Every finding on record at Miletree Center

Based on observation and staff interview, the facility failed to maintain an infection control program while serving from the tray line in the resident dining room. This was a random opportunity for discovery. This practice had the potential to affect more than an isolated number of residents. Facility Census: 56. Findings Include:a) Resident Dining RoomOn 08/11/25 12:12 PM, an observation was made of Dietary Aide #46 working the tray line in the resident dining room. The Dietary Aide #46 kept her gloves on and pushed a tray cart from the tray line to the dining room door. The Dietary Aide #46 used the telephone in the dining room with the same gloves on. On 08/11/25 at 12:15 PM, the Dietary Aide #46 returned to the tray line and began putting items on the dining tray while continuing to wear the same gloves. After Surveyor intervention, the Dietary Aide #46 stepped away from the tray line. Dietary Aide #46 completed hand hygiene and returned to the tray line and donned a clean set of gloves.On 08/11/25 at 2:00 PM, Regional Dietary Manager #62 was notified. The Regional Dietary Manager #62 confirmed the dietary aide should have removed her gloves and completed hand hygiene prior to returning to the tray line.

Based on record review and staff interview, the facility failed to provide an accurate and complete medical record for Resident #10's Physician's Order for Scope of Treatment (POST) form and two (2) transfer forms for Resident #5. This is true for two (2) of 22 residents reviewed during the survey process. Resident Identifiers: #10 and #5. Facility Census: 56.Findings Include: a) Resident #10 On 08/11/2025 at 3:04 PM, a record review was completed for Resident #10. The review found the POST form dated 01/31/25 was incomplete. Section D, entitled Medically Assisted Nutrition, did not list a choice regarding feeding through a new or existing surgical tubes, a time-limited trial of the amount of days but no surgically placed tubes, or no artificial means of nutrition desired or discussed but no decision made (provide standard of care). On 08/14/2025 at 10:08 AM, the Administrator and the Director of Nursing (DON) confirmed Section D of the POST form was incomplete. b) Resident #5 On 08/14/25 at 1:15 PM, a record review was completed for Resident #5 regarding hospitalizations. The review found the resident had been transferred to an acute care facility ton two (2) different occasions. The second transfer form listed the transfer date as 11/14/22. However, the correct date was 07/14/25. On 08/14/25 at 2:20 PM, the Administrator did confirm the transfer dates were incorrect due to a system issue.

Based on record review the facility failed to provide at least three (3) meals daily, at regular times comparable to normal mealtime in the community in accordance with resident needs, preferences, requests and plan of care. Resident identifier: #63. Facility census 56.Findings Included:a)Resident #63A review of the Five-Day Follow-Up investigation completed by the facility on 04/25/25 after resident alleged that she did not receive a breakfast or lunch tray on 04/20/25 revealed the facility substantiated the the report. Nurse Aide (NA) #37 and Licensed Practical Nurse #101 acknowledged that Resident #63 was not given a breakfast tray or lunch tray on 04/20/25.Posted Meal times for residents are as follows: 7:15 AM Breakfast12:00 PM Lunch5:15 PM DinnerInterview with Administrator on 08/19/25 at 2:33 PM who acknowledge that Resident's incident report was substantiated by staff who completed investigation prior to current Administrators current position at this facility.

Based on record review, staff interview and observations, the facility failed to ensure a resident was served food in the correct consistency according to the National Dysphagia Diet Levels as ordered by the physician. This was a random opportunity for discovery. Resident Identifier: #16. Facility Census: 56.Findings included:a) Resident #16At approximately 12:40 PM on 8/12/25, Resident #16 was given crackers on her plate with a puree diet. This was verified with the Regional Dietary Manager that Kitchen Aide #49 placed the crackers on the plate for Resident #16. Resident #16 crumbled the crackers up with her hands, dropped the crumbled crackers into the soup, and was getting ready to take a bite before surveyor intervention prevented Resident #16 from eating the soup with crackers. The Regional Dietary Manager produced a speech therapy document that read, Dysphagia Advanced (residents) may have crackers with soups. However, Resident #16 had an order for puree which is a different diet description.

Based on record review and staff interview, the facility failed to follow a physician's order for Resident #4 for side effect monitoring and behavior monitoring of a psychotropic medication. This was true for one (1) of four (4) residents reviewed under the care area of hospitalizations. Resident identifier: #4. Facility Census: 56.Findings Include:a) Resident #4On 08/13/25 at 11:30 AM, a record review was completed for Resident #4. The resident had a diagnosis of depression, unspecified and schizophrenia, unspecified. The resident is receiving Prozac 40mg (milligram) by mouth daily for depression. The resident is not currently receiving any medication for the diagnosis of schizophrenia. However, there is no behavior or side effect monitoring documenation for the antidepressant, Prozac. On 08/13/25 at 11:50 AM, the Director of Nursing (DON) acknowledged there is no behavior or side effect monitoring for the antidepressant Prozac.

Based on record review and staff interview, the facility failed to revise a care plan when a psychotropic medication was discontinued and an incorrect diagnosis was listed for Resident #5. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #5. Facility Census: 56.Findings Include:a) Resident #5On 08/13/25 at 9:15 AM, a record review was completed for Resident #5. The review found the care plan had not been revised when an antidepressant was discontinued and an incorrect diagnosis was listed. The review found the resident was ordered Celexa 10mg (milligram) by mouth daily for depression from 01/12/24 through 11/16/24. Also, the review found a diagnosis of Parkinson's Disease, which the resident has never been diagnosed with.On 08/13/25 at 3:00 PM, the Director of Nursing (DON) was notified. The DON confirmed the Celexa had been discontinued and the resident did not have a diagnosis of Parkinson's Disease. DON notified.

