Every finding on record at Morgantown Heights of Journey

Based on record review and staff interview, the facility failed to notify residents and their representatives of room changes. This failed practice was found true for (2) two of (3) three residents reviewed for room change notifications during the complaint survey. Resident identifiers: #60, and #68. Facility Census: 89. Findings include: a) Resident # 60 A record review on 07/28/26 at 10:00 AM, revealed that Resident #60 had been in room [ROOM NUMBER] since her admission on [DATE]. Resident was moved to room [ROOM NUMBER] on 07/02/25. No room change notification could be found in the medical record. b) Resident #68 A review of the medical record revealed that Resident #68 was admitted to room [ROOM NUMBER] on 03/10/26, On 4/27/26 she was moved to room [ROOM NUMBER], and then on 06/16/26 moved to room [ROOM NUMBER]. No room change notification could be found in the medical record. During an interview on 07/28/26 at 10:40 AM, Resident #15 who has Brief Interview for Mental status (BIMS) of 15, stated, I was okay with my room change, but I did not know that I was moving until the day I moved. c) Staff interview During an interview on 07/28/26 at 2:54,The Licensed Social Worker, (LSW) stated, No, the room change notifications were not completed for those two residents. I have a text conversation on my phone where I was talking to (Resident #68 name) daughter about it. The State Agency (SA) asked, Can you show me that the resident was aware of the room change? LSW stated, No, I cannot. d) Policy reviewA review on 07/29/26 at 10:15 AM, of the policy titled {Notification of Change}, under compliance guidelines reads: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include:5. A change of room or roommate assignment.

Based on resident interview, record review, observation, and staff interview, the facility failed to ensure one resident (Resident #71) received timely incontinent care and was protected from neglect by allowing the resident to remain in urine-soaked clothing and bed linens for an extended period, failing to provide care even after staff were directed by the Director of Nursing (DON) to do so, and documenting care that had not been provided. This failed practice resulted in the resident remaining in saturated clothing and linens for an additional hour, causing emotional distress as evidenced by the resident crying during the survey. Resident identifier: #71 Facility census: 89During an interview with Resident #71 on 07/27/26 at approximately 10:15 AM, a strong odor of urine was noted upon entering the resident's room. Resident #71 stated she had not been changed since approximately 11:00 PM the previous evening and stated she likely would not be changed until 1:00 PM or 2:00 PM. The resident stated this occurred all the time because there were only three staff members working the night shift.Record review revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further record review revealed Nurse Aide (NA) #30 documented that Resident #71 had received incontinent care on 07/27/26 at 8:55 AM.During an interview with NA #30 on 07/27/26 at approximately 10:30 AM, NA #30 stated, I have not changed her today and have not had any help. NA #30 stated she reported to work at 7:00 AM. The nurse surveyor then observed Resident #71 and noted the resident's bed linens were completely saturated with urine.The Director of Nursing (DON) was notified and arrived at the resident's bedside at approximately 11:10 AM. The DON stated it was unacceptable for the resident to have remained in urine that long and instructed staff at the nurses' station and in the hallway to immediately provide incontinent care to Resident #71.At approximately 12:30 PM, the surveyor returned to Resident #71's room. A urine odor remained present. When asked how she was doing, Resident #71 tearfully stated, I'm the same, I have not been changed yet, while a tear rolled down her left cheek.During a follow-up interview at approximately 12:40 PM with the Administrator and the DON regarding why Resident #71 had not been changed after the DON's earlier direction, the DON stated, Yeah, they are in there now doing it. I'm not sure why they hadn't. You heard me tell them when we first came out of the room. The Administrator offered no additional comment.

Based on record review, resident representative interview, and staff interview, the facility failed to ensure residents are allowed to return to the facility after requests to be sent to an acute care facility were honored without requiring an Against Medical Advice (AMA) discharge. This was true for two (2) of five (5) residents reviewed under the care area of Discharge. Resident Identifiers: #92 & #93. Facility Census: 89. Findings Include: a) Resident #92 A record review was completed on 07/28/26 at 10:00 AM. The resident was ordered intravenous (IV) fluids and antibiotics for the refusal of medications, and meals as well as treatment for a urinary tract infection (UTI) on 05/14/26. The resident was noted to pull out her IV multiple times. A progress note dated 05/16/26 at 5:50 PM was reviewed. The progress note stated, resident's son was here and resident pulled out her IV again. The son was insistent on her being sent out to the hospital where they could restrain her to keep IV in place. (Staff member Name) was notified and she called (Name of facility physician's assistant) to explain the situation. (Name of facility physician's assistant) did not want her sent out. I called the son back and explained to him that (Name of facility physician's assistant) did not want her sent out and if they choose to send her out it is against medical advice. He hung up on me. He has since called me back and they want to proceed with sending her out. I will let (Staff member Name) know and call for transport to the hospital. However, the resident was sent out to an acute care facility due to worsening edema at the IV site on 05/16/26 6:59 PM. A progress note dated 05/17/26 at 7:11 PM states, Resident hospitalized at (Name of the acute care facility). This nurse spoke with hospital nurse for status update. Per Hospial staff, resident was diagnosed with pneumonia and difficulty maintaing BP (blood pressure). Resident noted to be combative and placed in restraints for safety. Resident using BIPAP intermittentlyfor SOB and receiving 1L via NC while awake. Facility to continue monitoring for updates and changes in condition, (Typed as written,) An interview was held with the Administrator on 07/29/26 at 1:00 PM. The Administrator was asked, if a family wants their person sent out to an acute care facility, are you making them sign out of the facility as an AMA? The Administrator stated, not all requests are looked at as AMA. If the physician states the resident can be treated in the facility, then it would be against medical advice to take the resident out of the facility. I understand the resident and/or the family have the right to request a higher level of care. But if the provider doesn't agree, technically it is against medical advice. On 07/29/26 at 1:30 PM, an interview was held with Corporate Nurse. The Corporate Nurse was asked for clarification on an AMA, if the resident's representative requests a higher level of care. The Corporate Nurse stated, They are not AMAs, I don't know why the staff thinks this, they are confused .we had a different physician in the past and he insisted it was an AMA. We are going to get some training done. The Corporate Nurse confirmed the resident's representative should not have been told this information. b) Resident #93 On 07/28/26 at 1:00 PM, a record review was completed. The review was in reference to a complaint received by the resident's family. The resident was admitted on [DATE] and was sent to an acute care facility on 07/21/26 for behavioral issues. However, the family had requested the resident be sent out to acute care facility prior to the actual transfer. The family was told if the resident is sent to an acute care facility, it will be considered an AMA discharge. At this time, the facility reassured the family the resident could be cared for in the facility. Within a few hours, the resident was sent to acute care facility. An interview was held with the resident representative on 07/28/26 at 11:30 AM. The resident representative stated, (Name of resident) is still in the acute care facility. I was told by the social worker here (hospital), that he was not allowed to return to the facility due to leaving AMA. He did not leave AMA. At this point, we don't want him to return. We feel like they don't know what they are doing. We are discussing our options. An interview was held with the Administrator on 07/29/26 at 1:00 PM. The Administrator was asked, if a family wants their person sent out to an acute care facility, are you making them sign out of the facility as an AMA? The Administrator stated, not all requests are looked at as AMA. If the physician states the resident can be treated in the facility, then it would be against medical advice to take the resident out of the facility. I understand the resident and/or the family have the right to request a higher level of care. But if the provider doesn't agree, technically it is against medical advice. An additional interview was held with the Administrator on 07/29/26 at approximately 1:00 PM. The Administrator confirmed the facility liason told the acute care facility the resident could not return because the resident left AMA. Upon further review of the medical record, the resident was transferred by the facility. The Administrator stated, we got our wires crossed, the liason did tell the acute care facility, the resident could not return. However, that was an incorrect. On 07/29/26 at 1:30 PM, an interview was held with Corporate Nurse. The Corporate Nurse was asked for clarification on an AMA, if the resident's representative requests a higher level of care. The Corporate Nurse stated, They are not AMAs, I don't know why the staff thinks this, they are confused .we had a different physician in the past and he insisted it was an AMA. We are going to get some training done. The Corporate Nurse confirmed the resident's representative should not have been told this information.

Based on record review and interview, the facility failed to provide the necessary care and services to ensure a resident received treatment in accordance with identified clinical needs by failing to timely initiate physician-ordered wound care and prescribed medication for one (1) of one (1) resident reviewed for quality of care. Resident #100. Facility census 89. a) Resident #100Resident #100 was admitted to the facility on [DATE] and was subsequently transferred to the hospital on [DATE].Based on clinical record review and interview with corporate nurse on 07/30/2026 at 9:00 AM, hospital records revealed Resident #100 was diagnosed with osteomyelitis of the toes of the right foot, a serious bone infection requiring timely assessment, physician-directed treatment, medication management, and ongoing wound care to reduce the risk of worsening infection, tissue destruction, delayed healing, and other serious medical complications.Review of the facility's admission assessment, physician orders, Treatment Administration Record (TAR), Medication Administration Record (MAR), and nursing progress notes revealed Resident #100 was admitted with an identified need for wound care. Despite this documented need, the facility failed to obtain physician wound care orders or initiate wound treatment until 12/19/2025. As a result, Resident #100 went four (4) consecutive days following admission without physician-ordered wound care. The clinical record contained no documentation indicating wound care was provided during this period, no evidence that nursing staff implemented interim protective interventions, and no documentation that the physician was contacted regarding the delay in establishing treatment orders.The facility's failure to timely initiate wound care and ensure prescribed medications were available and administered as ordered delayed necessary treatment for a resident with a documented bone infection. These failures had the potential to contribute to worsening infection, delayed wound healing, increased pain, progression of osteomyelitis, avoidable deterioration in the resident's clinical condition, the potential need for more extensive medical or surgical intervention, and an increased risk of hospitalization.These findings demonstrate the facility failed to provide the care and services necessary for Resident #100 to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment, plan of care, physician orders, and accepted professional standards of practice.

The facility failed to maintain an effective pest control program so that the facility is free of gnats in resident rooms and common areas. This was a random oppertunity for discovery and has the potential to affect all residents residing in the Long Term Care Facility. Facility census:89 During an interview on 07/27/26 at approximately 11:00 AM with Resident #71 who complained about gnats in the room,An observation made on 07/27/26 while interviewing resident #71 gnats were visible throughout the room and bed side trays. Further observations were made throughout the building and Gnats were observed in the dining area, nurses station and conference room. An interview was conducted on 07/27/26 at approximately 2:00 PM with the facilities Administrator who state We recently had roof repairs and it has stirred up the nats, The Director of Nursing and Corporate Nurse was also present during the interview and was in agreement that this could be due to the recent roofing repairs.

Based on observation, record review and staff interview, the facility failed to maintain an infection control program regarding the storage of resident urinals and linen. These were random opportunities for discovery. Resident Identifiers: #17, #29, #84, #62 and #19. Facility Census: 89.Findings Include: a) Resident Urinals On 07/27/26 at 9:36 AM and at 12:55 PM, a tour of the facility was completed. During the tour, observations of urinals containing urine sitting on the over-the-bed tables were made. These observations were for the following residents: --Resident #17 --Resident #29 --Resident #84 --Resident #62 --Resident #19 The care plans were reviewed for each resident. The care plan did not include the resident's preference regarding the storage of the residents' urinals. On 07/28/26 at approximately 1:30 PM, an interview was held with the Director of Nursing (DON) and the Corporate Nurse. The Corporate Nurse confirmed the used urinals should not be sitting on their over-the-bed tables unless it is the resident's preference. The Corporate Nurse stated, we will check with the residents on what their preference is. b) Facility Policy The facility policy entitled, Disinfection of Bedpans and Urinals was reviewed on 07/29/26 at 10:16 AM. Number 2 of the policy states, Store bedpans and urinals in the resident's bedside cabinet or drawer after placing in a plastic bag or as per resident preference. b) Shower room On 07/28/26 at 11:31 AM, the main shower room was toured. During the tour, the following observations were made: --Two (2) soiled wet wash clothes hanging on the arms of the shower chair--Ten (10) wash clothes and two (2) towels which were folded were laying in the bath tub.--Eight (8) wash clothes and two (2) towels, which were damp and used, were observed sitting on a mechanical lift. On 07/28/26 at 11:37 AM, an Interview was held with the DON. The DON confirmed the linen should not be stored in the shower room. The DON stated, let me get someone to clean this up. On 07/28/26 at 11:41 AM, Nurse Aide (NA) #34 arrived and stated, I'm the shower aide today, let me get this cleaned up .I didn't pay attention, I didn't see those (linen) over there. On 07/28/26 at 11:47 AM, the Corporate Nurse arrived and confirmed the linen should not be stored in the shower room.

Based on record review and staff interview, the facility failed to ensure the Medical Power of Attorney (MPOA) was notified regarding transfer to an acute care facility related to a change of condition. This failed practice has the potential to affect more than a minimal number of residents residing in the Long-Term Care Facility. Resident #100. Facility census 89. Based on staff interview and clinical chart review completed on 7/29/26 at approximately 1:30 PM, an interview was conducted with the Director of Nursing (DON) regarding the transfer of Resident #100 to the hospital on [DATE] The DON confirmed the resident was transferred to the hospital on that date and acknowledged that the resident's designated Medical Power of Attorney (MPOA) was not notified at the time of the transfer.The DON further confirmed, based upon review of the resident's clinical record, that documentation reflected the MPOA was not notified until April 28, 2026, when notification was sent via email. The DON acknowledged there was no documentation to support that the resident's representative had been notified on or near the date of transfer.The DON stated that facility practice is to notify the resident's representative as soon as practicable following a transfer to another healthcare setting to ensure the representative is informed of the resident's condition, location, and has the opportunity to participate in care decisions. The DON acknowledged that the delay in notification was not consistent with facility expectations or federal requirements and confirmed that the failure to timely notify the MPOA had the potential to negatively affect the resident representative's ability to participate in the resident's care and continuity of care.

