am to interview the resident about the above documented fall on 3/9/18. The surveyors spoke to the resident but the resident was attempting to speak but the surveyors were unable to understand what he was saying. The father was sitting at the bedside of the resident and this surveyor asked if he could remember what the staff told him about the fall that occurred on 3/9/18. The father stated, they took his side rails off the bed that morning and by that afternoon, the aide was in here changing him and he slid off the bed, hit his head on the table over there and had to get 6 stitches above his left eye. I don't understand why they took the side rails off the bed. The surveyor asked what exactly was he told regarding the removal of the side rails from the bed. The father stated, They said it was against state law to have side rails on the bed. The surveyor again interviewed the DON at 11:05 am in the conference room. The surveyor requested a copy of the bed rail assessments that were performed prior to the removal of the side rails from the bed. The DON stated, I don't think that we have an assessment immediately prior to the removal of the side rails but I could be wrong. I have only been the DON here since about (MONTH) and this was started prior to me accepting this position. At 1:38 pm, the surveyor interviewed LPN #2 by phone and asked if she could remember _____ (name of resident) falling off the side of the bed on 3/9/18. LPN #2 stated, The CNA called me to come into the resident's room and told me that she was changing him and he rolled off the side of the bed. I know she told me that she had been standing on the right side of the bed and turned him towards the window and that's when he fell . The surveyor asked if she could recall if there were side rails present on the bed at the time of the fall and she replied, No. The surveyor asked how many aides are needed to turn the resident in bed. LPN #2 stated, At that time we only used 1 aide but now after the fall we are required to have 2 staff in there so this does not happen again. The surveyor notified the administrative team on 6/4/18 at 4 pm of the above documented findings. The surveyor asked the administrative team if there was any other information that they would like for the survey team to consider in regards to the fall. The administrator stated, I believe you have everything that we could give you at this point. No further information was provided to the surveyor prior to the exit conference on 6/4/18. 3. The facility staff failed to maintain a hazard free environment for Resident #101 in regards to the bedside table. Resident #101 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/26/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident # 101 was also coded as requiring extensive assistance of 1 staff member for dressing, personal hygiene and being totally dependent on 2 staff members for bathing. On 5/30/18 at 3:30 pm, the surveyor went into Resident #101's room. During the resident interview, the surveyor observed the bedside table had worn edges that had sharp edge. The resident stated, It will cut you if you are not watching. The surveyor notified LPN #2 at 3:50 pm of the above documented findings concerning the sharp edges that were present on the bedside table. PN #2 and the surveyor retuned to the resident's room and stated, I'll go and get another one. That is worn out and the edges are sharp and you could get a splinter because the wood is showing. The nurse went and found another bedside table and replaced the one in the room. LPN #2 stated that she had notified the maintenance director and the nurse manager of the condition of the bedside table in the resident's room. The surveyor notified the administrative team of the above documented findings on 5/31/18 at 4 pm. No further information was provided to the surveyor prior to the exit conference on 6/4/18.

Based on observation, staff & resident interviews, facility document review, clinical record review, APS (Adult Protective Services) officer's and local law enforcement officer's interviews, and in the course of a complaint investigation, it was determined the facility staff failed to assess and provide treatment for [REDACTED].) ~ Resident #6 was suffering from grief & depression related to the loss/death of her daughter. She was also fearful and traumatized by the sexual abuse she alleged was committed against her by Resident #2. She had requested counseling during the admission process and never received any. ~ Resident #2 was suffering from [MEDICAL CONDITION] and had been diagnosed with [REDACTED]. He had not been assessed by a mental health specialist since his admission. Findings: 1. Facility staff failed to assess and provide Resident #6 with psychosocial treatment and counseling for on-going depression related to the death of her daughter and trauma induced by sexual abuse at the hands of another resident. Resident #6 was admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Resident #6 was documented as her own responsible party and was making all her own medical decisions. Her daughter was listed as her emergency contact. Resident #6's latest MDS (minimum data set) assessment dated [DATE] coded the resident as cognitively intact with a BIMS score of 13/15. The resident was coded with difficulty focusing attention and being easily distracted by things going on around her during the interview. She was not coded with any negative behaviors to other residents or staff members. Her ADL (activities of daily living) status was coded with "oversite only" for all activities. The MDS coded Resident #6 as independent for hygiene. bathing and eating with staff oversite only. She was coded to self toilet and had occasional incontinent episodes. Her latest CCP (comprehensive care plan) updated 3/5/13 documented the resident with the problem, " Sometimes have behaviors which include making false statements against others, with manipulative behaviors, Dx: depression. Refuses needs at times. Accuses nursing staff of not giving her medications." The intervention was "give medications as my doctor ordered." A second problem included in the CCP and initiated 12/21/11 was "Alteration in Respiratory Status due to [MEDICAL CONDITION] with long standing history smoking." The goal was "Patient will remain free of exacerbation of [MEDICAL CONDITION]." The interventions included, "Administer medications as ordered. Observe labs, response to medications and treatments." On 10/17/13 at 1:15 PM Resident #6 was interviewed in her room. She told the surveyor that Resident #2 had touched her inappropriately while they were out smoking in the solarium and later, in her room. Resident #6 told the surveyor that Resident #2 had grabbed her crotch when they were out smoking. She said he (Resident #2) came into her room one night and sat down on her bed while she was asleep. "I woke up and he was running his hand up my leg and trying to get in under my panties. I yelled for him to get out. He left." Resident #6 was sobbing and crying while relating this story to the surveyor. She said she had told staff members what he was doing right after it had happened, but they never did anything about it. The resident cried and said she was terrified that he might come back and no one would believe her. She also said she was afraid that staff members would "take it out on her if she complained too much about the other resident." Resident #6 could not remember the exact date when the events took place, but said it was a "few months ago." She said she had told her daughter about it when it happened. Resident #6 said she had come into the facility after the death of her daughter a couple of years ago. She grabbed her head in her hands and continued crying and stated, "I came here to get help. I told them I needed to see a doctor about what was going on in my head. I will never get over my daughter's death. The resident called her daughter and asked her to talk to the surveyor. The daughter told the surveyor that her mother had told her about Resident #2's treatment of [REDACTED]. The daughter could not remember the names of the nursing staff members that she had talked to. She said it was a few months ago, but could not remember the exact dates either. The daughter also told the surveyor that her mother had been very depressed since her admission and had been promised counseling when she entered the facility. She said she never got any counseling and was now suffering from the additional trauma of being housed in the same building with someone who had sexually abused her. Resident #2 was admitted to the facility on [DATE]. He had the following Diagnoses: [REDACTED]. On 10/17/13 at 9:40 AM Resident #2 was