Based on record review and staff interview, the facility failed to develop a care plan including all diagnoses for Resident #5 and #6. This is true for two (2) of five (5) residents reviewed under unnecessary medications. Resident Identifiers: #5 and #6. Facility Census: 56.Findings Include:a) Resident #5On 08/13/25 at 9:15 AM, a record review was completed for Resident #5. The review found the care plan had not been developed to include all diagnoses. The following diagnoses are as follows: --Non-Alzheimer's disease--Paraplegia--Transient Paralysis --Acute Embolism and Thrombosis, lower extremity--Obstructive and Reflux Uropathy--Retention of UrineOn 08/13/25 at 3:00 PM, the Director of Nursing (DON) was notified. The DON did confirm all the diagnoses were not included in the care plan.b) Resident #6On 08/13/25 at 11:00 AM, a record review was completed for Resident #6. The review found the care plan had not been developed to include all diagnoses. The diagnoses are as follows:--Panic disorder--Dizziness--Muscle Weakness (generalized)--Inflammatory Liver disease--Chronic Viral Hepatitis C--History of Methicillin-Resistant Staphylococcus Aureus (MRSA)--Disorder of Vestibular Function, unspecified ear--Benign Prostatic Hyperplasia (BPH)--Urinary Retention --Obstructive Sleep Apnea (OSA)--Hypertension (HTN)--Hyperlipidemia (HLD)--Age-related Nuclear Cataract, bilateral--Dry Eye Syndrome--Gastroesophageal Reflux Diseas (GERD)--Constipation On 08/13/25 at 3:00 PM, the Director of Nursing (DON) was notified. The DON did confirm all the diagnoses were not included in the care plan.

Based on documentation review and staff interview the facility failed to ensure resident's Pre-admission Screening reflected a current diagnosis for Resident #1. Resident identifier: #1. Facility Census 56. Findings included:a) Resident #1Resident #1 was admitted on [DATE]. A review of the Resident #1's documentation revealed the following:-Document titled [NAME] Virginia Department of Health and Human Resources Pre-admission SCREENING dated 04/14/25, Question 40. Major Mental Illness or suspected MI is marked i. None/N/A-Document titled Diagnosis Report included a diagnosis of Major Depressive Disorder, Single Episode, Unspecified on 04/18/25 Interview with Administrator on 08/14/25 at 10:50am who acknowledge that a Pre-admission Screening had not been completed to reflect resident's current diagnosis.

Based on record review and staff interview, the facility failed to provide an accurate Minimum Data Set (MDS) including all high risk drug classes for Resident #5. This is true for one (1) of five (5) residents reviewed under unnecessary medications. Resident Identfier: #5. Facility Census: 56. Findings Include:a) Resident #5On 08/14/25 at 9:00 AM, a record review was completed for Resident #5. The review found the MDS quarterly assessment dated [DATE] section N entitled Medications did not indicate the use of an antianxiety medication, Buspar.On 08/14/25 at 10:05 AM, the Director of Nursing (DON) and the Administrator were notified. The DON confirmed the MDS did not include the use of an antianxiety medication.

Based on record review and staff interview, the facility failed to notify a resident's legal representative, the resident's attending physician, and the dietician about a worsening Moisture-Associated Skin Damage (MASD) area on the resident's body. This was a random opportunity for discovery. Resident identifier: #67. Facility census: 56Findings included:a) Resident #67A record review, completed on 08/14/25 at 10:00 AM, revealed that Resident #67 had a documented Moisture-Associated Skin Damage (MASD) area on his intergluteal cleft on his buttocks. A Skin and Wound Evaluation, dated 06/11/25, revealed the following details:MASD Type: Incontinence Associated Dermatitis (IAD)In-house acquiredWound measurements: Area - 39.5 cm2, Length - 9.3 cm, and Width - 6.7 cmDenuded - loss of epidermis caused by exposure to urine, feces, body fluids, wound exudate or friction.Progress - deteriorating Notification boxes for Physician, Resident's Responsible Party, and Dietician were left blankThere was no evidence in the Progress Notes section of the electronic medical record that indicated the physician, resident's responsible party, or the dietician were notified. During an interview, on 06/18/25 at 2:15 PM, the Director of Nursing acknowledged the facility could not produce evidence that the physician, resident's responsible party, or the dietician were notified.

Based on record review and staff interview, the facility failed to develop and/or implement a comprehensive care plan for Resident #10 regarding a diagnosis of diabetes mellitus, Resident #20 for the use of restraints, Resident #52 for fall interventions and meal intake and Resident #47 regarding dental care. This was true for five (5) of 15 residents reviewed during the survey process. Resident Identifiers: #10, #20, #52 and #47. Facility Census: 57. Findings Include: a) Resident #10 On 07/09/24 at 11:15 AM, a record review was completed for Resident #10. The review found the care plan was not developed regarding the diagnosis of diabetes mellitus. On 07/09/24 at 11:50 AM, the Director of Nursing (DON) confirmed the care plan did not include the diagnosis of diabetes mellitus. b) Resident #20 On 07/09/24 at 1:30PM, a record review was completed for Resident #20. The review found the care plan was not developed regarding the use of restraints. On 07/09/24 at 2:00 PM, the DON confirmed the care plan did not include the use of restraints. c1) Resident #52 On 07/12/24 at 12:00 PM, a record review was completed for Resident #52. The review found the care plan was not implemented regarding a fall intervention. A fall intervention listed on the care plan stated, fall mat to left side of bed to prevent injury. (Typed as written.) On 07/12/24 at 12:15 PM, an observation of the resident resting in bed was made. The fall mat to the left side of the bed was not in place. On 07/12/24 at 12:19 PM, Nurse Aide (NA) #41 confirmed the fall mat was not in place at the left side of the bed. On 07/12/24 at 12:22 PM, the DON was notified and confirmed the fall mat should be in place. c2) Resident #52 On 07/12/23 at 12:00 PM, a record review was completed for Resident #52. The review found the care plan was not implemented regarding nutrition. An intervention listed on the care plan stated, monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated. (Typed as written.) On 07/10/24 at 2:15 PM, an interview was held with the DON. The DON was notified the meal intakes were not being monitored as care planned. The DON stated, I don't know why the meal percentages were not documented .the dietician and physician cannot monitor weight loss if all meals are not documented. d) Resident #47 During an initial interview on 07/08/24 at 4:55 PM, Resident #47 stated, My teeth bother me a lot, some of them are broken off at the gums. I don't say much about it because I can not afford the dental care. I think I have two dollars. During the initial observation on 07/08/24 at 4:55PM, it was revealed Resident #47 has teeth which are in poor condition with many broken off at the gum line. A record review on 07/09/24 at 3:34 PM revealed, Resident #47 had the following care plan created on 01/14/23 related to dental care: Focus: Resident is at risk for oral health or dental care problems as evidenced by being edentulous. Goal: The resident will maintain intact oral mucous membranes as evidence by the absence of discomfort, gum inflammation/infection, oral lesions x 90 days. Interventions: Assess for oral lesions, inflammation and bleeding and signs and symptoms of pain during care and report to MD as indicated Encourage resident to brush teeth and gums twice daily and as needed Provide oral hygiene/mouth care twice per day and prn Use a mouth rinse as appropriate During an interview on 07/09/24 at 3:36 PM, Resident #47 stated, I was chewing on the left side because I have a cavity on the right side. Now the left side is starting to hurt. During an interview on 07/09/24 at 3:37 PM, in front of Resident # 47, The Director of Nursing (DON) confirmed, Resident #47 does have teeth in poor condition and stated, We have talked about this, I know you have teeth. I am working with appointments to get you a dental consult. At 3:53 PM, the DON further Stated, She told me about her teeth a while back. I thought I put a note in, but I cannot find it and there is no notes or dental consults in her chart. I will get that taken care of immediately. 49465