Based on record reviews and staff interviews, the facility failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. This failed practice has the potential to affect more than a minimal number of residents residing in the long term care facility. resident identifier: #100 Facility Census:87 Findings include: a) ombudsman notification record review completed on 7/29/26 revealed for the months of January,, February, and March 2026 the ombudsman was not notified of transfers.Discharges until April 2026. An interview conducted on 7/29/26 at approximately 1:30 PM with the Director of Nursing (DON) confirmed that the Ombudsman notification email was not sent until 04/26/26 and they currently have an action plan in place to ensure the ombudsman is notified at least monthly. b) Resident #100 Record review completed on 7/29/26 at 1:10 PM revealed the Resident #100 was transferred from the facility to the hospital on January 3, 2026. Review of facility documentation determined the Long-Term Care Ombudsman was not notified of the resident's transfer until April 28, 2026, when notification was sent via email. An Interview conducted on 7/29/26 at approximately 1:30 PM with the Director of Nursing (DON) confirmed the resident was transferred to the hospital on January 3, 2026, acknowledged that the Ombudsman notification email was not sent until April 28, 2026. The facility's failure to provide timely notification to the Long-Term Care Ombudsman did not ensure compliance with federal transfer and discharge notification requirements and had the potential to adversely affect the resident's rights, continuity of care, and the resident representative's ability to participate in care decisions.

Based on record review and staff interview, the facility failed to develop and/or implement the care plan regarding a diagnosis for Resident #43, include antipsychotic medications for Resident #80, and the use of adaptive utensils for Resident #5. This was true for three (3) of 31 residents reviewed during the survey process. Resident Identifiers: #43, #80, and #5. Facility Census: 72.Findings Include: a) Resident #43 On 09/08/25 at 11:30 AM, a record review was completed for Resident #43. The review found all diagnoses were not included in the care plan. The diagnosis, which was added to the medical record on 09/26/24, that was not included was obstructive and reflux uropathy. On 09/08/25 at 2:13 PM, Corporate Nurse (CN) #300 confirmed the care plan had not been developed regarding the diagnosis obstructive and reflux uropathy. b) Residnet #80 On 09/09/25 at 10:00 AM, a record review was completed for Resident #80. The review found the care plan was not developed completely under the focus area of antidepressant and antipsychotic medications. The care plan focus areas were listed as follows: --The residnet uses antidepressant medication (SPECIFY medications r/t (related to) depression. --The resident uses psychotropic medications (antipsychotics) r/t behavior management. On 09/09/25 at approximately 11:45 AM, the Corporate Nurse #300 confirmed the care plan had not been developed completely, due to blank areas. c) Resident #5 On 09/03/25 a record review was completed for Resident #5 and revealed resident required adaptive utensils/not care planned. Review of document titled Current Order Summary revealed resident is ordered to use right curved silverware for all meals on 09/19/24. Review of Resident #5's care plan on 09/03/25 revealed no mention of any adaptive silverware needed for meals. Interview on 09/04/25 at approximately 4:00 pm with Corporate Nurse #300 who acknowledged that resident's order for curved silverware was not discussed in her care plan.

Based on record review and staff interview, the facility failed to revise a care plan regarding actual falls for Resident #12, amount of assistance needed for showering for Resident #20, and physical and verbal aggression for Resident #46. This was true for three (3) of 31 residents reviewed during the survey process. Resident Identifiers: #12, #20, and #46. Facility Census: 72.Findings Include: a) Resident #12 On 09/09/25 at approximately 1:00 PM, a record review was completed for Resident #12. The review found the care plan focus area was listed as fall risk r/t (related to) weakness, balance problem. The review, also, found the resident had two (2) actual falls on 04/24/25 and 06/21/25. On 09/09/25 at 2:15 PM, the Corporate Nurse #300 confirmed the care plan was not revised to include the two (2) actual falls. b) Resident #20 On 09/10/25 at 9:00 AM, a record review was completed for Resident #20. The care plan was reviewed with the focus area of Requires assistance with Activities of Daily Living debility. The interventions included Shower/Bathe: set up/clean up. However, in reviewing the documentation under tasks tab for Bathing (Prefers: Monday and Thursday day shift.) On five (5) occasions, documented from 08/01/25 through 08/31/25, the assistance noted physical help in part of bathing activity; and, on two (2) occasions the assistance was noted was total dependence. On 09/10/25 at approximately 11:30 AM, the Corporate Nurse #300 confirmed the care plan intervention did not match the actual assistance needed for bathing. c) Resident #46 Record review and interview on 09/09/25 at approximately 1:30 PM revealed that Resident #46 had hit Resident #74 with a closed fist, in the dining room, on 08/22/25. Records reveal that the residents were separated. Resident #74 was assessed and found to be free of injury, and Resident #46 was placed under one-on-one supervision. A review of Resident #46's Care Plan on 09/09/25 at 1:30 PM revealed no updates or implementations to address the resident's abusive behavior. The Care Plan revealed the following documentation: A review of the resident's care plan revealed the following focus areas: Occasionally grabbing at staff, making suggestive gestures toward female residents, becoming easily annoyed and aggressive with staff, During an interview with the [NAME] President of Clinical Services (VPCS) #300, on 09/09/25 at 2:45 PM, she confirmed that the care plan had not been updated, and that no protocols had been put in place to address Resident #46's actions toward other residents.

Based on medical record review and staff interview, the facility failed to provide evidence the resident or the resident's representative was provided a written Notice of Transfer/Discharge when a resident was discharged from the facility. This was true for two (2) of three (3) residents reviewed for discharges. Resident identifiers: #60 and #82. Facility census: 72.Findings included: a) Resident #60A medical record review, completed on 09/09/25 at 12:26 PM, revealed Resident #60 was discharged from the facility on 06/25/25. The record did not reflect the resident or resident's representative was provided with a written Notice of Transfer / Discharge indicating the reason for transfer, the effective date of transfer, the location to which the resident was being transferred and a statement of the resident's appeal rights.During an interview on 09/09/25 at 3:00 PM, the Director of Nursing (DON) acknowledged the facility was unable to provide evidence that a written Notice of Transfer / Discharge had been provided. b) Resident #82A medical record review, completed on 09/09/25 at 2:55 PM, revealed Resident #82 was discharged from the facility on 06/15/25. The record did not reflect the resident or resident's representative was provided with a written Notice of Transfer / Discharge indicating the reason for transfer, the effective date of transfer, the location to which the resident was being transferred and a statement of the resident's appeal rights.During an interview on 09/09/25 at 3:01 PM, the DON acknowledged the facility was unable to provide evidence that a written Notice of Transfer / Discharge had been provided.

Based on record review the facility failed to submit a new Pre-admission Screening (PAS) when a diagnosis was not captured upon admission, This is true for one (1) of two (2) residents reviewed for PAS. Resident #57, Facility Census 72.Findings included: a) Resident #57 On 09/04/25 a review of Resident # 57's most recently completed Pre-admission Screening (PAS) submitted on 07/24/23 revealed the following: Question number 30. Current Diagnosis marked a. None Question 40. Major Mental Illness or suspected MI marked I. none Question 47. The individual has a primary diagnosis of: options Dementia, Related Neurocognitive Disorder Including Alzheimer's Disease, marked N/A. Review of Resident #57's current medical record document titled Diagnosis Report listed the resident's diagnosis to include the following:Alzheimer's Disease, Unspecified(G30.9), Primary Diagnosis, onset 03/25/24Schizophrenia, unspecified (F20.9), onset 7/27/23 Major Depressive Disorder, Single Episode, Mild (F32.0) , onset 07/22/24Interview with Social Worker at approximately 2:30 PM who reported PAS had been redone on this date and was awaiting the doctor's signature at this time to be submitted

Based on observation, record review and staff interview, the facility failed to assist with activities of daily living (ADLs) for a dependent resident. This was true for one (1) of one (1) residents reviewed under the care area of activities of daily living. Resident identifier: #20 Facility Census: 72.Findings Include: a) Resident #20 On 09/03/25 at 3:24 PM, the resident was observed in his room appearing unkempt with greasy hair. On 09/10/2025 at 9:00 AM, a record review was completed for Resident #20. The review, included showers and bed baths, between 08/01/25 through 09/04/25. The review found the resident did not have a shower or bed bath between 08/11/25 through 08/18/25, which was seven (7) days; 08/21/25 through 08/27/25, which was six days, and from 08/28/25 through 09/04/25, which is seven (7) days. No bed baths were noted during any of these time frames, as well as no refusals. The resident was, also, noted to need physical assistance or dependent for showers during this time frame. On 09/10/25 at 11:30 AM, the Corporate Nurse #300 was notified of the ADLs which were not provided. On 09/10/25 at approximately 1:30 PM, the Corporate Nurse #300 stated, I checked with the aide .she forgot to document because she was busy. On 09/10/25 at 1:40 PM, the Corporate Nurse #300 did acknowledge there was no documentation in the record to show any other showers or bed baths were given to Resident #20.

Based on observation, record review and staff interview, the facility failed to post the daily staff posting in a readily accessible area for residents and/or visitors to view and failed to provide an accurate daily posting on six (6) of eight (8) days sampled. Facility Census: 72. Findings Include: a) Staff Posting Accessibility On 09/09/25 at 1:45 PM, a tour of the facility was completed. There was no daily staff posting at or near the north side nurses' station. On 09/09/25 at 2:00 PM, a tour of the facility was taken. The south side of the facility was noted with the daily staff posting on a glass panel behind the receptionist's desk near the administrative offices. This was not readily accessible to the residents and/or the visitors. On 09/09/25 at 2:05 PM, an interview was held with the [NAME] President of Operations (VPO) #19. VPO #19 did confirm the daily staff posting was not readily accessible at the South nurses' station. VPO #19 stated, We have had problems with residents taking it if it is placed at the desk. The [NAME] President of Operations #19 stated, We will try and put it in a frame at the receptionist's desk. b) Inaccurate Daily Staff Posting On 09/10/25 at 10:00 AM, a review of eight (8) daily staff postings were reviewed. The following six (6) daily staff postings were not accurate: --01/04/25 missing evening shift census--02/14/25 missing evening shift census--03/09/25 missing evening shift census--04/12/25 missing evening shift census--06/28/25 missing evening shift census--07/03/25 missing day and evening shift census On 09/10/25 at approximately 1:30 PM, an interview was held with Payroll Benefits Coordinator #6 regarding the daily staff posting being not accurate. The Payroll Benefits Coordinator stated, I'm not sure why it wasn't filled out completely.

Based on interview, and record review, the facility failed to ensure medically related socail services were provided to one (1) resident. The facility failed to notify the resident that the Notice of Medicare Non-Coverage issued to him was deemed invalid, that Medicare would continue to pay for services, and that no specific date had been set for discharge. This was true for one (1) of thirty-one (31) residents surveyed. Resident Identifier: #62. Facility Census: 72.b) Resident #62During an interview with Resident #62 on 09/03/25 at approximately 11:35 AM Resident #62 stated that he was scheduled to be discharged from the facility on 09/04/25 because he had received a Notice of Medicare Non-Coverage (NOMNC). Resident #62 was concerned about the clutter in his house. He states that he would be unable to wheel his walker or wheelchair through the house because there is no clear path. Resident also stated that he had spoken to the Social Worker (SW) on 09/02/25 and asked her about his appeal. He stated that he had not received any notification that his appeal had been successful.During interviews with the Physical Therapist (PT) #53 on 09/04/25 at 11:39 AM she stated that the resident had reached his potential. She stated that resident can walk approximately 400 ft with his walker. He is also able to transfer safely. During an interview with Occupational Therapist (OT) #39 on 09/04/25 at approximately 11:59 AM, she stated that she had worked with the resident on medication management. She noted that the resident is not interested in managing his medications by himself. Currently, the resident's wife, who resides with him at the facility, manages his medications. OT #39 also stated that she was working with the resident on some higher-level tasks, such as preparing meals for himself and showering. OT #39 indicated that the resident can perform these tasks but expresses concern about safely ambulating around his house.During an interview with the SW on 09/03/25 at approximately 12:44 PM, the SW stated that the resident had appealed and won the appeal and would remain at the facility till 09/19/25. During another interview with the resident on 09/03/25 at approximately 1:10 PM, the resident stated that he had not been informed that his appeal had been successful. The SW was notified that on 09/04/25 at approximately 1:20 AM, Resident #62 had no knowledge that his appeal had been successful, and he still believed that he had to leave on 09/04/25. The SW stated that she would go over and notify him.Record review on 09/04/25 at approximately 1:39 AM revealed that the resident had received a NOMNC from the facility on 08/22/25, which stated that his Medicare Coverage of his Current Skilled Nursing Facility Services would end on 08/28/25.

Based on observation, interview, and record review, the facility failed to ensure that residents received necessary dental services, including routine dental care. Additionally, the facility failed to provide the assistance needed or requested by residents to obtain these services. This finding applied to one (1) of the thirty-one (31) residents surveyed Resident Identifier: #68. Facility Census:72.Findings include a) Resident #68 During a brief interview on 09/03/25 at approximately 3:04 PM it was observed that Resident #68's teeth were severely discolored and decayed. During an interview with Resident #68's Case Manager at Adult Protective Services (APS) on 09/04/25 at approximately 10:45 AM, she stated the following: I signed consent for dental surgery for the resident on 12/26/24. My coworker signed consent for Medicaid 360 services in November of 2024. There are no other mentions of dental issues in the system. Below is a general description the oral surgeon provided:Full Mouth Debridement Silver Diamine Fluoride Treatment Ext.Erupt Tth/Expsd Root-Elev &/Or Forceps Remvl.Record review revealed that resident was seen by 360 Care on 01/09/25:Physician's note stated: [Typed as Written]Emergency exam. Patient presents for a limited exam with root tips still present. Probable cause - broken teeth. Location-upper. Area has been a problem a year plus ongoing. The following course of treatment was recommended - Extraction needed but patient declined treatment today and did not want to remove any teeth at this time. Several attempts made with her today and unsuccessful.Record review on 09/04/25 at 11:22 AM revealed that the resident had been admitted to the facility on [DATE] and had not been referred for a dental evaluation till December 2024.The facility had scheduled another evaluation for 04/03/25, but the resident refused to be seen by the dentist.During an interview with the [NAME] President of Clinical Services (VPCS) #300 on 09/09/25 at 10:45 AM, she confirmed that the resident had not been referred for services in a timely manner after admission to the facility.