interviewed. He acknowledged that he had sex with (name of Resident #6) out on the solarium. When questioned how he did that on the smoking porch with staff members around he grinned and stated, "Naw we didn't do it out there. we just fooled around and touched and kissed some." Resident #2 said he had also gone to Resident #6's room to visit her. "I sat down on the bed and rubbed her leg for awhile. She told me to get out. I left." The resident said he didn't care that Resident #6 was "old enough to be my grandma." He added he liked women and what they could do for him. The resident maintained throughout the interview that he had sex with Resident #6 in her room at different times. On 10/17/13 during an exit conference, the administrator and DON were informed of the surveyor's allegations of sexual abuse regarding Resident #6. She said this was the first time she had heard that Resident #6 had a problem with Resident #2. She said she would investigate that matter and report her findings to the survey team. On 10/18/13 at 9:15 AM the facility SW (social worker) was interviewed. She said she had talked to Resident #6 about the sexual allegations the night before and had called the police. The SW said the resident had told her the incidents occurred in the smoking area and in her room. She said one incident had allegedly taken place in the smoking area while nursing staff were present. The SW said Resident #6 had cried while she was telling her the story and stated, "I don't want him in here anymore." The SW said the resident told her she didn't want to get into trouble by telling on Resident #2 and said she had informed staff members previously, but nothing ever changed. The SW stated, "It bothers me I didn't know this. Something is not right." She said the DON was doing a report on the allegations. The SW was asked if Resident #6 had ever had any counseling since her admission, as she had expressed both grief and fear after being admitted . The SW was told of the resident's request to see a counselor. The SW told the surveyor that a psychological evaluation had been obtained on 2/5/13. The evaluation documented the resident had prolonged depression with some dementia noted. The [DIAGNOSES REDACTED]. The consulting clinician recommended the resident's [MEDICATION NAME] be discontinued and replaced by [MEDICATION NAME] 10 mg TID to help cope with daily anxiety. Resident #6's physician did not change the resident's medications after this consult. There were no follow up counseling sessions to help the resident cope with her many issues. On 10/22/13 at 2:30 PM the area VP (vice president) addressed the surveyors about obtaining a psychiatric service to assess and treat the facility residents that need mental health services. The VP said the ADON had obtained a psychiatric consult for Resident #6. On 10/23/13 at 10:00 AM the resident's physician was interviewed. The MD said Resident #6 was very focused on her physical being and was obsessed with her health. He said he didn't know if the resident had seen a psychiatrist or not and didn't know if counseling would help with her issues. 2. Facility staff failed to provide Resident #2 with psychological assessment and treatment necessary to address his psychosexual disorder and continuous/ongoing sexual behaviors reported by staff and residents since his admission three years prior. His clinical record was reviewed on 10/17/13 at 9:00 AM. Resident #2 was admitted to the facility on [DATE]. He had the following Diagnoses: [REDACTED]. On 10/22/13 MD 2 (Resident #2's physician) documented a follow-up on psych issues. This was in response to the surveyor's query as to why Resident #2 was receiving the antipsychotic [MEDICATION NAME]. She wrote, "I think it is appropriate to add delusional disorder to his diagnoses." The latest MDS (minimum data set) assessment, dated 7/24/13 coded the resident as cognitively intact, with a BIMS score of 15/15. He was not coded with any behaviors during the look-back period. (He was documented as recovering from a surgical procedure during that time.) The resident was coded as independent for all ADLs (activities of daily) with staff oversite only for eating and hygiene. The resident ambulated independently. The resident's CCP initiated on 8/10/10 and periodically updated, documented the following problem: "I sometimes have behaviors which include being socially inappropriate, verbally abusive, and sexually inappropriate. Resident has history of exposing himself inappropriately to others. Makes inappropriate gestures and comments to staff, residents and family members. Resident has poor impulse control makes sexual comments to female staff members and visitors....Noted to have DX of unspecified psychosexual disorder....." The CCP goal was "My behavior will stop with staff intervention." The interventions included: "Give me my medications as my doctor ordered.....let my doctor know if my behaviors are interfering with my daily life....Please refer me to a psychologist/psychiatrist as needed." On 8/29/13 the CCP was updated to include "Q. 15 minute checks to monitor behaviors." On 10/8/13 it was again updated to include "1:1 supervision at all times." The following incident report was documented in the clinical record by LPN II, "On 2/13/13 13:50 (1:00 PM), the following occurred: Behavior: Alleged sexual abuse (Resident to Resident) in resident's room (pt room), injury: No apparent injury." The nursing progress note by LPN II on the same day included, "pt in room with pants down standing in front of another pt with penis erect." This was determined to be Resident #3--who was NOT Resident #2's roommate, but resided on the same unit.) On 2/20/13 LPN I documented the following in Resident #2's progress notes, "Resident's roommate wheeled up to nurse's med cart and stated resident (#2) told him he wanted to have sex with a man. Roommate stated, "It won't be with me." (Name of SW) - made aware." On 2/21/13 RN 8 documented, "(Name of MD 2) was seen in yesterday and new orders given for Depo [MEDICATION NAME] to decrease desire r/t behaviors. Resident is own RP and aware of the new orders." On 2/20/13 MD 2 ordered "Start Depo [MEDICATION NAME] (150 mg/ml) 1 ml ([MEDICATION NAME] Acetate (Contraceptive). Give 150 mg IM Q three weeks." On 2/20/13 MD 2 documented the following in the progress notes, "Pt has a long history of inappropriate sexual behaviors - has been put on various SSRIs over time due to impulsive behaviors and sexual behaviors. Staff report he exposed his erect penis to a roommate and has also made some sexual comments to a family member visiting another resident...." On 2/26/13 at 11:27 PM this incident report was documented in Resident #2's clinical record, " Behavior: Alleged physical abuse (Resident-to-resident) in resident's room, injury: Other (scratches noted to right upper arm)..." The SW was notified and called the sheriff's department to report this on 2/26/13. Documentation in the nursing progress notes indicates the resident was moved to a different room and placed on 1:1 supervision for that day. A police officer did come and interview the resident, but no charges were filed. The MARS (medication administration records) from February 2013 until present were reviewed for the Depo-[MEDICATION NAME] administration which was to be provided every three weeks. It was administered by nursing staff on 2/21/13, 3/21/13, 6/11/13, 7/23/13, 8/13/13, and 10/16/13. The nursing notes reviewed indicate Depo-[MEDICATION NAME] was not provided every three weeks per the physician's orders [REDACTED]. The nurse documented on 4/30/13 the med was not available and notified MD 2 it may take a couple of days to get it. The medication was rescheduled for administration on 5/21/13 but was refused by the resident on that date. It was refused by the resident on 9/24/13. On 9/25/13 LPN 8 documented, "Res. seen on rounds by (name of MD 2). She spoke to him at length about his refusal of the depo shot. Res. is afraid that it will take away all sexual desires and he does not want that to happen. MD explained that it does not take away the desires but helps with his control issues and the way he continually wants to talk about sex. She gave orders for him to be seen by counselor to help with his impulse control issues. Nurse spoke with social worker and she will set up visitation with the counselor if they pick him back up." On 10/16/13 at 11:30 AM the resident was observed to ambulate independently down the hallway. He moved with a limping gait. His left arm and hand were contracted. He was carrying two canned sodas. The resident was smiling, very friendly and engaging those around him in conversation. His speech was unimpaired. LPNs 2, 7 and 8 were all asked