Based on observation, record review and staff interview the facility failed to maintain acceptable parameters of nutrition which are consistent with professional standards of practice. This failed practice was found true for two (2) of (2) two residents looked at for nutrition during the Long-Term Care Survey Process. Resident identifiers #9, and #52. Facility Census 57. Findings Include: a) Resident #9 An initial observation on 07/08/24 at 1:00 PM, of Resident #9 eating lunch revealed, she had only eaten about 25% of her lunch and her tray was away from her. A record review on 07/09/24 at 2:20 PM, of Resident #9's weights read as follows: 7/5/2024 16:23 138.8 pounds (Lbs) 6/4/2024 10:18 140.4 Lbs 6/3/2024 17:02 140.4 Lbs 6/3/2024 10:58 144.4 Lbs 5/4/2024 10:57 148.8 Lbs 4/2/2024 10:20 139.0 Lbs 4/1/2024 15:52 139.0 Lbs 3/1/2024 15:15 155.8 Lbs These weights show a 10.91 percent weight loss in (4) four months and a (6) six percent weight loss in one month. Further record review revealed a Nutritional Assessment completed on 06/05/24 by the Registered Dietician (RD) which read under summary: 1. Recommend adding snacks in-between meals given her suboptimal daily avg. PO intake. 2. If her daily average PO intake remains suboptimal, if medically appropriate, consider then incorporate an appetite stimulant at the MD/NP'S discretion in the scenario. Record review on 07/10/24 at 9:30 AM, of Resident #9's meal intake from 05/01/24 to present revealed out of the 70 days which were reviewed, 29 of those days had no intake recorded for some meals and only 25% meal intake recorded for some meals. Further record review of Resident #9's physician visit on 06/09/24, found the physician marked her appetite as OK. No further notes from the physician are found in the medical record regarding Resident #9's weight loss. During an interview on 07/10/24 at 10:06 AM, the administrator stated, (Resident #9 name) has refused supplement in the past due to it having [NAME] Gum in it, saying that it had [NAME] in it. When the surveyor asked the administrator, Why the appetite stimulant had not been started per the RD's recommendation if the residents' intake remained suboptimal? The administrator responded by saying, I see what you are saying, the documentation does not show that she is eating. No further documentation was provided by the end of the survey. b) Resident #52 On 07/10/24 at 1:45 pm, a record review was completed for Resident #52. The review found a care plan intervention under the focus area of nutritional risk related to the diagnosis of dementia which may impact nutritional status. Also, under the focus area was noted significant weight loss with variable intake. On 07/10/24 at 1:50 PM, the meal percentages for May, 2024 through July, 2024 were reviewed. Reviewed meal percentages for May through July, 2024. The review found the meal percentages were not documented throughout the months reviewed. The following list show the documentation of how many meals meals were documented daily throughout the month reviewed: --05/01/24 one meal only --05/03/24 one meal only --05/06/24 one meal only --05/12/24 one meal only --05/16/24 two meals only --05/23/24 one meal only --05/28/24 two meals only --05/30/24 one meal only --06/03/24 two meals only --06/06/24 one meal only --06/07/24 one meal only --06/13/24 one meal only --06/17/24 two meals only --06/29/24 one meal only --07/03/24 one meal only --07/05/24 one meal only The review found 28 meals had no documentation of percentages of meal intakes. The resident's weights were also reviewed. The following list show the documented weights by dates: --12/21/23 116.2 pounds --12/28/23 118.1 pounds --01/01/24 119.0 pounds --02/07/24 112.5 pounds --03/01/24 98.4 pounds --03/28/24 118.5 pounds --04/03/24 114.0 pounds --05/09/24 99.00 pounds --06/03/24 99.00 pounds --07/04/24 96.2 pounds On 07/10/24 at 2:15 PM, an interview was held with the Director of Nursing (DON). The DON stated, I don't know why the meal percentages were not documented .the dietician and physician cannot monitor weight loss if all meals are not documented. 49465

Based on observation, record review and staff interview, the facility failed to record temperatures for the medication refrigerator. This was a random opportunity for discovery. Facility Census: 57. Findings Include: a) Medication Refrigerator On 07/10/24 at 9:25 AM, a tour of the medication room was completed. The tour found one (1) medication refrigerator temperatures were not being documented in June, 2024 and July, 2024. The following dates indicate no documentation had been completed: --07/08/24 PM --06/26/24 PM --06/27/24 PM --06/28/24 PM b) Facility Policy A review of the facility policy entitled, Medication and Vaccine Refrigerator/Freezer Temperatures with a revision date of 07/01/24 was reviewed on 07/10/24 at 9:35 AM. The review found under the heading, Policy, which stated, Refrigerators and freezers used to store medications and vaccines will operate within acceptable temperature range and will checked twice a day for proper temperatures. On 07/10/24 at 9:45 AM, the Director of Nursing (DON) confirmed the refrigerator temperatures were not documented.