Based on interview and record review, the facility failed to perform a thorough investigation after an instance of resident-to-resident abuse. This was a random opportunity for discovery. Resident Identifiers: Resident #46. Facility Census: 72.Findings Include:a) Resident #46On September 9, 2025, during an interview conducted at approximately 1:08 PM, Resident #5 expressed concern about the behavior of Resident #46 towards other residents in the dining room. Resident #5 reported that Resident #46, who is known for his temper, threw a cup at another male resident, narrowly missing him. Additionally, about a month ago, Resident #46 became irritated with Resident #74 when she approached and began touching items on his table. In that instance, Resident #46 reportedly hit Resident #74 and told her, Go sit down! Sit down, or I will put you down, and you will be down for the rest of the day. Resident #5 also mentioned that Resident #46 called Resident #74 a bitch. It's worth noting that staff members were present during both incidents.Record review revealed that Resident #46 has a Brief Interview for Mental Status (BIMS) score of 15. When questioned about the incident on 09/08/25 at 1:20 PM, while the resident was coloring a picture mounted on the wall, the resident ignored the question. Resident #74 had a BIMS score of 00.A record request on 09/09/25 revealed that the incident between Resident #46 and Resident #74, which occurred on 08/22/25 at approximately 5:45 PM, had been reported to the Office of Health Facility Licensure and Certification (OHFLAC) and Adult Protective Services (APS) at approximately 6:00 PM on 08/22/25.Facility records also revealed that the five-day follow-up report had been submitted to OHFLAC on 08/25/25 at 8:32 PM.Report submitted to OHFLAC at 08/25/25 at 8:32 PM.A review of the facility's investigative records revealed the following statements from facility staff:A statement by Nursing Assistant (NA) #32 on 08/25/25 stated: Before dinner was served, the residents were gathered in the dining room, waiting for supper services. Resident #74 was ambulating throughout the dining room, adjusting tablecloths when she approached Resident #46's table, he told her to get away from his table, and she replied No, we then were heading toward the table to intervene (NA #51 and I). Before we got there , he had struck Resident #74 in the arm shoulder area with a closed fist. (I was sitting near the kitchen; NA #51 was passing drinks). Resident #74 then pointed at Resident #46 and said something, but I could not hear her. Resident #46 continued to yell to get that stupid bitch away from me. NA #51 escorted Resident #74 out of the dining room to the North nurses station. Resident #46 refused to leave separate from the dining room. He calmed down and ate dinner. We kept him under one-on-one supervision. Resident #74 then returned to the dining room after being assessed by the nurse and ate her dinner. No change in mood or behavior noted. Another verbal statement by Licensed Practical Nurse (LPN) #70 stated:I was [Resident #74's] nurse. [Resident #74] did not act any differently than usual. Resident went to dining room for dinner and showed no agitation at that time. [Resident #74] after the event was fine. She showed no signs of being upset.Interviews were conducted with Residents #52, #59 and #62 on 09/09/25 at approximately 11:44 AM. Residents #59 and #62 had no knowledge of the incident because they ate their meals in their rooms. Resident #52 stated that her memory was bad, and she was unable to remember any incident.Record review on 09/09/25 at 1:20 PM revealed that the facility investigation consisted of asking the residents the following two questions: 1. Do you feel safe here?2. Has any resident hit you? The facility failed to conduct a thorough investigation of the incident by not interviewing any residents regarding the incident that occurred in the dining room on 08/22/25.

Based on record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessment included all diagnoses for Resident #43. This is true for one (1) of five (5) residents under the care area of unnecessary medications. Resident Identifier: #43. Facility Census: 72. Findings Include: a) Resident #43 On 09/08/25 at 12:30 PM, a record review was completed for Resident #43. The review found all diagnoses were not included on the MDS quarterly dated 07/28/25 section I. After reviewing all diagnoses, the diagnosis, which was added to the medical record on 09/26/24, was obstructive and reflux uropathy. On 09/08/25 at 2:15 PM, the Corporate Nurse #300 confirmed the diagnosis of obstructive and reflux uropathy was not included in the MDS dated [DATE].

Based on interview, and record review, the facility failed to promote residents' right to self-determination and choices in the areas of medication administration and discharge planning. Resident Identifier: #52. Facility Census: 72.Findings Includea) Resident #52During an interview on 09/03/2025 at approximately 10:55 AM, the resident stated that on 08/30/25, she and her roommate had to wait until around 11:45 PM for their medications. Resident stated that she requests her prescribed PRN Oxycodone and Tizanidine when her arm spasms become uncontrollable. The resident further stated that she usually requests these medications before she goes to sleep.On 08/29/25 at approximately 9:30 PM, the resident stated that she asked a Nursing Aide (NA) to notify the nurse that she wanted her medications. The resident could not remember who the NA was. The resident reported that the nursing assistant (NA) returned and informed her that the nurse could not be located on the floor. The NA promised to notify the nurse about the resident's need for medication as soon as the nurse was available. The resident stated that she received her medication at 11:45 PM, after which she went to sleep. Additionally, the resident mentioned that on 08/24/25, she requested her medication at approximately 9:30 PM but did not receive them until 10:30 PM.Record review on 09/04/24 at 11:41 AM revealed that the resident is prescribed the following medications:Oxycodone HCl Oral Tablet 10 MG - Give 10 mg by mouth every 6 hours as needed for pain control-Start Date- 05/29/25 at 4:15 PM.Tizanidine HCl 2 MG Tablet - Give 1 tablet by mouth every 12 hours as needed for tremors-Start Date- 05/30/25 at 2:30 PMFurther record review of the Medication Administration Record (MAR) confirmed that the medications were administered on 08/24/25 at 10:30 PM, and on 08/30/25 at 11:45 PM.On 09/0925, at approximately 1:55 PM, an interview was conducted with Resident #52, accompanied by the [NAME] President of Clinical Services (VPCS) #300. During the interview, the resident expressed that she did not receive her medication when she needed them. She further indicated that after requesting her medications, it took almost one and a half hours for the nurse to return with them.VPCS #300 asked the resident about her preferred time to receive her medications. The resident explained that she needed her medications when the spasm in her arm became difficult to manage, usually around 9:00 PM. In response, VPCS #300 stated that she would instruct the nurses to offer the medications to the resident at around 8:00 PM each day. The resident could then decide whether to take the medications at that time or later. The resident voiced her agreement with the arrangement.

Based on record review and staff interview, the facility failed to notify the representative / emergency family member of medical changes. This was true for one (1) of three (3) residents reviewed for the care area of hospitalization during the annual long-term care survey process. Resident identifier: #60. Facility census: 72. Findings included:a) Resident #60A record review, completed on 09/04/25 at 12:40 PM, revealed Resident #60 had capacity to make his own medical decisions. It also revealed Resident #60 was transferred to the hospital on [DATE]. Resident #60's daughter was listed as Emergency Contact on the profile page of resident's electronic medical record. Section E1, of the 06/25/25 eINTERACT Transfer Form, entitled Key Contacts displayed the wording null. A progress note, dated 06/25/25 at 10:04 PM, stated, . pt (patient) has capacity and is aware of situation.There was no evidence that Resident #60's emergency contact was notified of the acute transfer to the hospital. During an interview, on 09/04/2025 at 1:13 PM, the Director of Nursing (DON) indicated the facility had not notified Resident #60's designated representative/family member of the transfer to the hospital.