if the Depo-[MEDICATION NAME] had reduced the resident's sexual behaviors since it was begun on 2/21/13. The nurses all said they had seen "no change" in his behaviors. CNAs 1, 4, 5, 6 and 7 were asked if they noticed any reduction in Resident #2's behaviors in recent months. They all said they had not noticed any reduction in his sexually inappropriate behaviors. On 10/16/13 two surveyors entered the facility to investigate a complaint filed with our office by the Adult Protective Services officer for the area. The allegations (dated February 1st, 2013) by the APS officer documented Resident #2 had admitted to rubbing his penis on Resident #3's mouth and also to having had sex with two other residents in the nursing home. The facility staff had failed to report these incidents to the appropriate state agencies. On 10/21/13 at 10:00 AM the APS officer met with the survey team to discuss the allegations. The APS officer said she had filed a request to impose civil monetary penalties on the facility for failing to follow the mandatory reporting laws for the State. Copies of these letters were provided by the facility administrator. The APS officer told the survey team that the resident was being moved to a local ALF (assisted living facility) and that they had ordered an immediate consult with a mental health specialist from the Brain Center, to determine the resident's mental status and assess appropriate treatment options to control his behaviors. On 10/17/13 at 10:15 AM the DON told the survey team members that she had not reported the incident between Resident #2 and Resident #3 because it was not considered abuse. The DON said that she and the administrator had decided that since no one had observed actual physical contact between the residents it was treated as an incident--and was not reported as sexual abuse. On 10/18/13 at 9:15 AM the facility SW (social worker) was interviewed about the 2/13/13 incident between the residents. She said she remembered being told of the incident, because corporate was here. We were all sitting in the administrator's office. I thought it had been taken care of. "I considered it to be an issue that would be looked into. I thought it had been reported (to APS.) The SW stated, "You don't have to touch someone to abuse them. It's just like a fall. If it happens they're supposed to investigate. We need to know what happened." The SW said Resident #2 had not had a psychological evaluation since his admission and that his doctor considered him to be competent to manage his own affairs as his own RP. The SW stated, "I have tried to discharge (name of Resident #2) several times. He's not appropriate for here. He is more appropriate for assisted living. I couldn't get him placed anywhere--because of his behaviors." The SW said MD 2 had ordered a psychiatric evaluation of the resident after APS visited in September. "I called Piedmont Community Services and set the appointment up, then the doctor canceled it." On 10/23/13 at 3:00 PM the surveyor spoke to the local law enforcement officer investigating the abuse allegations against Resident #2. The officer voiced concern that the resident was now at a new facility where he might continue his pattern of sexual behaviors and, potentially, find new victims. The officer stated, "I cannot understand how that nursing home could let this go on for all these years and never have that man evaluated by a psychiatrist. He shouldn't have been allowed to do what they say he did--but I see him as a victim as well. That man never got the treatment that he obviously needed to contain those impulses." The officer said that Resident #2 had been evaluated and screened by a mental health professional earlier that day and that he was awaiting the results of that screening to determine his next course of action. "We need to be sure the people of this community are safe--and that means getting this man the help he needs before more people are hurt."

Based on observation, resident interview, staff interview, facility document review and clinical record review it was determined the facility staff failed to follow physician's orders [REDACTED].) ~ Failed to provide Resident #6's [MEDICATION NAME] per MD orders. ~ Failed to provide Resident #2's Depo-[MEDICATION NAME] per MD order. ~ Failed to obtain Resident #4's vital signs (pulse & blood pressure q shift x two weeks) per MD order. Findings: 1. Facility staff failed to provide Resident #6's [MEDICATION NAME] inhaler per physician's orders [REDACTED]. Hospital records documented Resident #6 was treated with [MEDICATION NAME] sulfate/[MEDICATION NAME] nebulizers every six hours during her stay between 9/6/13 and 9/11/13. This was the same medication that her physician ordered in the [MEDICATION NAME] inhaler,but was delivered via nebulizer. Resident #6 was admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Resident #6 was documented as her own responsible party and was making all her own medical decisions. Her daughter was listed as her emergency contact. Resident #6's latest MDS (minimum data set) assessment dated [DATE] coded the resident as cognitively intact with a BIMS score of 13/15. The resident was coded with difficulty focusing attention and being easily distracted by things going on around her during the interview. She was not coded with any negative behaviors to other residents or staff members. Her ADL (activities of daily living) status was coded with "oversite only" for all activities. The MDS coded Resident #6 as independent for hygiene. bathing and eating with staff oversite only. She was coded to self toilet and had occasional incontinent episodes. Her latest CCP (comprehensive care plan) updated 3/5/13 documented the resident with the problem, " Sometimes have behaviors which include making false statements against others, with manipulative behaviors, Dx: depression. Refuses needs at times. Accuses nursing staff of not giving her medications." The intervention was "give medications as my doctor ordered." A second problem included in the CCP and initiated 12/21/11 was "Alteration in Respiratory Status due to [MEDICAL CONDITION] with long standing history smoking." The goal was "Patient will remain free of exacerbation of [MEDICAL CONDITION]." The interventions included, "Administer medications as ordered. Observe labs, response to medications and treatments." On 10/17/13 at 1:15 PM Resident #6 was interviewed in her room. She told the surveyor that she had not always received medications she was supposed to have. The resident said she used to have a [MEDICATION NAME] inhaler at home for her asthma but had not been given one at the facility. She stated, "They said they didn't have one for me. I got real short of breath and ended up in the hospital with pneumonia." The resident called her daughter and asked her to talk to the surveyor. The daughter told the surveyor that her mother had not received her medications that she was supposed to have. She said they say they gave them, but my mother says she never got them. The daughter confirmed that her mother was able to determine which meds she had received and which meds were not provided. Resident #6's MARS (medication administration records) were reviewed for the past year. Her behavior monitoring sheets were observed to contain the behavior of "false accusations about not getting meds." This was documented in July 2013. Resident #6 had a physician's orders [REDACTED]. Every six hours 2 puffs q6h aerosol." The resident's MARS for August-September 2013 were reviewed. The resident's [MEDICATION NAME] inhaler was not administered between 8/26/13 and 9/5/13. The nursing progress notes reviewed for that time frame indicated the medication was not available and they were waiting for the pharmacy to deliver it. On 9/6/13 the resident was sent to the the emergency room because she was short of breath and having problems breathing. The initial report on 9/6/13 from the the ER doc indicates "she presents with worsening chest congestion, shortness of breath, difficulty breathing and wheezing. Her illness started several days ago and has gotten steadily worse. she states that she began febrile this morning (increased temperature) this morning and also complained of chills. On emergency room evaluation she was found to have a pneumonia with a left lower lobe infiltrate found by chest x-ray, prompting admission to the hospital for further care and management. Hospital records documented Resident #6 was treated with [MEDICATION NAME] sulfate/[MEDICATION NAME] nebulizers every six hours during her stay between 9/6/13 and 9/11/13. This was the same medication that her physician ordered in the [MEDICATION NAME] inhaler,but was delivered via nebulizer. On 