Based on resident interview, record review and staff interview the facility failed to assist residents in obtaining routine and emergency dental care. This failed practice was found true for (1) one of (1) one residents looked at for dental treatment during the Long-Term Care Survey Process. Resident identifier #47. Facility Census 57. Findings Include: a) Resident #47 During the initial interview on 07/08/24 at 4:55 PM, Resident #47 stated, My teeth bother me a lot, some of them are broken off at the gums. I don't say much about it because I can not afford the dental care. I think I have two dollars. During the initial observation on 07/08/24 at 4:55 PM, it was revealed Resident #47 has teeth which are in poor condition with many broken off at the gum line. A record review on 07/09/24 at 3:34 PM revealed, Resident #47 had the following care plan created on 01/14/23 related to dental care: Focus: Resident is at risk for oral health or dental care problems as evidenced by being edentulous. Goal: The resident will maintain intact oral mucous membranes as evidence by the absence of discomfort, gum inflammation/infection, oral lesions x 90 days. Interventions: Assess for oral lesions, inflammation and bleeding and signs and symptoms of pain during care and report to MD as indicated Encourage resident to brush teeth and gums twice daily and as needed Provide oral hygiene/mouth care twice per day and prn Use a mouth rinse as appropriate During an interview on 07/09/24 at 3:36 PM, Resident #47 stated, I was chewing on the left side because I have a cavity on the right side. Now the left side is starting to hurt. During an interview on 07/09/24 at 3:37 PM, in front of Resident # 47, The Director of Nursing (DON) confirmed Resident #47 does have teeth in poor condition and stated, We have talked about this, I know you have teeth. I am working with appointments to get you a dental consultation. At 3:53 PM, the DON further Stated, She told me about her teeth a while back. I thought I put a note in, but I cannot find it and there are no notes or dental consults in her chart. I will get taken care of immediately.

Based on observation and staff interview, the facility failed to maintain an appropriate infection control program for storage of a bath basin, bed pan, disposal of soiled linen and transportation of personal belongings. These were random opportunities for discovery. Facility Census: 57. a) room [ROOM NUMBER]A On 07/08/24 at 1:28 PM, an observation was made in room [ROOM NUMBER]A. The observation found a used bath basin and bed pan sitting in the bathtub; a soiled washcloth was on the side of the bathtub as well as a soiled washcloth was hanging on the window seal. Nurse Aide (NA) #58 was notified and removed the bath basin, bed pan, and soiled washcloths from the room. NA #58 stated, let me take care of this. On 07/08/24 at approximately 1:45 PM, the Director of Nursing (DON) was notified and confirmed the bath basin and the bed pan were not stored correctly; and, the soiled linens were not disposed of in the correct manner. The DON stated, Hospice was just in there giving the resident a bath .the items should have been stored and disposed of in the correct manner. b) Linen Cart On 07/09/24 at 2:06 PM, an observation of Laundry Aide (LA) #38 pushing a linen cart of clean personal items was completed. The observation found the clean personal items were not covered. The linen cart flaps were laying across the top of the cart. On 07/09/24 at 2:08 PM, LA #38 was interviewed regarding the linen cart not being covered. Laundry Aide #38 stated, I forgot to cover it. On 07/09/24 at 2:10 PM, the DON was notified and confirmed the linen cart should have been covered during transport.

b) Resident #42 On 07/09/24 at 1:00 PM, a record review was completed for Resident #42. The review found a physician's order dated 05/31/24 stating, Restraint: Seatbelt while in wheelchair for inability to maintain upright sitting position independently. Release seatbelt every 2 (two) hours for repositioning. (Typed as written.) A review of the Minimum Data Set (MDS) dated [DATE] significant change did not have any indication for the use of restraints. On 07/09/24 at 2:00 PM, the Director of Nursing (DON) confirmed the MDS was incorrect and should have indicated the use of restraints. c) Resident #20 On 07/09/24 at 1:30 PM, a record review was completed for Resident #20. The review found a physician's order dated 05/31/24 stating, Restraint: Seatbelt while in wheelchair for inability to maintain upright sitting position independently. Release seatbelt every 2 (two) hours for repositioning. (Typed as written.) A review of the Minimum Data Set (MDS) dated [DATE] significant change did not have any indication for the use of restraints. On 07/09/24 at 2:00 PM, the Director of Nursing (DON) confirmed the MDS was incorrect and should have indicated the use of restraints. 49465 Based on resident interview, observation, staff interview and record review the facility failed to complete an accurate assessment to reflect resident's dental status, and for the use of restraints for two (2) other residents. This failed practice was found true for (3) three of 15 residents reviewed for assessment accuracy during the Long-Term Care Survey Process. Resident identifiers #47, #42, and #20. Facility Census 57. Findings Include: a) Resident #47 During an initial interview on 07/08/24 at 4:55 PM, Resident #47 stated, My teeth bother me a lot, some of them are broken off at the gums. I don't say much about it because I can not afford the dental care. I think I have two dollars. During the initial observation on 07/08/24 at 4:55PM, it was revealed Resident #47 had teeth which were in poor condition with many broken off at the gum line. A record review on 07/09/24 at 3:34 PM, of Resident #47's Minimum Data Set (MDS) annual assessment with an assessment reference date (ARD) of 12/22/23, Section L, question B, indicated Resident #47 has no natural teeth or tooth fragments. Question D indicated Resident #47 has no obvious or likely cavity or broken natural teeth. During an interview on 07/09/24 at 3:37 PM, in front of Resident # 47, The Director of Nursing (DON) confirmed Resident #47 does have teeth in poor condition and stated, We have talked about this, I know you have teeth. I am working with appointments to get you a dental consultation. At 3:53 PM, the DON further Stated, She told me about her teeth a while back. I thought I put a note in, but I cannot find it and there are no notes or dental consults in her chart. I will get that taken care of immediately. b) Resident #42 On 07/09/24 at 1:00 PM, a record review was completed for Resident #42. The review found a physician's order dated 05/31/24 stating, Restraint: Seatbelt while in wheelchair for inability to maintain upright sitting position independently. Release seatbelt every 2 (two) hours for repositioning. (Typed as written.) A review of the Minimum Data Set (MDS) dated [DATE] significant change did not have any indication for the use of restraints. On 07/09/24 at 2:00 PM, the Director of Nursing (DON) confirmed the MDS was incorrect and should have indicated the use of restraints. c) Resident #20 On 07/09/24 at 1:30 PM, a record review was completed for Resident #20. The review found a physician's order dated 05/31/24 stating, Restraint: Seatbelt while in wheelchair for inability to maintain upright sitting position independently. Release seatbelt every 2 (two) hours for repositioning. (Typed as written.) A review of the Minimum Data Set (MDS) dated [DATE] significant change did not have any indication for the use of restraints. On 07/09/24 at 2:00 PM, the Director of Nursing (DON) confirmed the MDS was incorrect and should have indicated the use of restraints.