Based on observation, record review, staff interview, and resident interview the facility failed to ensure residents were free from abuse and neglect. The survey team witnessed the failure of staff to provide timely incontinence care to Resident's #6 and #237. When the observations of the surveyors were presented to the facility, the facility reported the incident to the state agency as required. Immediate jeopardy (IJ) occurred when the facility failed to provide education and servicing to one of the witnessed perpetrators before allowing this staff person to return to work. This failure placed all residents currently residing in the facility at an immediate risk for serious harm and/or death. After the immediacy was removed a deficient practice remained for Resident #331 who was improperly lifted off the floor after 2 falls. This was a random opportunity for discovery and had the potential to affect all residents at the facility. Therefore, the scope and severity was decreased from a L to a D. The facility was first notified of the IJ at 4:24 PM, on 03/06/24. The state agency (SA) received the Plan of Correction (POC) at 8:45 PM on 03/06/24. The SA accepted the POC on 03/06/24 at 9:00 PM. The SA observed for the implementation of the POC and the IJ was abated on 03/11/24 at 2:30 PM. Resident identifiers #6, #237, and #331. Facility census 82. Findings included: a) Resident #6 Upon an unannounced entrance to the facility on [DATE] at 11:08 PM, staff member Licensed Practical Nurse (LPN) #62 and Nursing Assistant (NA) #63 were observed sitting in the room labeled Conference room with their feet propped up in a chair looking at their cell phones. These staff members were unable to see resident call lights. An observation, on 02/27/24 at 11:10 PM, of the North Nurse's station revealed six (6) call lights were going off, according to the call light board on the wall. An observation, on 02/27/24 at 11:15 PM, of North 2 (two) hall revealed the following: - At 11:15 PM Resident #6's call light came on. - At 11:30 PM NA #63 went into Resident #6's room, and his light went off. NA #63 came out of the room at 11:31 PM. -At 11:33 PM Resident #6's light came back on. During an interview, on 02/27/24 at 11:34 PM, Resident # 6 stated, I just want changed. They came in and turned my light off and told me they would be back. I just want to get dry and go to sleep. I am sick of this. Observation on 02/27/24 at 11:40 PM, of North Nurses station found NA# 63, NA#65, LPN #63, and LPN #43 at the nursing station. During an observation, on 02/27/24 at 11:44 PM, of the North Nurses station, the surveyor heard LPN # 40 announce, I am going on my 15-minute break, because I am supposed to get it. I will set my watch. Resident #6's call light continued to go off. Further observation at 11:47 PM, showed LPN #62 going into Resident #6's room and immediately walked back out. The call light was turned off. She then stated, He is a 2 person assist, I got to wait on help. An observation on 02/27/24 at 11:50 PM, showed LPN #62 and NA #63 going into Resident #6's room to change him. Resident #6's room was under constant observation by a surveyor from 02/27/24 at 11:15 PM to 02/27/24 at 11:50 PM. Assistance and incontinence care was not provided to Resident #6 until 02/27/24 at 11:50 PM. On 02/28/24 at 12:35 AM the Director of Nursing (DON) confirmed residents should not wait that long to be changed and staff should not be turning call lights off and saying I will be back. She further stated, yes, this is neglectful. A record review, on 02/28/24 at 12:15 PM, of Resident #6's care plan found the following: -Focus: I have the Potential for Skin Issues related to incontinence of bowel and bladder, decreased mobility/ability to reposition myself. -Goal: My skin will remain intact without signs of breakdown by next review. -Interventions: Turn and reposition frequently to decrease pressure. Further review of the care plan reads as follows: Focus: I have an ADL self-care performance deficit due to limited mobility. Goal: I will maintain current level of function in all ADL's through the review date. Interventions: Assist resident to bathroom for toileting every 2 hours. Toilet use: I require extensive assistance by staff for toileting. A review of the facilities Abuse and Neglect policy on 02/28/24 at 11:30 AM described Neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional stress. The facility reported these allegations to the proper State authorities on 02/28/24. Employees #62 and NA #63 were suspended from 02/28/24 through 03/05/24. The facility stated they were going to in-service all staff on Resident Rights, Abuse/Neglect, using the care plans, call lights, safe lifting, teamwork, customer service, meals/snacks. At 2:45 PM on 03/06/24 the assistant director of nursing (ADON) confirmed NA #63 had not been in-serviced and NA #63 had worked from 7:00 PM to 7:00 AM on 03/05/24. Further review of the sign in sheets found NA #63 did not sign the acknowledgement of training before returning to work. B) Resident #237 02/27/24 Incident During an unannounced visit to the facility on [DATE] at 11:05 PM, the following observations were made: At 11:08 PM, Resident # 237 was lying in bed with his feet hanging over the right side of the bed touching the floor. His bottom was in the middle of the bed, his head and his upper torso leaning towards the left side of the bed off the pillows. A strong smell of urine appeared to come from the room. Another observation on 02/27/24 at 11:35 PM, showed Resident # 237 continued to be laying in the same position with the sheet now on the floor yelling, [NAME], [NAME] get the car let's go. Another observation on 02/27/24 at 11:53 PM, showed Resident # 237' s feet continued to be on the right side touching the floor. Now his head was hanging over the bed on the left side. Another observation on 02/28/24 at 12:05 AM, showed Resident # 237 was in the same position as before. The smell of bowel movement was present. This was observed by another surveyor as well. At that time, Resident # 237 was pulling the privacy curtain and yelling out. Another observation, on 02/28/24 at 12:08 AM, Resident # 237 was yelling [NAME], [NAME]. Nursing Assistant (NA) #31 walked to another resident's room to tell NA #6 in the room she needed assistance when she was done. An observation on 02/28/24 at 12:09 AM, revealed NA #31 told NA #6, I guess I will see what [Resident # 237] wants but he is not my resident. Another observation on 02/28/24 at 12:10 AM, showed NA #31 entered and exited Resident # 237's room without providing assistance. An observation, on 02/28/24 at 12:11 AM, showed NA #31 went to another resident's room where NA #6 was assisting the resident in that room. NA #31 stated, He needs changed. You can do it when you are done. He is not mine so I am not cleaning him up. An observation on 02/28/24 at 12:15 AM, showed NA #6 was in Resident #237's room assisting him. Resident #237's room was in constant observation by a surveyor from 02/27/24 at 11:08 PM to 02/28/24 at 12:15 AM. Assistance and incontinence care was not provided to the resident until 12:15 AM on 02/28/24, despite the resident yelling for help beginning at 11:08 PM on 02/27/24. During an interview on 02/28/24 at 1:30 AM, the DON stated, Are you kidding me. The nursing staff tells me all of this is being taken care of. They never mention call lights are not being answered. I thought everything was ok. They should not turn off a call light without the need being addressed, if they can't get to it they should leave it on until the resident is changed or whatever they need. And everyone can answer a call light not just the aides. That's not my job or my resident doesn't fly. Sounds to me like a bunch [staff] need to be in the unemployment line. That should have never happened, they should work as a team. He should have never laid there that long without assistance. On 02/28/24 at 1:34 PM, the Corp RN #97 stated, The DON told me there were small issues last night, call lights not answered and late medications. RN #97 was unsure if the incidents with the call lights not answered, and residents being left soiled were reported. She said she would have to look around and see what she could find. DON was unavailable for any further comment at that time and not in the facility. The OHFLAC (Office of Health Facilities Licensure and Certification) 225 Allegation reporting form dated 02/28/24 completed by Social Worker #36. Alleged Victim Name: Resident #237's Name Alleged Perpetrator Name: name of Nurse Aide (NA) #31 Position/title: Certified Nsg (nursing) Assistant Date of Incident: 02/27/24 Time of Incident: Night Shift Location of Incident: room [ROOM NUMBER]-1 Brief Description of the Incident: Allegation was received that (Resident #237's) name was waiting for an extended period of time for his call light to be answered for incontinence care. The 5 five day follow up determination on Resident #237 was completed and faxed to the state agencies on 03/05/24. c) Resident #237 03/03/24 incident On 03/03/24 at 11:00 PM, an unannounced visit was made to the facility. During an observation on 03/03/24 at 11:05 PM, Resident # 237 was resting in bed with a pillow under his legs. During an observation on 03/03/24 at 11:35 PM, Resident # 237 ' s legs were hanging over the right side of the bed. Observation on 03/03/24 at 11:38 PM, Resident # 237 was yelling Hello. His head was now almost to the middle of the bed, and his feet continued to be on the floor. The following further observations were made: 03/03/04 at 11:41 PM, LPN #28 walked by Resident # 237 room. 03/03/24 at 11:44 PM, Resident #237 was yelling Help in here. 03/03/24 at 11:45 PM, Corporate nurse #97 was going from room to room. 03/03/34 at 11:47 PM, LPN #28 walked by resident's room again. 03/03/24 at 11:53 PM, NA #57 walked by Resident # 237's looking into his room. 03/03/24 at 11:56 PM, Resident # 237 yelling Help in here Hello, Help. 03/03/24 at 11:59 PM, Resident # 237 yelling Hello Corporate's Nurse #97 stated to Resident # 237 Hang on, let me get someone. 03/04/24 at 12:04 AM, Corporate RN #97 stating Did that fix it? [Resident # 237] pulled the call light halfway out of the wall, that is where the emergency light was coming from. During an interview on 03/04/24 at 1:34 PM, the DON and SW were informed of the incidents occurring on 03/03/24. During an interview on 03/05/24 at 11:30 AM, the Corporate Nurse #97 stated I will watch the cameras to see if I feel a report needs to be filed. During an interview on 03/05/24 at 2:35 PM, the ADON stated they do not feel a report needs to be done. On 03/06/24 at 5:47 PM, social worker #237 gave this report to the surveyor. The OHFLAC (Office of Health Facilities Licensure and Certification) 225 Allegation reporting form dated 03/05/24 completed by Social Worker # 36. Alleged Victim Name: Resident #237 ' s Name Alleged Perpetrator Name: Unknown Date of Incident: 03/04/24 Night Shift Time of Incident: Night Shift Location of Incident: Name of the Nursing Home Facilities Brief Description of the Incident: Surveyor alleged on 03/04/24 that Resident #237 ' s name was neglected with delayed response time in addressing his needs during night shift 03/03/24 into 03/04/24. The 5 five day follow up determination on Resident #237 was not completed upon exiting the facility on 03/11/24. Two (2) surveyors on 03/05/24 at 7:39 PM, Resident # 237 stated This is the best day since I have been here. I have not slept in four (4) days and I slept well last night, sleeping like a baby. I ate everything today, my dinner was good. I think I was admitted on Friday but I was so out of it, I am not really sure. Resident # 237 was asked, do you need assistance with the bathroom? Resident # 237 stated they make me use the call light when i need to use the bathroom, but they take so long to get here I pee myself. The other night I laid in pee all night. The DON was made aware of the above interview with Resident #237. d) Resident #331 On 02/27/24 at 11:54 PM Resident #331 was witnessed by a Surveyor falling out of his wheelchair in the hallway near the nurse's station on the south side. Resident scooted to the edge of his wheelchair, and leaned forward and fell out onto the floor. The Resident landed on his right side with his head against the wall. The Resident's right leg and arm were pinned under him. Resident was laying across the leg of the floor stand blood pressure monitor. Resident was yelling Oh, Oh, Oh damn. RN #55 came up the hallway and asked the resident if he was ok? RN #55 pulled up the sweatshirt sleeve of his right arm and said. I don't see anything; you did hit hard I bet that hurt. RN #55 was then joined by CNA #31 and they proceeded to try to lift the resident back into the wheelchair by grabbing his pants and reaching under his arms. RN #55 lifted under the right arm and CNA # 31 lifted under the left arm and they both grabbed the back of the resident's pants. After the third try with the wheelchair sliding backwards, RN #55 and CNA #31 tossed the resident back into the wheelchair. Resident #331 continued to yell, Oh. Oh, Oh damn it the entire time. RN #55 said, Yea he's heavy! RN #55 then reported to the Surveyor, Don't worry, he is care planned for falls, he slides out of his chair all the time. Once resident was back in chair at 12:00 AM, RN #55 attempted to take residents blood pressure and stated, This don't seem to be working right, but I think he's ok. Resident #331 was wearing an AAA (hinged) knee brace in place on his left lower extremity and was non weight bearing to left lower extremity at the time of the fall. The Resident was wearing regular socks at the time of the incident. Record review of care plan found an intervention of mechanical lift with two person assist for all transfers, resident was unable to bear weight with the right foot was not initiated until 02/28/2024. Record review showed no progress note to indicate the Power of Attorney (POA) was notified of the fall. On 02/28/24 at 10:50 AM, the Incident report for the fall (which occurred 02/27/24 at 11;54 PM) was requested from Corp RN #97. The report was given for a fall that happened on 02/27/24 during the day shift. Corporate RN #97 stated, Oh sorry about that I am sure they done one if not I will have them to do a late entry. Record review showed a radiology report dated 02/24/28 indicated Resident #331 had fractured right clavicle and slightly displaced fracture at the distal clavicle age indeterminate. Results for bilateral hips and pelvis showed a postoperative change at the right hip with a pin and side plate in place. Mild arthritic changes in both hip joints. Review of incident report dated 02/27/24 at 11:30 PM for a fall that occurred on 02/27/24 at 11:54 PM, completed by the Director of Nursing (DON). The DON was asked how she completed the incident when she wasn't there to witness the fall. The DON stated, The other nurse started it and never finished it. I thought I was already here at that time. If the time is wrong its because I redone it. You are right I never witnessed the fall. -The incident description stated (typed as written), resident fell out of wheelchair outside of his room near the Rosies that were plugged into the wall. This RN witnessed the fall from down the hallway. -The incident reports' immediate action taken stated, (typed as written), Before putting him [resident #331] back into the wheelchair this RN [#55] did a full body assessment checking for injuries. Resident stated that he banged his elbow, assessment of elbow was done including visual assessment and full ROM [range of motion] to right hand and right shoulder. After confirming there were no injuries, the resident was assisted by myself and CNA to his wheelchair. During a phone interview on 03/05/24 at 1:50 PM Resident #331's Power of Attorney (POA) stated, I don't think they are calling me every time he is falling. He falls so much. I can tell you they did not call me Tuesday night (02/27/24) when he fell around midnight. They called me Tuesday on the 27th (02/27/24) during the evening sometime to tell me he fell that day. The POA further stated that when he was admitted they promised her he would be close to the nurses station and when she got there he could not have been further away. She made them move him closer and would not leave until they put some fall mats down for him. The POA stated, I am physical therapist myself; they are not transferring him right either. He is not supposed to be bearing weight on that one leg and they just drag him around everywhere. I don't know why they don't use a lift. On 03/04/24 at 3:04 PM the Assistant Director of Nursing (ADON) verified a mechanical lift should have been used to pick the resident up off the floor when he fell from the wheelchair on 02/27/24. The ADON stated, Especially since [resident #331 name] is unable to put any weight on his leg and wearing that brace. e) Resident 331 During a tour of the facility, on 03/11/24 at 01:27 PM, Resident #331 was observed to be lying on the floor on his left side and his wheelchair was laying over on its side directly behind him. Three staff members were observed to be standing around him and they all three lifted him by his upper body and simultaneously picked the wheelchair upright and sat him in it. During an interview with the Licensed Practical Nurse Unit Manager (LPN-UM) #30, she stated that the facility was not a no lift facility, and they can pick him up if he is safe. Staff identified to assist LPN-UM #30 physically picking up the resident and the chair are LPN # 64 and Certified Nursing Assistant (CNA) #99. 03/11/24 02:17 PM During an interview with Assistant Director of Nursing (ADON) #42, he stated that he had completed the resident's assessment himself and Resident #331 was a total lift. He further stated that LPN-UM #30 had been educated on this previously and a lift should have been used with this fall. The residents ELC Lift Transfer Reposition Evaluation dated 03/06/24, physicians order dated 03/06/24 and care plan with the total lift intervention revision dated 03/07/24 that identified the resident being a total lift was provided by the ADON at this time. f) Plan of Correction (POC) HOW WILLL CORRECTIVE ACTIONS BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO BE AFFECTED BY THE DEFICIENT PRACTICE? The allegation of neglect was reported by state surveyor to VPCO and ADON on 2/28/24. The allegation was reported to the state survey office, APS and Ombudsman, by Social Worker on 2/28/24. A thorough investigation was initiated. Resident # 237 A skin assessment was completed on 2/28/24 by a nurse. A trauma assessment was completed 3/1/24 by Social worker. Resident # 6 A skin assessment was completed on 2/28/24 by ADON. A trauma assessment was completed on 3/1/24 by the Social Worker. Resident # 237 was assessed on 2/28/24 by social worker, with no concerns noted. A thorough investigation was initiated on 2/28/24 and completed on 3/4/24 by social worker. Resident # 6 was assessed on 2/28/24 by social worker, with no concerns noted. A thorough investigation was initiated on 2/28/24 and completed on 3/4/24 by social worker. HOW WILL THE FACILITY IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTIONS WILL BE TAKEN TO PREVENT REOCCURENCE? Current residents have been assessed for any signs and symptoms of abuse/neglect. Those residents with BIMs >8 were interviewed by the management team for any abuse/neglect concerns 2/28/24 through 3/1/24. Those residents with BIMs < 8 were physically assessed by the nursing supervisors for any signs and symptoms of abuse/neglect on 2/29/24. Abuse/neglect assessments, interviews and questionnaires were reviewed by the Administrator on 3/1/24 for any indications of abuse/neglect concerns. There were 5 concerns voiced during the interviews and were addressed at time of concern. Grievances/concerns were reviewed for the last 60 days with no trends noted by social worker and Administrator on 3/6/24. WHAT MEASURES WILL BE PUT IN PLACE OR SYSTEMATIC CHANGES MADE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT REOCCUR? All staff will be re-educated on abuse/neglect starting on 3/6/24 and completed by 3/7/24 by the ADON or designee. This training was performed to facilitate discussion and question and include examples. Staff who were unable to attend will be provided with the education prior to working their next scheduled shift. Any new staff will be educated upon hire prior to providing patient care. Agency staff will be educated prior to working their next scheduled shift. 5 Call light audits will be conducted per shift by DON or designee daily x 30 days. 5 residents will be interviewed per day by DON or designee daily x 30 days for care concerns/allegations of neglect. Observations for resident needs will be conducted of 5 residents on day shift and 5 residents on night shift daily x 30 days. The results of these audits will be reviewed through the QAPI committee weekly. A nurse from the regional team or corporate office has been onsite or available by phone since 2/26/24 and will follow up with facility daily for 2 weeks, then daily M-F for 2 weeks. The nurses from the regional team or home office assist with investigations, observing staff treatment of residents, performing chart audits and providing oversight and consultation. 49650 c2) Resident 331 During a tour of the facility on 03/11/24 at 01:27 PM, Resident #331 was observed to be lying on the floor on his left side and his wheelchair was laying over on its side directly behind him. Three staff members were observed to be standing around him and they all three lifted him by his upper body and simultaneously picked the wheelchair upright and sat him in it. During an interview with the Licensed Practical Nurse Unit Manager (LPN-UM) #30, she stated that the facility was not a no lift facility, and they can pick him up if he is safe. Staff identified to assist LPN-UM #30 physically picking up the resident and the chair are LPN # 64 and Certified Nursing Assistant (CNA) #99. 03/11/24 02:17 PM During an interview with Assistant Director of Nursing (ADON) #42, he stated that he had completed the resident's assessment himself and Resident #331 was a total lift. He further stated that LPN-UM #30 had been educated on this previously and a lift should have been used with this fall. The residents ELC Lift Transfer Reposition Evaluation dated 03/06/24, physicians order dated 03/06/24 and care plan with the total lift intervention revision dated 03/07/24 that identified the resident being a total lift was provided by the ADON at this time.