10/23/13 at 10:02 during an interview with Resident #6's physician, he was informed the resident had not received her medication for [MEDICAL CONDITION]/ASTHMA as he had prescribed. He stated, " She probably didn't need the medication anyway." The MD further described the resident as a "hypochondriac" that was overly concerned with her medical conditions and he thought most of it was in her mind." The MD stated that he had never recommended a psychiatric eval for the resident's hypochondria because he was aware of her problems and was treating them accordingly. He did not know if this resident would benefit from psychiatric therapy. The physician was asked to determine if the 11 days without the resident's [MEDICATION NAME] had caused her to have breathing problems and pneumonia and resulted in her hospitalization . The physician replied, "I know what you are trying to do. You will never find a doctor that is willing to say that that her not receiving that [MEDICATION NAME] resulted in her having pneumonia. I don't think it mattered. Her [MEDICAL CONDITION] was at such a low level--I don't think she needed the [MEDICATION NAME]. The surveyor refrained from asking the doctor why he had ordered it four times a day, for a patient that didn't need it. On 10/23/13 at 12:15 PM the facility pharmacist was consulted regarding the medications that were not provided per physician's orders [REDACTED]. The RX (facility pharmacist) said she was very familiar with [MEDICAL CONDITION] (chronic obstructive [MEDICAL CONDITION] disorder.) She told the surveyor that [MEDICATION NAME] was a maintenance drug to prevent [MEDICAL CONDITION] symptoms. The RX described the [MEDICATION NAME]/Inhaler medication prescribed for Resident #6 as a "maintenance medication." She stated, " This is a maintenance medication and if you miss a dose it could cause a [MEDICATION NAME] and breathing problems for the patient." When asked to explain the breathing problems, the RX pointed out the obvious for a [MEDICAL CONDITION] patient. She described the chronic OBSTRUCTIVE [MEDICAL CONDITION] disorder as a "blockage of the airways and subsequent increased chance of infections, such as pneumonia." The RX said not using the medication as prescribed would result in narrowing/blockage of the airways and that would increase a patient's susceptibility to infection. The RX was asked if the [MEDICATION NAME] inhaler was the same medication as the nebulizer treatment ordered in the hospital to treat her shortness of breath and wheezing. The RX said the medication was essentially the same but the nebulizer delivered the medication in a form that was more rapidly available to the body. "It's a faster acting delivery system, but the medication is the same." On 9/11/13 Resident #6 returned from the hospital after her breathing problems had been treated and she was stabilized. The resident's physician wrote new orders for her readmission to include "[MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) inhalation Dose: 0.5-2.5 (3) ml. Every six hours. 1 ampoule every six hrs solution." This was the same medication ordered prior to her hospitalization ([MEDICATION NAME] inhaler) and used in the emergency room when she developed breathing problems and was administered via nebulizer. The MARS for September-October 2013 were reviewed. The resident had received the medication as ordered since her return from the hospital. The nurses administered the medication via nebulizer four times every day. The facility administrator and DON were informed of the surveyor's findings prior to the survey team exit. On 10/22/13 at 11:00 AM the ADON said she had researched the incident and the pharmacy had not delivered the [MEDICATION NAME]. She said she had talked to the nursing staff, but they had no explanation as to why the medication was not obtained from the pharmacy. No additional info was provided. For additional info on Resident #6 please see F-223, 226, 242, 250, 319, 425. 2. Facility staff failed to provide Resident #2's Depo-[MEDICATION NAME] per MD ordered. Resident #2 clinical record was reviewed on 10/17/13 at 9:00 AM. Resident #2 was admitted to the facility on [DATE]. He had the following Diagnoses: [REDACTED]. On 10/22/13 MD 2 (Resident #2's physician) documented a follow-up on psych issues. This was in response to the surveyor's query as to why Resident #2 was receiving the antipsychotic [MEDICATION NAME]. She wrote, "I think it is appropriate to add delusional disorder to his diagnoses." The latest MDS (minimum data set) assessment, dated 7/24/13 coded the resident as cognitively intact, with a BIMS score of 15/15. He was not coded with any behaviors during the look-back period. (He was documented as recovering from a surgical procedure during that time.) The resident was coded as independent for all ADLs (activities of daily) with staff oversite only for eating and hygiene. The resident ambulated independently. The resident's CCP (comprehensive care plan) initiated on 8/10/10 and periodically updated, documented the following problem: "I sometimes have behaviors which include being socially inappropriate, verbally abusive, and sexually inappropriate. Resident has history of exposing himself inappropriately to others. Makes inappropriate gestures and comments to staff, residents and family members. Resident has poor impulse control makes sexual comments to female staff members and visitors....Noted to have DX of unspecified psychosexual disorder....." The CCP goal was "My behavior will stop with staff intervention." The interventions included: "Give me my medications as my doctor ordered.....let my doctor know if my behaviors are interfering with my daily life....Please refer me to a psychologist/psychiatrist as needed." On 8/29/13 the CCP was updated to include "Q. 15 minute checks to monitor behaviors." On 10/8/13 it was again updated to include "1:1 supervision at all times." The following incident report was documented in the clinical record by LPN II, "On 2/13/13 13:50 (1:00 PM), the following occurred: Behavior: Alleged sexual abuse (Resident to Resident) in resident's room (pt room), injury: No apparent injury." The nursing progress note by LPN II on the same day included, "pt in room with pants down standing in front of another pt with penis erect." On 2/20/13 LPN I documented the following in Resident #2's progress notes, "Resident's roommate wheeled up to nurse's med cart and stated resident (#2) told him he wanted to have sex with a man. Roommate stated, "It won't be with me." (Name of SW 'social worker') - made aware." On 2/21/13 RN 8 documented, "(Name of MD 2) was seen in yesterday and new orders given for Depo [MEDICATION NAME] to decrease desire r/t behaviors. Resident is own RP (responsible party) and aware of the new orders." On 2/20/13 MD 2 ordered "Start Depo [MEDICATION NAME] (150 mg/ml) 1 ml ([MEDICATION NAME] Acetate (Contraceptive). Give 150 mg IM Q three weeks." On 2/20/13 MD 2 documented the following in the progress notes, "Pt has a long history of inappropriate sexual behaviors - has been put on various SSRIs over time due to impulsive behaviors and sexual behaviors. Staff report he exposed his erect penis to a roommate and has also made some sexual comments to a family member visiting another resident...." On 2/26/13 at 11:27 PM this incident report was documented in Resident #2's clinical record, " Behavior: Alleged physical abuse (Resident-to-resident) in resident's room, injury: Other (scratches noted to right upper arm)..." The SW was notified and called the sheriff's department to report this on 2/26/13. Documentation in the nursing progress notes indicates the resident was moved to a different room and placed on 1:1 supervision for that day. A police officer did come and interview the resident, but no charges were filed. The MARS (medication administration records) from February 2013 until present were reviewed for the Depo-[MEDICATION NAME] administration which was to be provided every three weeks. It was administered by nursing staff on 2/21/13, 3/21/13, 6/11/13, 7/23/13, 8/13/13, and 10/16/13. The nursing notes reviewed indicate Depo-[MEDICATION NAME] was not provided every three weeks per the physician's orders [REDACTED]. The nurse documented on 4/30/13 the med was not available and notified MD 2 it may take a couple of days to get it. The medication was rescheduled for administration on 5/21/13 but was refused by the resident on that date. It was refused by the resident on 9/24/13. On 9/25/13 LPN 8 documented, "Res. seen on rounds by (name of MD 2). She spoke to him at length about his refusal of the depo shot. Res. is afraid that it will take away all sexual desires and he does not want that to happen. MD explained that it