Based on observation, and staff interview the facility failed to treat each resident with respect and dignity regarding meal service in the main dining room and for Resident #36. This was a random opportunity for discovery. Resident Identifier: #36. Facility census: 57 Findings included: a) Main Dining Room During an observation of meal services on 07/09/24 at 12:15 PM, dependent resident's trays being placed in front of them at the same time as table mates without dining limitations. The dependent resident was not assisted until all trays were served in the dining room and there was an available staff member to assist them. An interview took place at 1:36 PM with the Director of Nursing (Don). The Director of Nursing was present throughout the serving process and verified that all residents at a table should be serve at the same time and dependent residents should be assisted when their tray is placed in front of them. 45173 b) Resident #36 On 07/09/24 at 11:40 AM, an observation of Resident #36 was made during the noon meal. Occupational Therapist Aide (OTA) #71 was standing while feeding Resident #36. On 07/09/24 at 11:42 AM, the Director of Nursing (DON) was notified and confirmed the staff should not be standing while feeding a resident.

Based on record review and staff interview, the facility failed to notify the ombudsman of multiple transfers to the hospital for Resident #10. This was true for one (1) of one (1) residents reviewed under the care area of hospitalization s. Resident Identifier: #10. Facility Census: 57. Findings Include: a) Resident #10 Findings Include: On 07/10/24 at 3:30 PM, a record review was completed for Resident #10. The review found the resident had been transferred to an acute care facility three (3) times. The dates of transfer are as follows: --09/30/23 --10/01/23 --10/09/23 On 07/11/24 at 9:50 AM, upon request of the notifications to the Ombudsman, the Director of Nursing (DON) stated, we don't have anything .the person doing the notifications didn't know it included transfers .they thought it was only discharges.

Based on record review and staff interview, the facility failed to provide bed hold notices of multiple transfers to the hospital for Resident #10. This was true for one (1) of one (1) residents reviewed under the care area of hospitalization s. Resident Identifier: #10. Facility Census: 57. Findings Include: a) Resident #10 On 07/10/24 at 3:30 PM, a record review was completed for Resident #10. The review found the resident had been transferred to an acute care facility three (3) times. The dates of transfer are as follows: --09/30/23 --10/01/23 --10/09/23 On 07/11/24 at 9:50 AM, upon request of the bed hold notices , the Director of Nursing (DON) stated, we don't have anything .they weren't done.

Based on record review and staff interview, the facility failed to transmit a Minimum Data Set (MDS) upon discharge of Resident #22. This was true for one (1) of one (1) residents reviewed under the care area of resident assessment. Resident Identifier: #22. Facility Census: 57. Findings Include: a) Resident #22 On 07/10/24 11:10 AM, a record review was completed for Resident #22. The review found the MDS Discharge Return Not Anticipated dated on 03/01/24 was completed but not transmitted within greater than 120 days. On 07/10/24 at 12:10 PM, an interview was held with Clinical Reimbursement Coordinator (CRC) #5. CRC #5 was notified and acknowledged the discharge MDS was completed but was not transmitted. CRC #5 stated, I don't know why it wasn't transmitted .I'll have to look into this.