45174 .Based on observation, resident interview, record review, and staff interview the facility failed to ensure potential allegations of neglect were thoroughly investigated and failed to provide a corrective action for an allegation that did happen prior to letting the Nursing Assistant (NA) #63 return to work. This placed resident #6 and #237 in an immediate jeopardy situation by not thoroughly investigating allegations of neglect, and letting the alleged perpetrator return to work without the required Abuse and Neglect training. This deficient practice had the potential to affect all residents currently residing in the facility and was a random opportunity for discovery. In addition, the facility failed to maintain accurate records and investigate medication distribution for controlled substances for Resident #64, and #65. This deficient practice had the potential to affect all residents currently residing in the facility and was a random opportunity for discovery. The state agency determined these failures caused Resident #6 and #237 to suffer psychosocial harm because of the allegation of neglect not being thoroughly investigated. The facility allowed NA #63 to return to work without having The Abuse and Neglect training, and by not interviewing the day shift, which was the next following shift. Not only did these failures harm Residents #6 and #237, but they also placed them and the remaining 80 residents at risk for serious harm because the alleged perpetrator was not given the proper training prior to her return to work, and the allegation was not thoroughly investigated. This placed all 82 residents in an immediate jeopardy (IJ) situation. The facility was first notified of the IJ at 4:24 PM, on 03/06/24. The state agency (SA) received the Plan of Correction (POC) at 8:45 PM on 03/06/24. The SA accepted the POC on 03/06/24 at 9:00 PM. The SA observed for the implementation of the POC and the IJ was abated on 03/11/24 at 2:30 PM. Once the Immediate Jeopardy was abated a deficient practice did remain for Resident #64 and #65. Therefore, the scope and severity were decreased from a L to a F. Resident identifiers #6, #237 #64 and #65. Facility census 82. a) Resident #6 Upon an unannounced entrance to the facility on [DATE] at 11:08 PM, staff member Licensed Practical Nurse (LPN) #62 and Nursing Assistant (NA) #63 were observed sitting in the room labeled Conference room with their feet propped up in a chair looking at their cell phones. An observation on 02/27/24 at 11:10 PM, of the North Nurse's station revealed that 6 call lights were going off, according to the call light board on the wall. An observation on 02/27/24 at 11:15 PM, of North 2 (two) hall revealed the following: - At 11:15 PM Resident #6's call light came on. - At 11:30 PM NA #63 went into Resident #6's room, and his light went off. NA #63 came out of room at 11:31. -At 11:33 PM Resident #6 ' s light came back on. During an interview on 02/27/24 at 11:34 PM, Resident # 6 stated, I just want changed. They came in and turned my light off and told me they would be back. I just want to get dry and go to sleep. I am sick of this. Observation on 02/27/24 at 11:40 PM, of North Nurses station showed NA# 63, NA#65, LPN #63, and LPN #43 at the nursing station. Nobody appeared to be paying any attention to the light going off in resident # 6's room. Observation on 02/27/24 at 11:44 PM, of North Nurses station surveyor heard LPN # 40 announce, I am going on my 15-minute break, because I am supposed to get it. I will set my watch. Resident #6's call light continued to go off. Further observation at 11:47 PM, showed LPN #62 going in Resident #6's room and immediately walked back out. The call light was turned off. She then stated, He is a 2 person assist, I got to wait on help. An observation on 02/27/24 at 11:50 PM, showed LPN #62 and NA #63 going into Resident #6's room to change him. Resident #6's room was under constant observation by a surveyor from 02/27/24 at 11:10 PM to 02/27/24 at 11:50 PM. Assistance and incontinence care was not provided to Resident #6 until 02/27/24 at 11:50 PM. An interview with the Director of Nursing (DON) on 02/28/24 at 12:35 AM she confirmed the residents should not wait that long to be changed and staff should not be turning call lights off and saying I will be back. She further confirmed that yes this is neglectful. A review of the facilities Abuse and Neglect policy on 02/28/24 at 11:30 AM describes Neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional stress. A record review on 02/28/24 at 12:15 PM, of Resident #6 ' s care plan reads as follows: -Focus: I have the Potential for Skin Issues related to incontinence of bowel and bladder, decreased mobility/ability to reposition myself. -Goal: My skin will remain intact without signs of breakdown by next review. -Interventions: Turn and reposition frequently to decrease pressure. Further review of the care plan reads as follows: Focus: I have an ADL self-care performance deficit due to limited mobility. Goal: I will maintain current level of function in all ADL ' s through the review date. Interventions: Assist resident to bathroom for toileting every 2 hours. Toilet use: I require extensive assistance by staff for toileting. b) Resident #237 02/27/24 Incident During an unannounced visit to the facility on [DATE] at 11:05 PM, the following observations were made: At 11:08 PM, Resident # 237 was lying in bed with his feet hanging over the right side of the bed touching the floor. His bottom was in the middle of the bed, his head and his upper torso leaning towards the left side of the bed off the pillows. A strong smell of urine appeared to come from the room. Another observation on 02/27/24 at 11:35 PM, showed Resident # 237 continued to be laying in the same position with the sheet now on the floor yelling, [NAME], [NAME] get the car let's go. Another observation on 02/27/24 at 11:53 PM, showed Resident # 237' s feet continued to be on the right side touching the floor. Now his head was hanging over the bed on the left side. Another observation on 02/28/24 at 12:05 AM, showed Resident # 237 was in the same position as before. The smell of bowel movement was present. This was observed by another surveyor as well. At that time, Resident # 237 was pulling the privacy curtain and yelling out. Another observation on 02/28/24 at 12:08 AM, Resident # 237 was yelling [NAME], [NAME]. Nursing Assistant (NA) #31 walked to another resident's room to tell the NA #6 in the room she needed assistance when she was done. An observation on 02/28/24 at 12:09 AM, revealed NA #31 told NA #6, I guess I will see what [Resident # 237] wants but he is not my resident. Another observation on 02/28/24 at 12:10 AM, showed NA #31 entered and exited Resident # 237's room without providing assistance. An observation on 02/28/24 at 12:11 AM, showed NA #31 went to another resident's room where NA #6 was assisting the resident in that room. NA #31 stated, He needs changed. You can do it when you are done. He is not mine, so I am not cleaning him up. An observation on 02/28/24 at 12:15 AM, showed NA #6 was in Resident #237's room assisting him. Resident #237's room was in constant observation by a surveyor from 02/27/24 at 11:08 PM to 02/28/24 at 12:15 AM. Assistance and incontinence care was not provided to the resident until 12:15 on 02/28/24, despite the resident beginning to yell for help at 11:08 PM on 02/27/24. During an interview on 02/28/24 at 1:30 AM, the DON stated, Are you kidding me. The nursing staff tells me all of this is being taken care of. They never mention call lights are not being answered. I thought everything was ok. They should not turn off a call light without the need being addressed, if they can't get to it they should leave it on until the resident is changed or whatever they need. And everyone can answer a call light not just the aides. That's not my job or my resident doesn't fly. Sounds to me like a bunch [staff] need to be on the unemployment line. That should have never happened, they should work as a team. He should have never laid there that long without assistance. On 02/28/24 at 1:34 PM, the Corp RN #97 stated, The DON told me there were small issues last night, call lights not answered and late medications. RN #97 was unsure if the incidents with the call lights not answered, and residents being left soiled were reported. She said she would have to look around and see what she could find. DON was unavailable for any further comment at that time and not in the facility. The OHFLAC (Office of Health Facilities Licensure and Certification) 225 Allegation reporting form dated 02/28/24 completed by Social Worker # 36. Alleged Victim Name: Resident #237 ' s Name Alleged Perpetrator Name: Nurse Aide (NA) #31 Position/title: Certified Nursing Assistant Date of Incident: 02/27/24 Time of Incident: Night Shift Location of Incident: room [ROOM NUMBER]-1 Brief Description of the Incident: Allegation was received that Resident #237's name was waiting for an extended period for his call light to be answered for incontinence care. The 5 five day follow up determination on Resident #237 was completed and faxed to the state agencies on 03/05/24. c) Resident #237 03/03/24 incident On 03/03/24 at 11:00 PM, an unannounced visit was made to the facility. During an observation on 03/03/24 at 11:05 PM, Resident # 237 was resting in bed with a pillow under his legs. During an observation on 03/03/24 at 11:35 PM, Resident # 237's legs were hanging over the right side of the bed. Observation on 03/03/24 at 11:38 PM, Resident # 237 was yelling Hello. His head was now almost to the middle of the bed, and his feet continued to be on the floor. The following further observations were made: 03/03/04 at 11:41 PM, LPN #28 walked by Resident # 237 room. 03/03/24 at 11:44 PM, Resident #237 was yelling Help in here. 03/03/24 at 11:45 PM, Corporate nurse #97 was going from room to room. 03/03/34 at 11:47 PM, LPN #28 walked by resident's room again. 03/03/24 at 11:53 PM, NA #57 walked by Resident # 237's looking into his room. 03/03/24 at 11:56 PM, Resident # 237 yelling Help in here Hello, Help. 03/03/24 at 11:59 PM, Resident # 237 yelling Hello Corporate's Nurse #97 stated to Resident # 237 Hang on, let me get someone. 03/04/24 at 12:04 AM, Corporate RN #97 stating Did that fix it? [Resident # 237] pulled the call light halfway out of the wall, that is where the emergency light was coming from. During an interview on 03/04/24 at 1:34 PM, DON and SW were informed of the incidents occurring on 03/03/24. During an interview on 03/05/24 at 11:30 AM, the Corporate Nurse #97 stated I will watch the cameras to see if I feel a report needs to be filed. During an interview on 03/05/24 at 2:35 PM, the ADON stated they do not feel a report needs to be done. On 03/06/24 at 5:47 PM, social worker #237 gave this report to the surveyor. The OHFLAC (Office of Health Facilities Licensure and Certification) 225 Allegation reporting form dated 03/05/24 completed by Social Worker # 36. Alleged Victim Name: Resident #237 ' s Name Alleged Perpetrator Name: Unknown Date of Incident: 03/04/24 Night Shift Time of Incident: Night Shift Location of Incident: Name of the Nursing Home Facilities Brief Description of the Incident: Surveyor alleged on 03/04/24 that Resident #237 ' s name was neglected with delayed response time in addressing his needs during night shift 03/03/24 into 03/04/24. The 5 five day follow up determination on Resident #237 was not completed upon exiting the facility on 03/11/24. Two (2) surveyors on 03/05/24 at 7:39 PM, Resident # 237 stated This is the best day since I have been here. I have not slept in four (4) days and I slept well last night, sleeping like a baby. I ate everything today, my dinner was good. I think I was admitted on Friday but I was so out of it, I am not really sure. Resident # 237 was asked, do you need assistance with the bathroom? Resident # 237 stated they make me use the call light when I need to use the bathroom, but they take so long to get here I pee myself. The other night I laid in pee all night. The DON was made aware of the above interview with Resident #237. d) Interview wit Nurse Aide (NA) #49 On 02/28/24 at 12:07 PM, NA #49 asked to speak to surveyors in private. NA #49 stated, I guess the best way I can put it is this place is awful and residents are being neglected. NA #49 stated this morning Resident #237 and Resident #6 were brown ringed, meaning the residents ' urine had seeped out of the adult briefs, leaving brown stains on the sheets. NA #49 stated, It happens all the time. Resident #237 brief was so saturated with urine it started to disintegrate. We have taken this issue to Human Resources (HR), and we are not on good terms and nothing is being done. Administration is stressing on us now to get showers done because the state is here, but any other time they do not care. CNA #49 informed surveyor that she relieved NA #63 and CNA #57 this morning and was not sure which one or if both were assigned to the residents left wet. CNA #57 stated she told the ADON this morning what shape she found Resident #237 and Resident #6 very saturated with urine. e) Facility investigation for Resident #6 and #237 A review of the investigation on 03/06/24 at 9:00 AM, revealed that the Allegation was unsubstantiated. No day shift staff, which was the staff that followed the shift, that was accused of the allegation, had been interviewed. The facility reported these allegations to the proper State authorities on 02/28/24. Employees #62 and NA #63 were suspended from 02/28/24 through 03/05/24.The facility stated they were going to in service all staff on Resident Rights, Abuse/Neglect, using the care plans, call lights, safe lifting, teamwork, customer service, meals/snacks. At 2:45 PM on 03/06/24 the assistant director of nursing (ADON) confirmed NA #63 had not been in-serviced and NA #63 had worked from 7:00 PM to 7:00 AM on 03/05/24. Further review of the sign in sheets found NA #63 did not sign the acknowledgement of training before returning to work. f) Morgantown Health and Rehabilitation Place of Correction (POC). Typed as written: HOW WILL CORRECTIVE ACTIONS BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO BE AFFECTED BY DEFICIENT PRACTICE? 1. The allegation of neglect was reported by state surveyor to VPCO and ADON on 2/28/24. The allegation was reported to the state survey office, APS and Ombudsman, by Social Worker on 2/28/24. A thorough investigation was initiated. Resident # 237 1. A skin assessment was completed on 2/28/24 by a nurse. 2. A trauma assessment was completed 3/1/24 by Social worker. Resident # 6 1. A skin assessment was completed on 2/28/24 by ADON 2. A trauma assessment was completed on 3/1/24 by the Social Worker. Resident # 237 was assessed on 2/28/24 by social worker, with no concerns noted. A thorough investigation was initiated on 2/28/24 and completed on 3/4/24 by social worker. Resident # 6 was assessed on 2/28/24 by social worker, with no concerns noted. A thorough investigation was initiated on 2/28/24 and completed on 3/4/24 by social worker. HOW WILL THE FACILITY IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTIONS WILL BE TAKEN TO PREVENT REOCCURENCE? 2. Current residents have been assessed for any signs and symptoms of abuse/neglect. Those residents with BIMs above 8 were interviewed by the management team for any abuse/neglect concerns 2/28/24 through 3/1/24. Those residents with BIMs below 8 were physically assessed by the nursing supervisors for any signs and symptoms of abuse/neglect on 2/29/24. Abuse/neglect assessments, interviews and questionnaires were reviewed by the Administrator on 3/1/24 for any indications of abuse/neglect concerns. There were 5 concerns voiced during the interviews and were addressed at time of concern. 3. Grievances/concerns were reviewed for the last 60 days with no trends noted by social worker and Administrator on 3/6/24. WHAT MEASURES WILL BE PUT IN PLACE OR SYSTEMATIC CHANGES MADE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT REOCCUR? 4. [NAME] President of Clinical Operations will educate Administrator, DON, ADON, and Social Services on conducting a thorough to include interviewing all potential witnesses. investigation by 3/7/24. 5. All potential witnesses will be interviewed to identify any further potential allegations of abuse or neglect by 3/7/24. 6. All staff will be re- educated on abuse/neglect starting on 3/6/24 and completed by 3/7/24 by the ADON. to facilitate discussion and question and include examples. Staff who were unable to attend will be provided with education prior to working their next scheduled shift. Any new staff will be educated upon hire prior to providing patient care. Agency staff will be educated prior to working their next scheduled shift. 7. 5 Call light audits will be conducted per shift by DON or designee daily x 30 days. 5 residents will be interviewed per day by DON or designee daily x 30 days for care concerns/allegations of neglect. Observations for resident needs will be conducted of 5 residents on day shift and 5 residents on night shift daily x 30 days. The results of these audits will be reviewed through the QAPI committee weekly. 8. A nurse from the regional team or corporate office has been onsite or available by phone since 2/26/24 and will follow up with facility daily for 2 weeks, then daily M-F for 2 weeks. The nurses from the regional team or home office are assisting with investigations, observing staff treatment of residents and providing oversight and consultation. g) Resident #64 On 02/26/24 at 3:35 PM Resident #64 stated he is not getting the right meds. Resident said about a week ago on a Sunday (02/18/24) he got the wrong blue pill for pain. Resident produced pictures from his iPhone of the pill he was given and the right medication lying beside it. Resident stated he looked it up and the medicine he was given was Finasteride, that he wasn't even prescribed to take. (Finasteride is used to shrink an enlarged prostate in adult men by decreasing the amount of a natural body hormone). The incorrect blue tablet had F5 stamped on the pill and the Resident knew it wasn't right. The Resident should have gotten morphine sulphate. The resident said the staff brings his medicine and leaves it set for him to take when he is ready overnight. Resident stated he has gotten the wrong medication for pain twice. On 02/28/24 at 10:00 AM Resident stated it was the Sunday before Presidents' Day that he got the wrong medication. He was going to tell the Director of Nursing (DON) on Monday, but she was off for the holiday. Resident stated he showed the picture on his phone of the medications (blue pills) to the DON the Tuesday (02/20/24) of the week and told her what happened. Resident #64 stated, I feel like I need to be an advocate for these people. I am not your typical nursing home resident. I know my mediations and pay attention to what I get, some of these people can't speak for themselves. If it is happening to me, it is happening to others here. Record review showed Resident #64 has the capacity to make medical decisions. Record review showed an order for MS (Morphine Sulphate) Contin Oral Tablet Extended Release 15 mg. Give 15 mg by mouth two times a day for Pain. Start Date 09/09/2023. On 03/04/24 at 4:00 PM the DON stated, Yea he told me about getting the wrong med and I thought the nurse that gave it told me it was Nifedipine (Nifedipine extended-release tablet 60 MG) that he gets. I never went and looked. On 03/04/24 Licensed Practical Nurse (LPN) #101 reviewed mediations in cart and found no blue pills to match the description of the pill he got. Nifedipine that was prescribed to the resident just pulled out of drawer and reviewed. The Nifedipine tablet was brown/tan in color. The DON stated, Well it couldn't have been that then. On 03/05/24 at 9:52 AM the DON stated, You are right, I was off president's day just like he [Resident #64] said I was. He gave me the pill, but I didn't look it up, he said he already researched it. The DON further stated, It may have been a reportable, I will have to let you. Record review shows a reportable completed on 03/05/24 for Resident #64 for the alleged incident on 02/18/22. The reportable stated, State surveyor reported misappropriation of medication. Date of incident 02/18/24. During an interview on 03/06/24 at 4:07 PM Corporate Registered Nurse (CRN) #97 stated, He [Resident #64] didn't take the wrong pill so it technically wasn't a medication error and so it didn't hurt because he didn't take it. When we talked to her [RN # 55] she said they were correct. He said he got his morphine so there was no cause for concern. No misappropriation of funds to begin with. h) Resident #65 On 02/27/24 9:45 AM, LPN #64 stated We got a problem here with controlled substances coming up missing. The DON knows about it . This is my license. See here, this hydromorphone for [Resident #65's name] was signed out and he wasn't even taking it. LPN #64 showed surveyor the controlled substance sign-out book for Resident #65 where Registered Nurse (RN) #55 signed out the pain medication on 02/08/24. LPN #64 then stated, I clean out the med cart at the end of my shift and only leave enough pain meds for the night. That's what I was told to do. Record review shows and order for Hydromorphone HCl Oral Tablet 2 MG (Hydromorphone HCl). Give1 tablet by mouth every 24 hours as needed for pain control. Order was discontinued on 10/17/23. Review of the controlled substance sign-out long showed RN #55 signed out one (1) Hydromorphone 2mg tablet on 02/08/24 at 11:00 PM. No documentation of where the hydromorphone was administered to the Resident. On 03/04/24 at 4:15 PM the DON stated, Now that does spark my interest. CRN #97 stated, How did she sign it out and administer it if the was no order was discontinued? DON stated, I done a med error on it, she said he needed something for pain and that was the first thing she saw and pulled it out and gave it. Record review shows no pain medication to documented as given on 02/08/24 at 11:00 PM. On 03/05/24 at 9:31 AM no reportable or investigation was found to have been done. The DON said this wasn't a reportable issue. On 03/05/24 at 9:52 AM DON stated they are still investigating what the Surveyor has brought to their attention and it may end up being reportable. DON stated, I told you I didn't know about this, but I guess I did. When they gave me the mediations to destroy last week the nurse told me I may want to take a look at that this one, a pill was missing. Record review of the Controlled substance destruction log showed Hydromorphone 2 tabs were destroyed on 02/29/24 by the DON and pharmacist. At that time DON was made aware of the missing hydromorphone tablet by nursing staff. On 03/05/24 at 11:30 AM the DON presented a form titled Employee Warning form and stated she had filled this report out for RN #63 due to Resident #65's mediation error. The reason for the written warning was Mediation was given without an order. No follow up completed. All medications given must have an order and all PRN meds must have a follow up to verify effectiveness. Always follow the 5 rights of medications Administration. The DON clarified the form was originally completed for resident #65 but could be used for both Resident #64 and #65 since they both involved pain pills. The form was signed by the DON on 02/22/24, by the Administrator on 03/04/24, by RN #63 on 02/22/24. Record review shows a reportable completed on 03/05/24 for Resident #64 for the alleged incident on 02/18/22. The reportable stated, State surveyor reported misappropriation of medication. Date of incident 02/08/24. During an interview on 03/06/24 at 4:07 PM Corporate Registered Nurse (CRN) #97 stated, We went ahead and reported [Resident #65 name] missing hydromorphone pill as misappropriation of property since we done [Resident #64's] since we don't know what was done with the hydromorphone that was signed out. 49465