does not take away the desires but helps with his control issues and the way he continually wants to talk about sex. She gave orders for him to be seen by counselor to help with his impulse control issues. Nurse spoke with social worker and she will set up visitation with the counselor if they pick him back up." On 10/16/13 at 11:30 AM the resident was observed to ambulate independently down the hallway. He moved with a limping gait. His left arm and hand were contracted. He was carrying two canned sodas. The resident was smiling, very friendly and engaging those around him in conversation. His speech was unimpaired. LPNs 2, 7 and 8 were all asked if the Depo-[MEDICATION NAME] had reduced the resident's sexual behaviors since it was begun on 2/21/13. The nurses all said they had seen "no change" in his behaviors. CNAs 1, 4, 5, 6 and 7 were asked if they noticed any reduction in Resident #2's behaviors in recent months. They all said they had not noticed any reduction in his sexually inappropriate behaviors. On 10/22/13 at 11:00 AM the ADON (who was the acting DON at that time) was asked why Resident #2 did not receive his medications per the physician's orders [REDACTED]. The ADON said she did not have an answer for that. 3. For Resident #4 the facility staff failed to obtain physician ordered blood pressures and pulses every shift for two (2) weeks. Resident #4 was a [AGE] year old male who was originally admitted on [DATE] and readmitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was a Quarterly MDS assessment with an Assessment Reference Date (ARD) of 9/5/13. The facility staff coded that Resident #4 had a Cognitive Summary Score of 3. The facility staff also coded that Resident #4 required extensive (3/2) to total nursing care (4/2) with Activities of Daily Living (ADL's). On October 17, 2013 at 11 a.m. the surveyor reviewed Resident #4's clinical record. Review of the clinical record revealed a "physician's orders [REDACTED]. The document read in part ... "3. Check BP (blood pressure) and Pulse q (every) shift. X 2 weeks." (sic) Continued review of the clinical record produced Medication Administration Records (MAR's), Treatment Administration Records (TAR's), Progress Notes and Weights and Vitals Summary for the time period of 8/2/13 through 8/17/13. Review of the documents failed to produce evidence that the physician ordered B/P's and Pulses were obtained every shift for two weeks. On October 17, 2013 at 11:15 a.m. the surveyor observed the Director of Nursing (DON) at the nurses' station. The surveyor notified the DON that Resident #4 had a physician order [REDACTED]. The surveyor and DON reviewed the clinical record. The surveyor specifically pointed out the physician order [REDACTED]. The DON continued to review the clinical record. The DON was unable to produce evidence that the facility staff obtained the physician ordered B/P and pulses every shift times 2 weeks. On October 17, 2013 at 2:30 p.m. the surveyor notified the Administrator (Adm) and DON that Resident #4 had a physicians order, dated 8/2/13, for B/P and pulse every shift times two weeks. The surveyor notified the Administrative Team (AT) that the facility staff had failed to obtain the physician ordered B/P's and pulses. No additional information was provided prior to exiting the facility as to why the facility staff failed to obtain the physician ordered B/P's and pulses every shift for two weeks on Resident #4.

Based on observation, resident, family, staff & APS (Adult Protective Services) interviews, facility document review, clinical record review and in the course of a complaint investigation, it was determined the facility staff failed to protect 8 of 14 residents in the survey sample from abuse (Residents 6, 3, 9, 10, 11, 12, 13 & 14.) Findings: 1. The facility staff failed to protect Resident #6 from sexual abuse. During the course of describing the sexual abuse incident to this inspector that had happened months ago, Resident #6's emotional state was one of displaying sobbing, crying and stating that she felt terrified and felt fear. Resident #6 was admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Resident #6 was documented as her own responsible party and was making all her own medical decisions. Her daughter was listed as her emergency contact. Resident #6's latest MDS (minimum data set) assessment dated [DATE] coded the resident as cognitively intact with a BIMS score of 13/15. The resident was coded with difficulty focusing attention and being easily distracted by things going on around her during the interview. She was not coded with any negative behaviors to other residents or staff members. Her ADL (activities of daily living) status was coded with "oversite only" for all activities. The MDS coded Resident #6 as independent for hygiene. bathing and eating with staff oversite only. She was coded to self toilet and had occasional incontinent episodes. Her latest CCP (comprehensive care plan) updated 3/5/13 documented the resident with the problem, " Sometimes have behaviors which include making false statements against others, with manipulative behaviors, Dx: depression. Refuses needs at times. Accuses nursing staff of not giving her medications." The intervention was "give medications as my doctor ordered." A second problem included in the CCP and initiated 12/21/11 was "Alteration in Respiratory Status due to [MEDICAL CONDITION] with long standing history smoking." The goal was "Patient will remain free of exacerbation of [MEDICAL CONDITION]." The interventions included, "Administer medications as ordered. Observe labs, response to medications and treatments." On 10/17/13 at 1:15 PM Resident #6 was interviewed in her room. She told the surveyor that Resident #2 had touched her inappropriately while they were out smoking in the solarium and later, in her room. Resident #6 told the surveyor that Resident #2 had grabbed her crotch when they were out smoking. She said he (Resident #2) came into her room one night and sat down on her bed while she was asleep. "I woke up and he was running his hand up my leg and trying to get in under my panties. I yelled for him to get out. He left." Resident #6 was sobbing and crying while relating this story to the surveyor. She said she had told staff members what he was doing right after it had happened, but they never did anything about it. The resident cried and said she was terrified that he might come back and no one would believe her. She also said she was afraid that staff members would "take it out on her if she complained too much about the other resident." Resident #6 could not remember the exact date when the events took place, but said it was a "few months ago." She said she had told her daughter about it when it happened. The resident called her daughter and asked her to talk to the surveyor. The daughter told the surveyor that her mother had told her about Resident #2's treatment of [REDACTED]. The daughter could not remember the names of the nursing staff members that she had talked to. She said it was a few months ago, but could not remember the exact dates either. Resident #2 was admitted to the facility on [DATE]. He had the following Diagnoses: [REDACTED]. On 10/17/13 at 9:40 AM Resident #2 was interviewed. He acknowledged that he had sex with (name of Resident #6) out on the solarium. When questioned how he did that on the smoking porch with staff members around he grinned and stated, "Naw we didn't do it out there. we just fooled around and touched and kissed some." Resident #2 said he had also gone to Resident #6's room to visit her. "I sat down on the bed and rubbed her leg for awhile. She told me to get out. I left." The resident said he didn't care that Resident #6 was "old enough to be my grandma." He added he liked women and what they could do for him. The resident maintained throughout the interview that he had sex with Resident #6 in her room at different times. Resident #2 said he had sex with several women in the facility and provided names. He said he had also had sex with a [AGE] year-old girl that was visiting there, and "really liked her a lot." On 10/17/13 at 10:00 AM CNA VI told the surveyor that Resident #6 had complained to her about Resident #2 bothering her. "She told me that (name of Resident #2) was coming into her room and touches her when she's asleep. She asked me if I saw him on the unit, to make sure he did not come into her room because she was afraid of him." CNA VI said she thought it was several months ago when it happened maybe as long as a year, she couldn't remember the date. She said she reported this to the nurse on duty at the time but didn't think anything was ever done about it. CNA VI also said Resident #2 had claimed