Based on observation, record review, and staff interview, the facility failed to ensure one (1) of six (6) sample residents was provided optimum care and services for a skin tear. The skin tear was not promptly identified and treated. It developed signs of infection and required treatment with antibiotics and specialty dressings to promote healing. The failure to identify the areas of skin breakdown and promptly treat the areas after they were identified, in accordance with the physician's orders [REDACTED]. Resident identifier: #13. Facility Census: 57. Findings Include: a) Resident #13 This resident was observed in bed on her side on 10/23/13 at 11:00 a.m. She had washcloths in her hands. Her hands and arms were severely contracted. When spoken to, the resident was nonverbal. The most recent care plan, dated 09/09/13, was reviewed. This care plan identified the problem: "Resident has actual skin breakdown related to fungal infection to bilateral antecubital areas and unstageable wound to her coccyx". This care plan included an intervention written 09/09/13 that stated, "Weekly skin assessment by licensed nurse". A review of Resident #13's treatment record indicated the intervention to do a weekly skin assessment was written on the treatment sheet. A square was in place every seven (7) days to indicate when the skin assessment was to be done. There was no evidence the resident received a skin assessment for the entire month of September 2013. There were no initials or other notations on the treatment sheet to indicate these were assessments were competed. The Hospice Nursing Notes, dated 09/04/13, revealed a skin tear was noted to the resident's right arm above the elbow inner aspect when the arm protectors were removed for her shower. According to this note, the resident's primary nurse was notified and the Hospice nurse showed her the resident's right arm. She stated, in the Hospice note, "Nurse reports leaving the elbow protectors off to allow wound to right arm to dry/heal." The front sheet of the routine Hospice note, dated 09/04/13, indicated the resident had a skin tear to her antecubital area (in front of the elbow). Facility nursing notes, dated 09/04/13, contained no evidence Resident #13 received a skin tear when the arm protectors were removed. There was no evidence the facility nurse recorded or alerted other staff this resident received a skin tear to her antecubital area. Further review of the record found that there was no evidence arm protectors were ordered or used. The location of the skin tear made it difficult to see and/or assess. Due to contractures of the resident's arm, the skin tear required immediate attention because of moistness and skin to skin contact which would contribute to a worsening of the area if immediate care and treatment was not implemented. Nursing notes, written on 09/05/13 at 21:54, stated, "Cleanse Lt (left) and Rt (right) antecubital space with wound cleanser, pat dry. Apply intrdry qd (every day) and prn (as needed) until healed. DX: (diagnosis) redness and open area." The next nursing note was written 09/06/13 at 21:16. This note stated, "New order: Keflex 500 mg q 6 (every six) hours x (times) 7 (seven) days. DX: (diagnosis) wound infection. POA (power of attorney) aware. Another note, called a "change in condition note" was written on 09/06/13 at 21:21. This note stated the resident had a change in condition. She was noted to have open skin to the left and right antecubital areas that were red, had pus, and some drainage noted. This note stated the physician and responsible party were notified of the change in condition. New orders were obtained from the physician at that time for an antibiotic. The Director of Nursing (DON), Employee #17, was interviewed on 10/23/13 at 2:00 p.m. She was questioned about the facility's process for identification of skin breakdown and how the facility monitors, prevents, and identifies skin breakdown. The DON stated the nurses did weekly skin checks. She said as a second check, they did PUP (pressure ulcer prevention) rounds each week. The DON stated this consisted of reviewing residents for any red areas or areas of breakdown. She said the members of this team included the interdisciplinary team. When questioned about the notes or records for these rounds, the DON said they had notes, but they were the facility's notes which were not in the medical records. She verified notes from these rounds were not recorded in the medical record. The DON provided a copy of the notes for 09/03/13. The notes stated Resident #13's treatment to the coccyx continued. They also indicated elbow protectors to elbows continued, and the elbows were less red. When further questioned about the elbow protectors, the DON stated they were placed on both of the resident's arms because her elbows were red. The medical record contained no evidence this resident was identified with red elbows, or that the facility utilized elbow protectors for the resident. An interview was conducted with a nursing assistant (NA), Employee #42, at 2:45 p.m. on 10/24/13. She verified she was the regular caregiver for this resident. The NA stated she found the red elbows and talked with the nurse who told her to put the elbow protectors on the resident. She could not recall when this was, but it was a few days prior to finding the areas on the resident's arms. The NA described the protectors were like a sock with the end cut out, and had a padded part that went over the elbow. She stated the resident's arms were very contracted, so one had to pull the arms apart a little to get the protectors on her. When questioned about the skin tears, the NA stated she was at the facility on 09/05/13 when the areas were found on the resident's arms. When asked if she was the first one to find the skin tears, the NA said she thought she was at that time, because she was not aware the area on the resident's left arm was found during a shower given by the Hospice NA the day before. The NA verified the areas were in both creases of the arms and were very hard to see because of the resident's contractures. She stated the elbow protectors were not used after that, and the resident's elbows were not red anymore. The DON said, at 3:00 p.m. on 10/24/13, she was not aware of the skin tear found on this resident's left arm, and was not aware of what was written in the Hospice nursing notes. She verified the weekly skin assessments ordered by the physician were not done for this resident the entire month of September 2013. The DON said it was possible the right arm may have been a skin tear also, because of the limited visibility of these areas. The skin treatment was ordered on [DATE] by the physician. The order stated "Cleanse antecubital space left and right with wound cleanser , pat dry, apply intradry qd (every day) and prn (as needed) until healed. This was written on the facility treatment record to be done at 10:00 a.m. daily. An arrow had been extended each day on the treatment record and circled with the first treatment initialed on 09/08/13. When questioned about this treatment not being started until 09/08/13, the DON stated there were some issues with obtaining and paying for the dressing the physician ordered. She did not provide evidence the physician was notified the dressing was not available and had not been applied as ordered. There was no evidence the physician was contacted to see if he wanted to use an alternative treatment until the ordered treatment was available. The resident received the oral antibiotic for the infection beginning 09/06/13. The dressing was ordered by the physician on 09/05/13; however, the treatment was not started until 09/08/13, due to its unavailability. The incident and accident reports were reviewed. There was no evidence an incident report was completed for a skin tear occurring on 09/04/13. The physician's notes dated 09/25/13 were reviewed. He documented in his notes that the resident had left and right antecubital fossa with excoriation. His clinical impression stated "bilateral antecubital excoriation/[MEDICAL CONDITION]." The notes did not indicate an awareness that a skin tear was known to have occurred to the right arm, causing a skin tear, when an elbow protector was removed from the resident's arm. The physician notes dated 10/17/13 were reviewed. His physical exam indicated the right antecubital area was healed with no open areas. The progress notes also noted the worsening of the left antecubital area when he described the biceps tendon of the area was exposed. His plan was for padding and regular cleansing. He also recorded this was discussed with the resident's family. .