Based on record review, resident and staff interview, and observation the facility failed to ensure pain management was provided in accordance with professional standards of practice for two (2) of seven (7) residents reviewed for pain. Resident #331 was not provided pain medication after continued presentation of pain. Resident #181 was not provided with adequate pain medication for pain control or prior to physical therapy to allow adequate participation. This failed practice resulted in Resident #331 and Resident #181 suffering actual harm becuase thier pain was not assessed and/or treated timely resulting in the pain lasting longer than needed. This failed practice had the potential to affect only a limited number of residents. Resident identifiers: #331, #181. Facility census: 82. Findings include: a) Resident #331 Upon entrance at 11:05 PM on 02/27/24, Resident #331 was in wheelchair following Registered Nurse (RN) #55 around in the hallway while she passed medications. Resident #331 was grimacing, extending his right leg and writhing in his wheelchair. RN #55 was asked if Resident had anything ordered for pain and she stated, He has a muscle relaxer due that should help. Record review showed Methocarbamol Oral Tablet 500 MG tablet to be used for muscle spasms was given 2/27/24 at 11:40 PM. No pain medication was ordered or administered. On 02/27/24 at 11:54 PM, Resident #331 was witnessed by Surveyor falling out of his wheelchair in the hallway near the nurse's station on south side. Resident scooted to edge of his wheelchair, and leaned forward and fell out onto the floor. Resident landed on his right side with his head against the wall. The Resident's right leg and arm were pinned under him. Resident was laying across the leg of the floor stand blood pressure monitor. Resident was yelling Oh, Oh, Oh damn. RN #55 came up the hallway and asked the resident if he was ok? RN #55 pulled up the sweatshirt sleeve of his right arm and said. I don't see anything; you did hit hard I bet that hurt. RN #55 was then joined by CNA #31 and they proceeded to try to lift the resident back into the wheelchair by grabbing his pants and reaching under his arms. RN #55 lifted under the right arm and CNA # 31 lifted under the left arm and they both grabbed the back of the resident's pants. After the third try with the wheelchair sliding backwards, RN #55 and CNA #31 tossed the resident back into the wheelchair. Resident #331 continued to yell, Oh. Oh, Oh damn it the entire time. RN #55 said, Yea he's heavy! RN #55 then reported to the Surveyor, Don't worry, he is care planned for falls, he slides out of his chair all the time. Once resident was back in chair at 12:00 AM, RN #331 attempted to take residents BP and stated, This don't seem to be working right, but I think he's ok. Resident #331 was wearing a AAA (hinged) knee brace in place on his left lower extremity and was non weight bearing to left lower extremity at the time of the fall. The Resident was wearing regular socks at the time of the incident. On 03/03/24 at 11:07 PM Resident #331 was heard yelling from his room. Oh, oh, help. Resident was observed laying cross ways in the bed writhing and flinging his legs. The resident was grabbing at his right leg hip area and legs were twitching. Certified Nursing Assistant (CNA) #9 went into the Resident's room and came back out and told LPN #40, He's in pain. LPN #40 stated to surveyor, He's been repositioned for pain. At 11:30 PM, LPN #40 stated I guess I'll get him an order for pain. An order was added for Tylenol Oral Tablet 325 MG, give 650mg for pain every 6 hours PRN . At 11:37 PM Tylenol was given for pain. On 03/05/24 at 4:30 PM Resident was observed setting at nurses station grimmacing and rubbing his leg. Resident was asked if he was hurting? The Resident stated, I hurt all the damn time. LPN #64 stated, Yea I just called the doctor and got him some Tramadol (pain medication), I was tired of watching him thrash around. Record review showed physicains orders for: Tylenol Oral Tablet 325 MG (Acetaminophen) Give 650 mg by mouth every 6 hours as needed for pain. Start Date 03/03/2024 at 11:30 PM. Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours for Pain Management. Start Date 03/05/2024 at 6:00 PM. b) Resident #181 During an interview on 02/27/24 at 1:00 PM, Resident # 181 stated, I hurt all the time, I feel like I need a different pain medicine or something. An observation on 03/05/24 at 3:32 PM, showed Resident #181 in the hallway rocking in her wheelchair back and forth saying, I want a pain pill. Further observation at 3:32 PM, showed the Assistant Director of Nursing (ADON) walking by and telling her the nurse would be there in a minute to give her a pain pill. An observation at 03/05/24 at 4:00 PM, showed that Resident #181 was taken to therapy. During an interview on 03/05/24 at 4:14 PM, with the Registered Nurse Unit Manager (RNUM), she stated, I am doing her finger stick. A record review on 03/05/24 at 4:16 PM, of Resident #181's Medication Administration Record (MAR) revealed that residents documented pain was 10 and was given a PRN order of oxycodone 15 milligrams. An interview on 03/05/24 at 4:33 PM, with Physical Therapy Assistant (PTA) # 100, she stated, (Resident #181 name) did not say she was in pain, but she was moaning. So it's really hard to tell. An interview and observation on 03/05/24 at 5:05 PM, with Resident #181, showed resident sitting on the edge of her bed doubled over. She stated, I don't even feel like I have had pain medicine. An observation on 03/05/24 at 5:24 PM, of Resident #181, she continues to sit on the edge of her bed with her head in her lap. A record review on 03/05/24 at 5:28 PM, of Resident #181's MAR, shows that she has not been assessed to see if the pain medicine was effective. Further record review of Resident #181's Minimum Data Set (MDS), Section F, Question JO520 is marked that the resident occasionally has pain that interferes with therapy activities. A review on 03/06/24 at 10:00 AM, of the facilities policy titled Administering Pain Medications under general guidelines number (5) five reads: Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after onset and reassessed as indicated until relief is obtained. An interview on 03/06/24 at 10:05 AM, with ADON, he stated, I will have them reasses her pain, and see what's going on. She does have a history of drug seeking but, pain should be assessed 30 minutes to an hour after pain medication is given. 49465

Based on record review, staff interview, policy review, training documentation and review of the State Board of Examiners for Licensed Practical Nurses, the facility failed to ensure Licensed Practical Nurses (LPN) were trained and competent to perform Intravenous (IV) therapy including administration of medications via a peripheral inserted central catheter (PICC) within their scope of practice and state regulations. The facility was unable to provide verification of sufficient IV training and competency for nine (#6, #20, #27, #33, #35, #39, #49, #59 and #64) of nine LPNs who were performing IV therapy. This practice resulted in Immediate Jeopardy. The facility census was 87. On 11/13/18 at 7:56 PM, the Administrator and Director of Nursing were notified verbally that Immediate Jeopardy began on 10/05/18 when Resident #48 was readmitted to the facility with a peripheral inserted central catheter (PICC) and receiving IV therapy. The Immediate Jeopardy continued when Resident #32 was re-admitted to the facility on [DATE] with a PICC line in her right arm for intravenous antibiotic therapy. LPN's #27, #33, #49 and #59 performed IV therapy for Resident #48 and LPNs #6, #20, #39, #49 and #64 performed IV therapy for Resident #32 without sufficient training and competency. Immediate Jeopardy was abated on 11/13/18 at 8:10 PM. The facility completed an assessment of Resident #48 and Resident #32 to identify any adverse effects related to IV therapy. The facility revised the staffing schedule to ensure an Registered Nurse would be performing IV therapy for the two residents and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a severity level two (no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy) until LPNs were trained and competent with IV therapy. See F684 (Quality of Care) regarding Resident #48 and #32. See F883 (Facility Assessment) and F867 (Quality Assurance and Performance Improvement program) for additional information. Findings include: During an observation on 11/13/18 at 4:00 PM, LPN #27 was observed entering Resident #48's room. LPN #27 was preparing to disconnect the [MEDICATION NAME] pump. An [MEDICATION NAME] pump is a device that infuses intravenous medication once the tubing is unclamped. The device pushes intravenous medication through the tubing and a filter that is attached to the reservoir. LPN #27 had a syringe with normal saline and was preparing to disconnect the [MEDICATION NAME] pump and flush the PICC line with 10 cubic centimeters (ccs) of normal saline as ordered by the physician. A PICC line is a thin, soft long catheter (tube) that is inserted into a vein in the upper arm, leg or neck. The tip of the catheter is positioned in a large vein that carries blood into the heart. The PICC line is used for long-term intravenous (IV) antibiotics, and for blood draws, which is considered IV therapy. The surveyor intervened prior to the administration and queried LPN #27 on her training to ensure proper care and services regarding medication administration via a PICC line. She stated she had received training from the facility regarding care and services required for a PICC line. When queried further about the difference between a PICC line and other peripherally inserted IVs, she stated, it's just higher up on the arm. When queried on adverse reactions that can occur with a PICC line, LPN #27 stated redness, swelling and hot to touch. LPN #27 did not include the life threatening adverse reactions of blood clots and [MEDICAL CONDITION] embolism. During an interview conducted on 11/14/18 at 11:35 AM, LPN #49 stated he was employed at facility for approximately three months. When queried about type of training he received regarding IV therapy he stated, I watched a 5-minute video on IV therapy and received a 4-5-page handout. When asked if he felt confident in his skill set for intravenous administration of medication, he stated yes since the IV medication was in a ball type device that delivered the medication. When queried about being assessed for competency, he stated the previous education nurse watched him perform IV therapy; however, he could not remember when the evaluation occurred. LPN #49 verified he had been administering IV medications via a PICC to Resident #48 and Resident #32. During an interview conducted 11/14/18 at 11:45 AM, LPN #33 stated being employed at the facility since (MONTH) (YEAR). She verified she had not received training on intravenous therapy including care of a resident with a PICC line. She stated she had not been provided training on how to administer medications via a PICC line nor had anyone at the facility verified her competency to care for a resident with a PICC line. She verified she had been administering medication via a PICC line to Resident #48. During an interview conducted on 11/14/18 at 11:55 AM, LPN #6 stated being employed at facility for approximately [AGE] years. She stated she received intravenous therapy training around [AGE] years ago. She stated the facility provided a one-hour intravenous therapy training approximately 6 months ago. She stated the training did not include a competency assessment to ensure an adequate skill set to care for residents receiving intravenous therapy through a PICC line. She verified she had administered IV medication to Resident #32 via a PICC line. During an interview conducted on 11/15/18 at 11:31 AM, Unit Manager RN #29 stated she had been employed by facility for approximately one year and does not remember receiving training on the facility policy for intravenous therapy nor remembers being assessed for competency for intravenous therapy. In addition, at 12:06 PM on 11/15/18, Unit Manager #29 was queried if she received training regarding scope of practice for License Practical Nurses regarding intravenous therapy. Unit Manager RN #29 stated No. A Training Attendance document dated 07/05/17 titled IV Certification with a duration of 1-hour was reviewed. LPN #27 and #6 were in attendance. The training content was reviewed and it did not contain information specific to care and services for a PICC line and the use of an [MEDICATION NAME] pump to administer intravenous antibiotics. During an interview conducted on 11/14/18 at 1:15 PM, District Director of Clinical Resources RN #112 produced a competency checklist for LPN #33 dated for 11/13/18. She stated the competency check was conducted yesterday by Staff Development Manager RN #5. She further verified the training material used by the facility during new employee orientation and the Licensed Nurse Competency Checklist did specifically include care for a resident with a PICC line. In addition, she verified the training material for the IV Certification conducted on 07/05/17 did not include content for the care of residents receiving intravenous medications through a PICC line. During an interview conducted on 11/14/18 at 1:30 PM, Staff Development Manger RN #5 stated she verified LPN #33's competency on 11/13/18 by having her repeat back to her how to care for a resident with a PICC line which included how to administer medications. During an interview conducted on 11/14/18 at 11:45 AM, District Director of Clinical Resources #112 stated in order to ensure nurse competency in caring for a resident receiving medications through a PICC line, the LPN should be observed performing the skill. She stated having the nurse repeat verbally the steps would not be sufficient to ensure competency. In addition, during the interview, a request was made for training documentation for LPN's #20, #35, #39, #49, #59 and #64. District Director of Clinical Resources #112 was unable to provide documentation of LPN training and verification of competency related to care and services for a resident with a PICC line prior to the time of date and time of exit. Review of the facility policy and procedure Peripherally inserted central catheter (PICC) drug administration dated (MONTH) 18, (YEAR) included Critical Notes! Note: PICC Line procedures may only be conducted by a Licensed Nurse with appropriate training. Review of APPENDIX B of the WEST VIRGINIA STATE BOARD OF EXAMINERS FOR LICENSED PRACTICAL NURSES revealed a statement originally issued in June, 1977. The statement indicated the administration of I.V. fluids is not a part of the standard curriculum for accredited schools of practical nursing in West Virginia. However, if additional training has been received and can be verified, providing there is adequate supervision and the licensed practical nurse is willing to accept responsibility, it is not illegal for a licensed practical nurse to perform administration of I.V. fluids.