he had sex with a twelve-year-old girl who was visiting someone else at the facility with her grandparents. CNA VI said the girl would often visit with Resident #2 and had been observed playing cards with him in a common area. On 10/21/13 at 2:30 PM CNA VII reported to the survey team that Resident #6 had complained to him that Resident #2 had touched her inappropriately while they were out smoking together. CNA VII stated, "That happened a long time ago and I immediately reported it to my supervisor. After that, they let her go out earlier and smoke so she wouldn't have to be around him. (Name of Resident #2) has sex on his mind 24 hours a day." On 10/17/13 at 11:00 AM CNA I was interviewed. She said she knew Resident #2's behaviors with staff and other resident were sexual and inappropriate. Everybody has told them and the nurses know how he (Resident #2) was. It should have been stopped a long time ago. His (#2's) behaviors are charted. They shouldn't wait until somebody like you (surveyors) comes in here to do something." CNA I said Resident #2 was a "sexual type" of person and was always saying "I want to f-ck you" or "You got a nice ass." She also reported having seen Resident #2 "kissing on" other female residents (Resident #7.) She said they reported all the incidents, but nothing was ever done about the resident's sexual behaviors. On 10/17/13 at 11:30 AM CNA IV was interviewed about Resident #2's behaviors. She stated, (Name of Resident #2) is nice but he's always mumbling things under his breath that are sexually related. It makes you uncomfortable and it's hard to deal with that." CNA IV told the surveyor that she had observed Resident #2 acting in a sexually inappropriate manner with another resident (Resident #3.) "I went right out and reported it to LPN VII who immediately came to the room." CNA IV said she then went straight upstairs and reported her observations and allegations directly to the facility administrator, who told her to make out a report and submit it for investigation. The CNA said in spite of her report and the reports of others--nothing was ever done. "They'd just move him to a different room. Nothing ever changed." On 10/17/13 during an exit conference, the administrator and DON were informed of the surveyor's allegations of sexual abuse regarding Resident #6. She said this was the first time she had heard that Resident #6 had a problem with Resident #2. She said she would investigate that matter and report her findings to the survey team. On 10/18/13 at 9:15 AM the facility SW (social worker) was interviewed. She said she had talked to Resident #6 about the sexual allegations the night before and had called the police. The SW said the resident had told her the incidents occurred in the smoking area and in her room. She said one incident had allegedly taken place in the smoking area while nursing staff were present. The SW said Resident #6 had cried while she was telling her the story and stated, "I don't want him in here anymore." The SW said the resident told her she didn't want to get into trouble by telling on Resident #2 and said she had informed staff members previously, but nothing ever changed. The SW stated, "It bothers me I didn't know this. Something is not right." She said the DON was doing a report on the allegations. On 10/21/13 at 9:30 AM the DON and ADON presented their findings on Resident #6's allegations. The DON presented the survey team with several grievance forms that had been filed on Resident #6 and said she like to make up false accusations against staff for not providing her with medications and failing to provide set up appointments for her. She said the Resident had complained about everything but Resident #2 and this was the first she had heard about it. The grievance reports included a report dated 6/3/13 and heard by (name of DON.) The report included several concerns voiced by Resident #6, her daughter and her daughter-in-law: ~ "(Name of Resident #2) touches her in private at times." ~ "Resident (#6) has accused resident (#2) of this in the past. However, all staff and other residents have been questioned about this. None of the staff have ever seen (name of Resident #2) be inappropriate with resident (#6.).......SW told resident that if the other resident bothered her that she needed to first tell him to leave and then to alert staff. She understood." The grievance report was signed by the SW and the administrator. The DON looked at the report and denied any knowledge of it, saying she would look into it and find out how her name got on the report. On 10/21/13 at 2:00 PM RN IV was interviewed. She told the survey team she had reported Resident #6's allegation against Resident #2 on 1/1/13. She said she documented the incident in a nursing progress note and informed the nursing supervisor of the incident. She said she never got any further feedback about the incident or an investigation. RN IV's progress note documented, "Resident reports inappropriate sexual touching from another resident during smoke break. Nursing supervisor notified of incident. Resident reports/shows no distress or anxiety at this time." On 10/23/13 at 9:00 AM, Resident #6 was visited by the surveyor. Resident #6 indicated she was tired of discussing Resident #2 and told the surveyor, "I feel sorry for the way he (Resident #2) is and the condition he's in. But, that did not give him the right to do what he did to me." The sexual allegations were never reported to the appropriate state agencies. No additional information was provided prior to the survey team exit. 2. The facility staff failed to protect Resident #3 from physical and sexual abuse by Resident's #2 and Resident #8. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His clinical record was reviewed on 10/16/13 at 3:00 PM. Resident #3's latest MDS (minimum data set) assessment dated [DATE] coded the resident with significant cognitive impairment. This resident's ADL (activities of daily living) function was totally dependent upon the help of at least one staff member. The resident was unable to ambulate and was dependent upon one staff member to assist him to move through the facility when he was in a wheelchair. Resident #3's latest CCP (comprehensive care plan) updated 7/3/13 documented the resident with a physical functioning deficit related to: Self care impairment. The interventions were for nursing staff to provide all ADL and mobility assistance as needed. Efforts to interview Resident #3 during this survey were unsuccessful due to his advanced dementia and impaired cognitive status. On 10/16/13 two surveyors entered the facility to investigate a complaint filed with our office by the Adult Protective Services officer for the area. The allegations (dated February 1st, 2013) by the APS officer documented Resident #2 had admitted to rubbing his penis on Resident #3's mouth and also to having had sex with two other residents in the nursing home. The facility staff had failed to report these incidents to the appropriate state agencies. On 10/21/13 at 10:00 AM the APS officer met with the survey team to discuss the allegations. The APS officer said she had filed a request to impose civil monetary penalties on the facility for failing to follow the mandatory reporting laws for the State. Copies of these letters were provided by the facility administrator. On 10/17/13 at 10:15 AM the DON told the survey team members that she had not reported the incident between Resident #2 and Resident #3 because it was not considered abuse. The DON said that she and the administrator had decided that since no one had observed actual physical contact between the residents it was treated as an incident--and was not reported as sexual abuse. She said the facility had thoroughly investigated the incident and offered to share the investigation results with the survey team. The investigation reports were reviewed and there was no documentation that the incident had ever been investigated in February 2013. The administrator and the DON said the original reports filed by the staff members during the initial investigation had all disappeared. The DON said she had re-interviewed staff about the incident in September after the APS investigator had first entered the facility about the allegations of sexual abuse. The DON was asked what measures were put into place to keep Resident #3 safe from Resident #2. She said Resident #2 was placed on 15 minute checks on 2/13/13 and 2/14/13. Then he was moved to a different unit of the facility. Resident #2 ambulated independently and continued to roam throughout the facility at will. On 10/16/13 at 1:43 PM LPN VII and LPN II were interviewed. LPN VII said she was the charge nurse the day that