Based on medical record review and staff interview, the facility failed to provide adequate supervision to promote resident safety, resulting in physical harm to one (1) of six (6) sampled residents. Resident #62 had a [DIAGNOSES REDACTED]. Her behaviors included wandering into other residents' rooms, hitting other residents and hitting staff, and engaging in verbally abusive behaviors towards others. On the evening of 06/23/11, she was observed holding a pillow over her roommate's face, after which she was transferred to local hospital on the evening of 06/23/11, and subsequently admitted to an inpatient psychiatric unit at a second hospital on [DATE]. When she returned to the nursing facility on 07/18/11, the facility's interdisciplinary team failed to review and revise her care plan with interventions such as increased staff supervision, to promote the safety of this resident and others because of her behaviors. On 07/25/11, Resident #62 wandered into the room of a male resident and hit him. The male resident hit her back, causing her to fall and sustain a fractured hip. Resident identifier: #62. Facility census: 61. Findings include: a) Resident #62 1. Record revealed Resident #62 was an [AGE] year old female who was originally admitted to this facility on 07/28/06. Her [DIAGNOSES REDACTED]. Further record review revealed, in December 2010, this resident exhibited signs and symptoms of psychosis and was transferred to a hospital's inpatient psychiatric unit for evaluation and treatment. According the hospital's discharge summary, her symptoms included the following (quoted as typed): "Restless behaviors like pacing and continually fingering certain object has increased. (Resident #62) cannot organize thoughts or following logical explanations. (Resident #62) becomes agitated and may hit, kick, bite, scream or grab. ... There are indications that (Resident #62) is hallucinating." Her treatment while on the inpatient unit consisted of medication adjustment, and she returned to the facility on [DATE]. -- 2. Review of nursing notes following her return to the facility after this inpatient psychiatric stay revealed the following entries (all quoted as typed): - 01/14/11 at 17:03 (5:03 p.m.) - "... was removed from another residents room she had been browsing thru residents things assisted resident into her own room ..." - 01/15/11 at 10:58 - "CNA (certified nursing assistant) (name), reported to this nurse that resident shut door this am (morning). When CNA opened door, resident was standing beside roommate's bed looking at her. This cont'd (continued) one more time. CNA explained to resident that door needed to remain open and to not bother roommate. Resident pleasantly confused but complied and layed back down in bed to watch tv ..." - 01/28/11 at 13:20 (1:20 p.m.) - "... CNA (name) reported that resident was standing over her room mate this am (morning) causing room mate to be agitated. (Name of CNA) also reported that resident was taking belongings off of window seal and placing them in roommate's bed. ... " - 02/11/11 at 13:04 (1:04 p.m.) - "... Wandering in hallways and in resident's rooms this shift. Staff cont's (continues) to redirect resident. ... " - 02/16/11 at 08:03 - "(Name) CNA reported to this nurse that resident was standing in doorway of another resident naked. (Name) explained that she attempted to redirect resident and (Resident #62) stated 'she wanted my clothes so I gave them to her.' Resident was clothed and redirected back to room without difficulty. " - 02/16/11 at 14:35 (2:35 p.m.) - "Resident came into this my office and was carrying a blue cup that she was drinking from. She sat it down on my desk and was saying something to me that was nonsensicle. She then proceed to go over to the arm chair and began removeing her pull up brief like she was going to use the restroom. ... I assisted her to her room and led her to the restroom. ... When I went back into my office, I noticed that the cup that she had been drinking from earlier contained tobacco and tobacco spit from another resident. Her nurse was immediately notified and she is to notify the physician. ... " - 02/17/11 at 05:15 - "Entered resident room to administer marinol (an appetite stimulant) - attempted to give resident a drink after pill placed in mouth. She slapped me and mumbled completely nonsensical words. I then poured the water into a cup thinking that resident could not drink from a straw D/T (due to) increased confusion. When I attempted to give resident a drink form the cup she grabbed my wrist and the cup in a combative manner causing the water to spill on herself. CNA (name) entered the room and stated that resident had slapped her on the side of the head earlier while they were doing bedcheck. " - 02/26/11 at 07:40 - "CNA reported to this nurse that while attempting to feed resident breakfast, resident slapped CNA on leg. CNA stated to resident that she was not allowed to hit people. Resident then stated 'We'll see.' CNA then explained to this nurse that she stopped feeding resident and switched places with another CNA to see if resident calmed down. Resident then began trying to slap again. ... " - 02/27/11 at 00:36 (12:36 a.m.) - "Asleep in bed at this time, noted to be oob (out of bed) at 11:30 pm and standing over her roommate. Bed alarm on, under pillow. Res. (resident) assisted to bed and alarm repositioned. ... " - 03/14/11 at 22:30 (10:30 p.m.) - "Resident's alarm noted to be sounding. This nurse entered resident's room and resident was sitting on side of roommates bed, playing with the call light. Resident's roommate was in no distress, however this woke the roommate. ... This nurse assisted resident over to her side of the room ... " - 05/26/11 at 22:15 (10:15 p.m.) - "CNA notified the nurse that resident was hitting resident (Resident #62's roommate) in her room. I came to doorway and witnessed resident hitting resident ... two times in the head with her open hand." Her roommate was moved to another room, and Resident #62 calmed down after the move. - 05/27/11 at 10:00 - A licensed practical nurse (LPN) observed Resident #62 going across the hallway from her room and exposing herself. - 06/14/11 at 18:01 (6:01 p.m.) - "(Resident #62) is upset because of the new residnet in her room. she want to residnet out of her room. (Resident #62) is over to her roomate and telling her to get out of her room. " - 06/14/11 at 21:29 (9:29 p.m.) - (Resident #62) is upset and want her roommate out of her room, (Resident #62) state she needs to clean her room and can not clean it with the other resident in her room. She is over to her room mate bed and trying to get her out of her room. i re directed (Resident #62) and brought her to the nurses station to talk to the nurses." - 06/14/11 at 05:41 - "(Resident #62) was up all night trying to help her roommate, wanting her to get out of bed so (Resident #62) can clean the room. (Resident #62) was over on her roommate side of the bed touching all her belonging and trying to get her roommate a drink and spilling her drink on the roommate. " - 06/15/11 at 05:44 - "(Resident #62) is upset and want the lady her roommate out of her room. " - 06/15/11 at 10:37 - "Resident is being observed for mood / behaviors. Resident received new roommate on 6/14/11 and is upset about this. She was noted several times last night hovering over her roommate and stating 'get out of my room'. It was reported per CNA that resident was kissing a male resident on the mouth two days ago ... " - 06/18/11 at 10:47 - "Behavior changes Blood test completed on 6/17/11 Been trying to obtain a U/A for 2 days unable to obtain. Resident in restroom was calm at the time I placed her in the restroom. A CNA was helping her change her brief the CNA was bend over and (Resident #62) hit the CNA in the back of the head with a shoe. ..." - 6/18/11 at 18:34 (6:34 p.m.) - "(Resident #62) pacing the hallway going up to Dinning room and returning to room