Based on staff interview and policy review, the facility QAA committee failed to identify Licensed Practical Nurses (LPNs) were performing Intravenous (IV) therapy without sufficient training and implement an appropriate plan of action. This resulted in an Immediate Jeopardy. The facility census was 87. On 11/13/18 at 7:56 PM, the Administrator and Director of Nursing were notified verbally that Immediate Jeopardy began on 10/05/18, when Resident #48 was readmitted with a peripheral inserted central catheter (PICC). In (MONTH) (YEAR), the facility conducted a medication management audit through the Quality Assurance and Performance Improvement (QAPI) committee. However, the audit did not include medication management for residents receiving IV therapy or PICCs in order to determine training needs and competency skills. Immediate Jeopardy was abated on 11/13/18 at 8:10 PM. The facility completed an assessment of residents currently receiving IV therapy via PICC and revised staffing schedules. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a severity level two (no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy) until the training and competency of LPNs are addressed in the QAA committee in accordance with the Quality Assurance and Performance Improvement (QAPI) plan. See F684 (Quality of Care), F726 (Staff Competency), and F838 (Facility Assessment) for additional information. Findings include: Facility documentation review was conducted on 11/15/18 at 12:00 PM and included the following. The Quality Assurance & Performance Improvement Program and Committee policy and procedure dated (MONTH) (YEAR) revealed, The facility maintains an ongoing, effective, comprehensive, data-driven Quality Assurance and Performance (QAPI) Program. The QAPI Program is managed by the QAPI Committee, which is responsible to the facility's Governing Body. The Quality Plan dated 11/01/17 under Addressing Care and Services stated, the QAPI program will strive for safety and quality with all clinical interventions and service delivery. The scope of the QAPI program covers all types and segments of care and services that impact clinical care, quality of life, resident's choice, and care transitions. During an interview conducted on 11/15/18 at 12:15 PM, Medical Director #113 stated he regularly attends the monthly quality assurance meetings. He stated that he was unaware LPNs were administering IV therapy without adequate training and competency assessments to ensure appropriate care and services were being delivered to residents with PICC lines. He stated the quality of the work being done by the QAPI committee had declined related to staff turnover. He stated his expectation was for nurses to be trained on the care they were providing. During an interview conducted on 11/15/18 at 12:50 PM, District Director of Clinical Services #112 stated on 10/15/18, she began a medication management audit through their QAPI program. The audit was conducted to identify concerns regarding medication management processes which included medication administration. However, the audit did not include any documentation of intravenous therapy or PICCs. During an interview conducted on 11/15/18 at 1:10 PM, Administrator #45 stated through their QAPI program they had not discovered that LPNs were performing IV therapy without training and competency assessments to ensure appropriate care and services were being delivered to resident's with PICC lines.

Based on staff interview and Facility Assessment review, the facility identified providing services to residents receiving Intravenous (IV) therapy via a peripheral IV and peripherally inserted central catheter (PICC); however, failed to ensure staff were competent to provide the care needed for this resident population resulting in Immediate Jeopardy. This affected two (Resident #48 and #32) of two sampled residents receiving Intravenous (IV) therapy via a PICC. The facility census was 87. On 11/13/18 at 7:56 PM, the Administrator and Director of Nursing were notified verbally that Immediate Jeopardy began on 10/05/18 when Resident #48 was admitted to the facility with a PICC and receiving IV antibiotics. The Immediate Jeopardy continued 11/05/18 when the facility readmitted Resident #32. The Facility assessment dated [DATE] identified providing care and services to residents receiving IV therapy via peripheral IVs and PICC. LPN's #27, #33, #49 and #59 performed IV therapy for Resident #48 and LPNs #6, #20, #39, #49 and #64 performed IV therapy for Resident #32 without adequate training and skill competency in accordance with the Facility Assessment. Immediate Jeopardy was abated on 11/13/18 at 8:10 PM. The facility revised the staffing schedule to ensure a Registered Nurse (RN) would be performing IV therapy for the two residents any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a severity level two (no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy) until LPNs are trained and competent with IV therapy as identified in the Facility Assessment. See F684 (Quality of Care), F867 (QAPI) and F726 (Staff Competency) for additional information. The facility census was 87. Findings include: The Facility Assessment tool dated 11/10/17 was reviewed on 11/15/18 at 10:10 AM. The facility assessment included a the section titled, Special Treatments and Resident Care Needs. At the time the facility assessment was completed, the facility had one resident with a peripheral IV, five residents with PICC lines and two residents receiving IV medications. Additionally, included in the facility assessment was a section titled, Additional References to the Facility Assessment. The facility assessment quoted the Code of Federal Regulations regarding Nursing Services and Training Requirements. The facility assessment stated: CFR 483.35 Nursing Services from the Code of Federal Regulations- The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by the resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. CFR 483.95 Training Requirements- A facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under contractual arrangement; and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on the facility assessment as specified at 483.70(e) of the code of federal regulations. The section titled, Resident Support/Care Needs Medications was reviewed. The section stated administer medications by appropriate route including intravenous (peripheral or central lines). The section titled, Staff training/education and competencies was reviewed. The : Training Requirements for Licensed Nurses included a valid Nursing license (RN or LPN) and Annual CEUs, LPNs 24 hours each two-year reporting period. Compliance training, HIPPA General Privacy training, Sexual Harassment Education, Dementia training See Licensed Nurse Competency Checklist. The Licensed Nurse Competency Checklist used by the facility to assess competency with Intermittent administration of intravenous fluids was reviewed. The checklist did not include care of a resident with a PICC line. During an interview conducted on 11/14/18 at 1:15 PM, Director of Clinical Resources RN #112 verified the training material used by the facility during new employee orientation and the Licensed Nurse Competency Checklist did not specifically include care of a resident with a PICC line. In addition, she verified the training material for the IV Certification conducted on 07/05/17 did not include content for residents receiving intravenous medications through a PICC line. During an interview on 11/15/18 at 10:30 AM, Administrator #45 stated he was not employed by the facility at the time of the development of the Facility Assessment; and therefore, was not aware of the content of the Facility Assessment. During an interview conducted on 11/15/18 at 10:45 AM, Director of Nursing #46 stated she participated in the development of the Facility Assessment. She verified the Facility Assessment identified caring for residents receiving intravenous therapy through the Facility Assessment. She verified the facility assessment did identify the need for competency with PICC lines even though at the time of the assessment there were five residents with PICC lines.

Based on observations, clinical record review, staff interviews and facility policy review, the facility failed to ensure two (Resident #48 and #32) of two sampled residents were provided appropriate care and services related to standards of practice and competency for Intravenous (IV) therapy resulting in Immediate Jeopardy. The facility census was 87. On 11/13/18 at 7:56 PM, the Administrator and Director of Nursing were notified verbally that Immediate Jeopardy began on 10/05/18, when Resident #48 was readmitted with a peripheral inserted central catheter (PICC) for IV therapy. Licensed Practical Nurses (LPNs) #27, #33, #49 and #59 performed IV therapy without sufficient training and verification of such. The Immediate Jeopardy continued when Resident #32 was re-admitted to the facility on [DATE] with a PICC line in her right arm for intravenous antibiotic therapy. LPNs #6, #20, #35, #39 and #64 performed IV therapy for Resident #32 without sufficient training and verification of competency. Immediate Jeopardy was abated on 11/13/18 at 8:10 PM. The facility completed an assessment of Resident #48 and Resident #32 to identify any adverse effects related to IV therapy. The facility revised the staffing schedule to ensure a Registered Nurse would be performing IV therapy for the two residents (Resident #48 and #32) and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a severity level two (no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy) until LPNs are trained and competent with IV therapy. See F883 (Facility Assessment), F867 (Quality Assurance and Performance Improvement program) and F726 (Staff Competency) for additional information. Findings include: 1. A comprehensive chart review for Resident #48 was conducted on 11/13/18 at 2:00 PM and noted the following information. The Admission Record identified Resident #48 was originally admitted to the facility on [DATE] with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #48's hospital Discharge Summary dated 10/05/18 revealed Resident #48 had a peripherally inserted central catheter (PICC) line in her right upper arm. A PICC line is a thin, soft long catheter (tube) that is inserted into a vein in the upper arm, leg or neck. The tip of the catheter is positioned in a large vein that carries blood into the heart. The PICC line is used for long-term intravenous (IV) antibiotics, and for blood draws, which is considered IV therapy. The referring physician's orders on the discharge summary included [MEDICATION NAME] (an antibiotic) 1250 mg intravenously once per day for two weeks. Continued review of the clinical record on 11/14/18 at 9:00 AM, revealed an Admission Note dated 10/05/18 that stated Resident #48 had a PICC line to right upper arm upon admission back to the facility. A quarterly Minimum Data (MDS) assessment dated [DATE], revealed Section C for cognition a Brief Interview for Mental Status (BIMS) test scored Resident #48 as 11 out of 15 which indicated the resident had moderately impaired cognition. Section N0410 subsection F received antibiotic medication for 7 days during the assessment period. Section O Subsection H received intravenous therapy during the assessment period. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. LPNs #27, #33, and #59 were documented as administering the antibiotic medication. The clinical record from 10/20/18 thru 10/26/18 did not include an order to flush the PICC line with normal saline 10cc every shift to ensure patency until 10/31/18. Review of a physician order dated 10/27/18, the physician ordered [MEDICATION NAME] (a medication to dissolve a blood clot) 5 units via PICC line due to an occlusion. The Nursing Progress Notes did not include a nursing assessment regarding the PICC line being occluded on 10/27/18 which required the use of [MEDICATION NAME] to dissolve the blood clot. On 10/31/18, Resident #48's physician again ordered [MEDICATION NAME] 1250 mg intravenously once per day for 6 weeks and to flush the PICC line with normal saline 10cc every shift to ensure patency. The intravenous antibiotic medication was documented as completed daily from 10/31/18 through 11/13/18 by the administering nurses. LPNs #27, #33, #48 and #59 were documented as flushing and/or administering the IV antibiotic medication. A plan of care dated 11/03/18 included the Focus of I receive IV antibiotic therapy r/t (related to) [MEDICAL CONDITION]. The interventions included provide PICC line care as ordered. During an observation on 11/13/18 at 4:00 PM, LPN #27 was observed entering Resident #48's room. LPN #27 was preparing to disconnect the [MEDICATION NAME] pump. An [MEDICATION NAME] pump is a device that infuses intravenous medication once the tubing is unclamped. The device pushes intravenous medication through the tubing and a filter that is attached to the pump reservoir. LPN #27 had a syringe with normal saline and was preparing to disconnect the [MEDICATION NAME] pump and flush the PICC line with 10 ccs of normal saline as ordered by the physician. The surveyor intervened and queried LPN #27 on her training to ensure proper care and services regarding use of a PICC line for medication administration. She stated she had received training from the facility regarding care and services required for a PICC line. When queried further about the difference between a PICC line and other peripherally inserted IVs, she stated, it's just higher up on the arm. When queried on adverse reactions that can occur with a PICC line, she stated redness, swelling and hot to touch. LPN #27 did not include the life threatening adverse reactions of blood clots and [MEDICAL CONDITION] embolism. During an interview conducted on 11/14/18 at 1:10 PM, Unit Manager RN #29 verified on 10/27/18, Resident #48's PICC line was occluded by the formation of a blood clot and required the use of [MEDICATION NAME] to dissolve the blood clot. Unit Manger #29 stated the standard of practice to ensure PICC line patency was to flush the PICC line every shift with 10 cc of normal saline. She verified there was not a physician order for [REDACTED]. During an interview conducted on 11/15/18 at 11:31 AM, Unit Manager RN #29 stated she had been employed by facility for approximately one year and does not remember receiving training on the facility policy for intravenous therapy nor remembers being assessed for competency for intravenous therapy. In addition, at 12:06 PM, RN #29 was queried if she received training regarding scope of practice for LPNs regarding intravenous therapy. Unit Manager RN #29 stated, No. During an interview conducted on 11/14/18 at 11:35 AM, LPN #49 stated being employed at the facility for approximately three months. When queried about type of training he received regarding IV therapy he stated, I watched a 5-minute video on IV therapy and received a 4-5-page handout. When asked if he felt confident in his skill set for intravenous administration of medication he stated, yes since the IV medication was in a ball type device that delivered the medication. When queried about being assessed for competency, he stated the previous education nurse watched him perform IV therapy; however, he could not remember when the evaluation occurred. LPN #49 verified he had been administering medications to Resident #48. During an interview conducted 11/14/18 at 11:45 AM, LPN #33 stated being employed at the facility since (MONTH) (YEAR). She verified she had not received training on intravenous therapy including care of a resident with a PICC line. She stated she had not received training on how to administer medications via a PICC line nor had anyone at the facility verified her competency to care for a resident with a PICC line. She verified she had been administering medication via a PICC line to Resident #48. 2. A focused chart review for Resident #32 was conducted on 11/15/18 at 9:00 AM. The following was reviewed related to Resident #32 receiving intravenous therapy through a PICC line. The Admission Record identified Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data (MDS) assessment dated [DATE], revealed Section C for cognition a Brief Interview for Mental Status (BIMS) test scored Resident #48 as 11 out of 15 which indicated the resident had moderately impaired cognition. Review of Progress Notes revealed readmission physician orders dated 10/05/18 that included [MEDICATION NAME] (an antibiotic) 2 GM (grams) intravenously every 4 hours until 12/16/18 for infection of the craniotomy incision line. A care plan dated 11/02/18 revealed a Focus of, I have a post op infection of my craniotomy incision and require IV antibiotics through a PICC line. The interventions included, Provide PICC line care per facility protocol. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. LPN's #6, #20, #35, #39 and #64 were documented as flushing the PICC line and/or administering the IV antibiotic medication. During an interview conducted on 11/14/18 at 11:35 AM, LPN #49 stated he was employed at facility for approximately three months. When queried about type of training he received regarding IV therapy he stated, I watched a 5-minute video on IV therapy and received a 4-5-page handout. When asked if he felt confident in his skill set for intravenous administration of medication he stated yes since the IV medication was in a ball type device that delivered the medication. When queried about being assessed for competency, he stated the previous education nurse watched him perform IV therapy; however, he could not remember when the evaluation occurred. LPN #49 verified he had been administering medications to Resident #32. During an interview conducted on 11/14/18 at 11:55 AM, LPN #6 stated being employed at the facility for approximately [AGE] years. She stated she received intravenous therapy training around [AGE] years ago. She stated the facility provided a one-hour intravenous therapy training approximately 6 months ago. She stated the training did not include a competency assessment to ensure an adequate skill set to care for residents receiving intravenous therapy through a PICC line. She verified she had administered IV medication to Resident #32 via a PICC line. Review of the facility policy and procedure Catheter Insertion and Care Flushing Midline and Central Line IV Catheters dated 05/12 revealed Midline and Central Line IV catheters ([MEDICAL CONDITION]) will be flushed to maintain patency and to ensure entire dose of solution or medication is administered into the venous system. Flushing protocol: 1. Flush catheters at regular intervals to maintain patency and before and after administration of medication. 2. Each lumen of a catheter is a separate catheter. Each lumen must be flushed at least every 24 hours to prevent occlusion. Some catheters (per manufacturers guidelines or organizational policy) may need to be flushed more often. Review of Power PICC SOLO manufacturers guidelines Recommended Flushing/Maintenance Procedure(s): The catheter should be maintained in accordance with standard hospital protocols. Recommended catheter flushing/maintenance is as follows: 1. Flush the catheter after every use, or at least weekly when not in use. Review of the facility policy and procedure Peripherally inserted central catheter (PICC) drug administration dated (MONTH) 18, (YEAR) included Critical Notes! Note: PICC Line procedures may only be conducted by Licensed Nurse with appropriate training.