Resident #2 was caught with Resident #3 in his room. She stated she had been called to the room by CNA #4 and observed Resident #2 to be standing in front of Resident #3's wheelchair and his (#2's) pants were down. His penis was erect and in Resident #3's face. LPN VII stated, "I wheeled (name of Resident #3) out of there. I wrote a report and gave it to the DON." LPN VII said that was not the first time that the pair had been caught in that same scenario. It had previously been reported that a CNA no longer with the facility had reported a similar situation that had occurred a few weeks before in Resident #3's room. LPN II stated, "I charted on the day it happened. I was Resident #3's nurse, but was on break when it happened so I did not observe any of it. I did document the other staff member's observations in Resident #3's progress notes." The following incident report was documented in the clinical record by LPN II, "On 2/13/13 13:50 (1:00 PM), the following occurred: Behavior: Alleged sexual abuse (Resident to Resident) in resident's room (pt room), injury: No apparent injury." The nursing progress note by LPN II on the same day included, "pt in room with pants down standing in front of another pt with penis erect." (This was determined to be Resident #3--who was NOT Resident #2's roommate, but resided on the same unit.) On 2/20/13 LPN I documented the following in Resident #2's progress notes, "Resident's roommate wheeled up to nurse's med cart and stated resident (#2) told him he wanted to have sex with a man. Roommate stated, "It won't be with me." (Name of SW-social worker) - made aware." On 2/21/13 RN 8 documented, "(Name of MD 2) was seen in yesterday and new orders given for Depo [MEDICATION NAME] to decrease desire r/t behaviors. Resident is own RP (responsible party) and aware of the new orders." On 2/20/13 MD 2 documented the following in the progress notes, "Pt has a long history of inappropriate sexual behaviors - has been put on various SSRIs (antidepressants) over time due to impulsive behaviors and sexual behaviors. Staff report he exposed his erect penis to a roommate and has also made some sexual comments to a family member visiting another resident...." On 2/26/13 at 11:27 PM this incident report was documented in Resident #2's clinical record after he and his roommate got into a physical battle, " Behavior: Alleged physical abuse (Resident-to-resident) in resident's room, injury: Other (scratches noted to right upper arm)..." The SW was notified and called the sheriff's department to report this on 2/26/13. Documentation in the nursing progress notes indicates the resident was moved to a different room and placed on 1:1 supervision for that day. A police officer did come and interview the resident, but no charges were filed. No ongoing interventions were implemented following this incident either. On 10/17/13 at 9:40 AM Resident #2 was interviewed. He acknowledged that he was in his room and in his bathroom, with the door open (both bathroom door and hallway doors were open) and heard someone in his room. He said he heard someone in his room and rushed out with his pants still down and his "thing" hit him Resident #3 in the lips. Resident #2 stated, "It just brushed him in the face, I'm not gay. I told him to get out because I was getting ready to take a piss. That's when I reached to turn his wheelchair around and my "thing" (indicating his penis with his hand) just brushed against his lips." On 10/17/13 at 11:00 AM CNA I was interviewed. She said she was on the unit on 2/13/13 when CNA IV observed the incident between Residents #2 & #3. "By the time I got to the room, Resident #2 had pulled his pants back up and was headed into the bathroom. There was another incident that happened when Resident #2 was found in Resident #3's room and it was just like what happened on 2/13/13. (Name of CNA V) walked in on them that time. Everybody has told them and the nurses know how he (Resident #2) was. It should have been stopped a long time ago. His (#2's) behaviors are charted. They shouldn't wait until somebody like you (surveyors) comes in here to do something." CNA I said Resident #2 was a "sexual type" of person and was always saying "I want to f-ck you" or "You got a nice ass." She also reported having seen Resident #2 "kissing on" other female residents. She said they reported all the incidents, but nothing was ever done about the resident's sexual behaviors. On 10/17/13 at 11:30 AM CNA IV was interviewed about the incident on 2/13/13. She stated, (Name of Resident #2) is nice but he's always mumbling things under his breath that are sexually related. It makes you uncomfortable and it's hard to deal with that." CNA IV said she was picking up lunch trays from the rooms on 2/13/13 and knocked on Resident #2's closed door. She said no one answered so she opened the door and that's when she saw Resident #2 with his pants down standing facing Resident #3 in his wheelchair. The CNA stated, "His (name of #2's) penis was erect and this close to (name of #3's) face--(placing her hand in front of her face just a fraction away from her nose.) I went right out and reported it to LPN VII who immediately came to the room." CNA IV said she then went straight upstairs and reported her observation directly to the facility administrator, who told her to make out a report and submit it for investigation. The CNA said that report had "gone missing" with everyone else's reports that were lost for that incident. CNA IV was told that Resident #2 had reported that Resident #3 had come into his room by himself and that the door was still open to the hallway when they were observed. CNA IV said that was not true--the door had been closed when she approached and she had knocked on it before she had entered. CNA IV stated, "For (name of Resident #2) to take advantage of (name of Resident #3) that was just wrong. (Name of Resident #3) doesn't know what's going on. Two ladies from corporate were here that day (names unknown) and nothing was done (about Resident #2.) They just moved him upstairs to a different room. He made advances to a visitor's [AGE] year old granddaughter and I also heard he was bothering another female resident (Resident #6.) CNA IV said Resident #2 was allowed to roam at will through the facility until after APS came in (September 2013) and ordered he be moved from the facility. "That's when they put him on 1:1 observation. It's been about a month now." On 10/18/13 at 9:15 AM the facility SW (social worker) was interviewed about the incident between the residents. She said she remembered being told of the incident, because corporate was here. We were all sitting in the administrator's office. I thought it had been taken care of. "I considered it to be an issue that would be looked into. I thought it had been reported (to APS.) The SW stated, "You don't have to touch someone to abuse them. It's just like a fall. If it happens they're supposed to investigate. We need to know what happened." The SW said Resident #2 had not had a psychological evaluation since his admission and that his doctor considered him to be competent to manage his own affairs as his own RP. The SW stated, "I have tried to discharge (name of Resident #2) several times. He's not appropriate for here. He is more appropriate for assisted living. I couldn't get him placed anywhere--because of his behaviors." Documentation was also observed in Resident #3's clinical record that indicated he had been struck by another resident on 8/1/13. At 12:14 PM a nursing staff member wrote, "Got hit by another resident....no injury." At 11:50 PM a second nursing staff member documented, "Resident received s/t at 2000 from being struck by another resident. No pain noted in associated to occurrence. Area cleansed and bandaged....Occurrence witnessed with no contributing factors initiated by (name of Resident #3.)" Both incidents were reported to the RP. An investigation of the incidents indicates the first happened on 8/1/13 at 10:20 AM and the second happened at 10:53 PM. After the second incident the same day, Resident #3 was quoted as saying, "She got me on the neck." On 10/18/13 at 2:40 PM the facility ADON was interviewed regarding the two incidents during which Resident #3 was struck by another resident on 8/1/13. The ADON said the resident-to-resident altercations were investigated by her since the DON was on leave. She said the reports were not considered to be physical abuse since (name of Resident #8) was mentally unstable at the time. The ADON said she consulted with the administrator at the time and the decision was made not to report the incidents to the state agencies because they were not considered to be abuse. The ADON was asked what measures had been put in place to protect Resident #3 from Resident #8, who had hit him twice on the same day. The ADON said she was unaware of any interventions other than separating the pair. The two residents had been seated next to one another in a common resident living area when both incidents were observed by staff members. Additional information reviewed in Resident #8's record indicated she had previously struck Resident #3 on 7/24/13. The following progress notes documented in Resident #8 ' s clinical record on 07/24/13: 1. 