many times this evening. Going over to her room mate and touching her roommate belongings. Sitting on her roommate bed, wanting her roommate to get out of the room so she can clean the room." - 06/22/11 at 11:18 - "... Mood varies. continues to have episodes of wandering, and continues to be confused." - 06/23/11 at 13:24 (1:34 p.m.) - "... Resident cont's to get up and hover over room mate and touch her belongings. Staff cont's to redirect. ..." - 06/23/11 at 19:20 (7:20 p.m.) - "Resident found in her room over her roommate. She had taken the roommates O2 (oxygen) tubing from her nose and had a pillow over her head. POA (power of attorney) notified of Haldol 25mg Im (via intramuscular injection) x 1 dose now and transfer to RGH (local hospital) for eval (evaluation). DON (director of nursing) was notified. Dr. (name) was notified." A subsequent entry, on 06/24/11 at 18:35 (6:35 p.m.) stated the local hospital was transferring Resident #62 to another hospital with an inpatient psychiatric unit. Resident #62 remained on the psychiatric unit until she returned to the facility on [DATE]. -- 3. The discharge instructions / continuing care plan from the psychiatric unit hospital was reviewed. This instruction sheet stated the following under the heading "Proposed intervention / follow up of problem(s) still evident at the time of discharge": "1. Management of signs and symptoms of agitation. 2. Management of medications compliance and medication treatment. 3. Reorient and redirect the patient with distraction of food and beverage." The resident was readmitted to the facility on [DATE] under Medicare-covered skilled services for which she was to be monitored for behaviors and the effectiveness of her medications. -- 4. The resident's care plan (last reviewed on 06/04/11) contained the following problem statement (quoted as typed): "Resident exhibits physical aggression as evidenced by hitting other residents and staff, wandering into other residents rooms and hitting them. She also has had other inappropriate behavior: exposing herself to other residents." The goal associated with this problem statement was (quoted as typed): "Resident will have not more than 1 episode of hitting others, wandering into others rooms, exposing herself per week times 90 days." The interventions included (quoted as typed): "Allow time to vent feelings / needs. Approach resident in a calm friendly manor. Assess and manage unmet needs such as: pain, toileting, fatigue and hunger. Divert resident by giving alternative objects or activity. Encourage family involvement. Listen to resident's needs and adjust plan as appropriate. Listen to the resident and try to calm. Maintain as consistent of a routine as possible and utilize consistant caregivers. Remove resident from enviornment. Notify MD when aggressive behavior occurs as resident has history of frequent UTI's (urinary tract infections) which causes resident to behave oddly. administer meds as ordered. Identify self with each interaction and purpose of visit. Redirect and provide reminders as needed. Encourage daily decision making by providing the resident with options that she can choose from. Provide simple, clear directions for task." There was no evidence to reflect the care plan for this resident's physical aggression towards others had been reviewed and revised by the facility's interdisciplinary team upon Resident #62's return from the psychiatric unit on 07/18/11, to include the provision of staff supervision to promote safety of the resident and others. -- 5. A nursing note dated 07/25/11 at 10:10 a.m. stated, "This nurse and RN (registered nurse) entered resident's room after hearing resident (Resident #62's roommate) yelling 'get her off me!' Resident standing behind (roommate's) w/c (wheelchair). (Roommate) stated that (Resident #62) was 'pulling and tugging on my wheelchair' (Roommate) also stated that resident hit her right arm. (Resident #62) stated 'none of your business' when asked what she was doing. Redirected resident back to her bed. No apparent injury to either resident." A subsequent nursing note dated 07/25/11 at 18:15 (6:15 p.m.) stated, "... This nurse and RN called to C-wing. Resident noted laying on floor on right side. CNS stated that (a male resident) stated resident entered his room and struck him. (The male resident) then struck resident back causing her to fall and hit floor." Resident #62 was transferred to the local hospital, where she was diagnosed with [REDACTED]. -- 6. During an interview with the DON on 09/26/11 at 2:00 p.m., when questioned about the resident's care plan and lack of interventions to ensure Resident #62's safety and the safety of others, she stated this resident did not really wander into other residents' rooms - that her behaviors were directed towards her roommates. - During an interview with Employee #46 at 10:40 a.m. on 09/27/11, she verified that she was a CNA who had provided care for Resident #62. Employee #46 stated she would see Resident #62 wander into other residents' rooms and bother their things, and she would have to redirect her. She stated that, at one time, they had a bed alarm on her, but she would take it off and hide it. She described this alarm as the type that would be clipped on to the resident's clothing. She could not recall any other type of alarm being tried on this resident. Employee #46 verified that other residents complained frequently about Resident #62. When questioned about what special instructions she was given about this resident when she returned from the psychiatric unit, Employee #41 said they told the nursing assistants to keep a close eye on her. - During an interview with Employee #49 on 09/27/11 at 11:00 a.m., she verified that she was a CNA who had been employed at this facility for eighteen (18) years. When questioned about when Resident #62 tried to hurt her roommate, Employee #49 reported Resident #62 exhibited these behaviors anytime she had a roommate. When questioned about special instructions she was given about this resident when she returned from the psychiatric unit, Employee #49 stated they were not given any special instructions - they were just told to watch her. - During an interview with Employee #41 on 09/27/11 at 4:30 p.m., she verified that she was an evening shift CNA. When questioned about Resident #62, Employee #41 stated she often wandered in other residents' rooms. She reported that Resident #62 still had issues with her roommate when she returned from the psychiatric unit, but it was a different roommate than she had before she left. Resident #62 would tell her to move her stuff, that this was her room when it was on her roommate's side of the room. Employee #41 reported that Resident #62 was no different when she returned from the psychiatric unit than she was prior to going. When questioned about special instructions she was given about this resident when she returned from the psychiatric unit, Employee #41 said she could not recall any instructions provided that were different than prior to her transfer to the hospital for attempting to hurt another resident. - During an interview with Employee #60 on 09/27/11 at 4:35 p.m., she verified that she was a CNA who had provided care for Resident #62. Employee #60 stated this resident got up independently and wandered down the hall into other residents' rooms and that other residents frequently complained about her bothering their things. When questioned about what special instructions she was given about this resident when she returned from the psychiatric unit, Employee #60 stated they were not given any different instructions for her care. -- 7. During an interview on 09/27/11 at 9:30 a.m., the social worker (Employee #11) identified that she wrote the behavior care plans. She verified that no interventions had been added to the care plan for the resident's physical aggression towards others upon Resident #62's return from the psychiatric unit.