3:05 PM " Alert and up and about this shift. feds self. ate some of breakfast but refused lunch. has been snacking throughout the day. assisted with adl ' s via therapy. came out of room and hit resident and knocked his glasses across the floor. was hitting at nurse. medicated with [MEDICATION NAME] with relief. " 2. 3:06 PM - Late Entry " Situation: pt came out of room in solarium and hit another resident and knocked glasses across the floor ...Assessment: no injury observed ... " Both nursing progress notes were transcribed by LPN #2. There was no documentation on Resident #3's chart that referenced this occurrence. There was no documentation in either clinical record that Resident #3's RP (responsible party) had been notified. LPN #2 was interviewed on 10/23/13 at 7:45 a.m. When asked if she charted on both parties when a resident to resident altercation occurred. She stated she tried to but sometimes she would get busy and forget. LPN #2 reviewed her notes on 7/24/13 and identified Resident #3 as the person who was struck by Resident #8 on that date. When asked how she could remember that incident and resident, she stated she "remembered the glasses." LPN #2 did not notify Resident #3's RP of the incident. No interventions were observed to have been documented to protect Resident #3 from further attacks by Resident #8. This information was reported to administrative staff by the survey team. No additional information was provided prior to the survey team exit. This was a complaint deficiency. 3. For resident #9, the facility staff failed to ensure the resident was free from abuse. Resident #9 was physically abused by resident #8 on 06/18/13 and 08/03/13. Resident #9 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment completed on resident #9 was a significant change in status assessment with an ARD (assessment reference date) of 08/07/13. Section C (cognitive patterns) of this assessment scored the resident 2 out of a possible 15 points. Section E (behavior) was coded to indicate the resident had no behavior issues. Section G (functional status) was coded to indicate the resident required limited assistance of one person to transfer, walk in room, and for locomotion on and off unit. Bed mobility was coded to indicate the resident required limited assistance of two people. The resident was coded as using a wheelchair for mobility. The resident was not interviewable. When reviewing resident #8's clinical record the following nursing entry was noted, "Situation: Resident attacked resident in ______ (room number omitted), who was asleep in bed. Continued to hit staff despite multiple redirections and PRN (as needed) medications...Assessment: Other resident not injured. This resident had to be pulled off the sleeping man to prevent injury..." This entry had been documented on 06/18/13 at 05:25 (5:25 a.m.) by RN (registered nurse) #7. RN #7 no longer worked at the facility and was not interviewed. Resident #8's [DIAGNOSES REDACTED]. The resident scored 1 out of a possible 15 points on section C of the MDS assessment with an ARD of 09/23/13. The resident was not interviewable. Resident #8's CCP (comprehensive care plan) included the following focus areas. "Decreased cognitive ability, Need for total care, decreased physical ability, visual deficits, inability to communicate. Interventions Behaviors, yelling, loud grunts, paranoia at times, Explain what you are going to do before providing care, Please don't have me near other that I disturb, Please don't have me near others who disturb me, Please explain my environment to me if I don't understand what is going on around me, Please re-direct me when I wander into other rooms or areas that are unsafe for me, Please remove me from potentially dangerous situations." "I sometimes have behaviors which include...refuses medications...H/O (history of) being physically abused...Swinging at staff and other residents. Scratching at staff and other residents...Interventions 1:1 sitter, Attempt interventions before my behaviors begin, do not seat others around me who disturb me, Give me my medications as my doctor has ordered, Help me maintain my favorite place to sit, Make sure I am not in pain or uncomfortable, Offer me something I like as a diversion, Please tell me what you are going to do before you begin, Speak to me unhurriedly and in a calm voice, Special checks q (every) 15 minutes to monitor behaviors as needed." "Potential for drug related complications associated with use of [MEDICAL CONDITION] medications related to: Anti-Anxiety medication, Anti-psychotic medication...Interventions Assess for pain, Monitor for side effects and report to physician...Monthly pharmacy review of medication regimen, Provide Medications as ordered by physician and evaluate for effectiveness..." "Impaired Communication due to "Impaired Cognition, Confusion, Not always being understood, Episodes of disorganized speech, Unclear speech...Interventions Allow calm unhurried environment to encourage communication, Anticipate patient needs, Consistent staff to work with patient, Maintain eye contact if possible, Provide for quiet setting, Use simple and direct communication to promote understanding." "I have a poor response to other and the environment limited ability to communicate, inappropriate response to stimuli...Interventions Call my name or gently touch my arm or hand to help me maintain awareness of the activity going on around me, Encourage me to maintain eye contact with you during 1:1 activities to help keep me focused on what you're doing...Make sure I have my things with me that make me comfortable." "I sometimes have behaviors which include Hitting during care, Resist care, striking out at others...Interventions 1:1 sitter, Attempt interventions before my behaviors begin...Help me to avoid situations or people that are upsetting to me, Let my physician know if my behaviors are interfering with my daily living...Please refer me to my psychologist/psychiatrist as needed..." The facility staff was able to identify resident #9 as the resident who had been attacked by using the resident's room number. A review of resident #9's clinical record was unable to produce any documentation that referenced the 06/18/13 incident. The administrative staff was able to provide to the surveyor a copy of a verification of investigation completed by the facility on 06/18/13. This investigation named resident #8 as the perpetrator and identified the victim of the attack by room number. "Resident attacked resident asleep in bed _____ (omitted), but did not injure him. Also attacked staff arriving for day shift. Redirection and multiple PRN meds ineffective...Immediate resident protection initiated Pulled resident away from sleeping man, lowered slowly to floor, resident was resisting being stopped from clawing at the man." Resident #8 was admitted to a local hospital on [DATE] for evaluation and treatment and was readmitted to the facility on [DATE]. Resident #9's clinical record included the following nursing entry documented by LPN (licensed practical nurse) #1 on 08/03/13 at 12:25 (12:25 p.m.) "Situation: Hit by another resident...Assessment: No injures noted Response: _____ (name omitted)-RP made aware." The facility staff provided the surveyor with a copy of a verification of investigation completed by the facility on 08/03/13. This investigation identified resident #8 as the perpetrator and read in part "This resident walked up to another resident while he was sitting in solarium and slapped him in the head from behind." Resident #8 was provided a 1:1 sitter after this occurrence. On 10/21/13 at approximately 2:15 p.m., administrative staff #8 verbalized to the survey team that they (the facility) had found evidence of potential resident abuse that had not been handled appropriately and not reported per company policy/procedure. On 10/22/13 the ADON (assistant director of nursing) provided the survey team with a copy of a document titled, "Preventing Resident Abuse." This document read in part, "YOUR RESPONSIBILITY: To protect all residents from any form of abuse...What is abuse? Abuse is the willful infraction of injury, unreasonable confinement, intimi