Based on observation, record review, and staff interview, the facility failed to provide treatment and services to prevent potential complications, such as aspiration pneumonia, for a resident receiving enteral nutrition. Even though the head of the bed was elevated 30 degrees, Resident #66 was observed to be slid down in the bed with their head flat during an enteral feeding for approximately thirty (30) minutes. Upon interviewing the staff, a Licensed Practical Nurse (LPN) and a Nurse Aide (NA) were both aware the resident frequently slid down in bed allowing for their head not to be elevated during enteral feedings. Neither staff member reported this behavior. Further investigation revealed there were no interventions in place to help prevent the resident from sliding down in bed allowing their head to be flat during enteral feedings. These findings were determined to pose an immediate jeopardy to the health and well-being of Resident #66. The facility Administrator and Director of Nursing were notified of the immediate jeopardy on 01/10/18 at 10:20 AM. The facility provided a plan of correction on 01/10/18 at 11:40 AM. The immediacy of this deficient practice was abated on 01/10/18 at 11:55 AM. This identified failed practice had the potential to affect four (4) of four (4) residents who received enteral nutrition in the facility. Resident identifier: #66. Facility census: 79. Findings include: a) Resident #66 An observation, on 01/10/18 at 7:15 AM, revealed Resident #66's head of bed was elevated approximately 30 degrees. The resident was slid down in the bed with their head flat. An observation, on 01/10/18 at 7:45 AM, revealed Resident #66's head of bed was elevated approximately 30 degrees. The resident was in the same slid down position in bed with their head flat. Upon closer observation, it was discovered the resident was receiving an enteral feeding via a pump. An immediate interview, on 01/10/18 at 7:45 AM, with Licensed Practical Nurse (LPN) #3, revealed the enteral feeding is started daily at 6:00 AM. The LPN stated the resident's head should be elevated during his feeding. The LPN stated she would seek assistance from another staff member to help pull the resident up in bed. The LPN stated the resident slides down in bed all the time. The LPN stated she had not communicated the resident's frequent sliding down in bed to her supervisor. The LPN stated there were no current interventions in place to prevent the resident from sliding down. A record review, on 01/10/18 at 7:50 AM, revealed the resident was initially admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further record review, on 01/10/18 at 7:55 AM, revealed the resident had a physicians enteral feed order for Glucerna 1.5 at 94 ml (milliliters) q (every) hr (hour) times 16 hours via pump with a start time daily of 6:00 AM. The order was dated 01/05/18. A review of the Care Plan was conducted on 01/10/18 at 8:20 AM. The Care Plan, with a revision date of 12/19/17, contained the focus of tube feeding and care needs with the intervention of the head of the bed being elevated 30 degrees at all times. The care plan did not include the resident sliding down in the bed when the head is elevated. An interview, on 01/10/18 at 8:45 AM, with Nurse Aide (NA) #57, revealed the resident slides down a lot and has to be pulled up at least twice a shift if not more. The NA stated she has not reported this behavior to anyone. The NA stated everyone knows he does it. An interview with the Director of Nursing (DON), on 01/10/18 at 8:55 AM, revealed she had no idea the resident slid down in bed especially during enteral feedings. The DON stated any staff member who knew the resident was sliding down in bed should have reported it immediately. The DON stated the resident's behavior should have been added to the Care Plan and interventions should have been put into place to ensure the resident remained elevated.

Based on observation, medical record review and staff interview, the facility failed to identify and/or adequately monitor a pressure injury, which resulted in actual harm to the resident. Resident #10 came to the facility with unclear identification date and description of a pressure wound on the right heel. Initially, the facility failed to adequately assess and/or monitor the pressure wound prior to the development of necrotic tissue on the right heel. Once the necrotic tissue was assessed, it was another eight (8) days before treatment was initiated beyond the use of sheepskin lined boots. The facility also failed to prevent the development of a second pressure ulcer on a resident with a current [DIAGNOSES REDACTED]. Its existence was unknown to the facility prior to surveyor intervention when asked to observe the wound. This affected one (1) of thirty (30) sampled residents. Resident identifier: #10. Facility census: 79. Findings include: a) Resident #10 1. Record review The resident first came to the facility on [DATE]. Review of the medical record on 01/09/18 found the lack of accurate, ongoing monitoring of a pressure injury to the right heel initially, and conflicting assessments as follows: --The Nursing Admission Data Collection, dated 08/03/17, assessed under section L that the resident had no skin issues. The nurse at admission assessed she was dependent on staff for eating, toileting, chair/bed-to-chair transfer. The nurse assessed that her body appearance was well-nourished; cognition with short -term memory loss; confusion; primary [DIAGNOSES REDACTED]. --The weekly nursing Skin Review by licensed nurse #6, dated 08/03/17, assessed that her skin was intact, with no redness, no bruising, no open areas. --The Physical Therapy Plan of Care, with start date 08/04/17, stated Skin Integrity: Bilateral posterior heels - slow rebounding tissue with depression L (Left heel) = 0.6 cm (centimeters); R (Right heel) = 0.5 cm. Therapy's goal date of 08/17/17 was for the patient to demonstrate improved skin integrity of bilateral heels with delayed tissue rebound to depression as follows: L (Left heel) = 0.4 cm; R (Right heel) = 0.3 cm. --The Order Summary Report for August, (YEAR) included a physician's orders [REDACTED]. The start date of this order was 08/07/17, which was four (4) days after she came to the facility. --The admission minimum data set (MDS), with assessment reference date (ARD) of 08/10/17, assessed under section M that the resident had no stage 1 or greater pressure ulcer and no unhealed pressure ulcers. --The weekly nursing Skin Review assessment by registered nurse #200, dated 08/10/17, stated pressure sore on R (right) heel, rook boots while in bed. There was no description of the wound as to its size or appearance or staging or other type of identification. Review of the medical record found no corresponding nurse progress notes or assessments related to this skin review assessment entry. --The weekly nursing Skin Review assessment by licensed nurse #300, dated 08/17/17, stated (typed as written) Resident has a 3 by 3 necrotic area to outside of right heal. Treatment ordered. --Review of the medical record found no situation, background, assessment, request (SBAR) for this change of condition of necrotic 3.0 by 3.0 cm area of tissue on the right heel, which was first identified on 08/17/17. --Review of a (name of hospital) emergency room encounter for an unwitnessed fall at the facility was reviewed. She sustained a laceration to the right hand, and a skin avulsion to the right forearm. She was non-verbal at baseline with history of altered mental status secondary to dementia. She would follow up within the next two (2) days with her primary physician for wound check, and with wound care as scheduled. Discharge instructions included a consult with the wound care clinic for complex right forearm wound. The wound care clinic appointment was scheduled for 08/25/17. --Review of physician progress notes [REDACTED]. He wrote has a heel wound as well, which included no descriptions, staging, or measurement. --Review of a (name of wound care center) Comprehensive Wound Center History and Physical, dated 08/25/17, addressed that the resident's daughter reports concerns of wound to the right heel. States she noticed a dark area to heel over six (6) weeks ago. Daughter unsure what wound is being dressed with. Wears Rooke boots while in bed. Patient is immobile and dependent for transfers. Daughter reports patient is in bed or wheelchair. --The Wound Center physician on 08/25/17 assessed the presence of a right calcareous (heel) deep tissue injury (DTI) pressure ulcer, 2.5 by 3.5. The physician described the wound base as soft eschar firmly attached without fluctuance.with no undermining/tunneling. There was no drainage. The peri wound skin was clean, absent of [DIAGNOSES REDACTED]//warmth. A picture of the wound revealed it was located on the outer part of the right heel. --The 08/25/17 report of consultation from (name of wound care clinic) assessed a DTI pressure ulcer to the right heel. The clinic recommended to clean the wound with wound cleanser; cover with border silver foam, change it every other day; keep dry. --The wound care clinic also stated to Elevate heels when in bed or use offloading waffle boots. Rooke boots for shearing prevention but does little help for pressure. F/U (follow-up) 5 (five) wks (weeks) for R (right) heel. --Review of the medical record found the resident's physician order, dated 08/25/17, to clean the right heel pressure ulcer with wound cleanser; keep dry; cover with border silver foam every two (2) days. --A physician's orders [REDACTED]. --The current care plan contained a focus for being at risk for further skin breakdown, as she has a history of pressure ulcers, impaired mobility, and incontinence. The date of initiation was 08/08/17. Interventions include a full body check weekly and document. Another intervention directed to inform the family of any new area of skin breakdown. It did not mention the pressure reducing boot. It did not mention any description of any type of current pressure ulcer that she may potentially have had. --The current care plan also contained a focus for an unstageable pressure ulcer to the right heel. The date this focus was initiated was 08/28/17. Interventions included pressure relieving boots on at all times while in bed, with initiation date of 10/04/17. (As a note, it did not specify which or what type of boot.) Another intervention included weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, with initiation date of 08/28/17. --The first nurse progress note in the electronic health record that mentioned the pressure wound of the right heel occurred on 08/28/17 at 12:33 p.m. In this note, the nurse addressed that the resident went to an appointment at the (name of wound care clinic) on 08/25/17. The consultation report states .3. Pressure ulcer to R (right) heel. Cover with border silver foam, change QOD (every other day). Clean w/ (symbol for with) wound cleaner. Keep dry. DO NOT apply any ointments to wound. If area opens and begins to dry please call w/new orders. Elevate heels when in bed or use offloading waffle boots. Rooke boots for shearing prevention but does little help for pressure. Follow-up in five (5) weeks for right heel. --A skin/wound note dated 09/01/17 by the director of nursing stated (typed as written) Resident admitted to facility with unstageable pressure ulcer to outer aspect of right heel. Wound 3 by 3 cm black necrotic area. No drainage. No discomfort noted during dressing change. Heels elevated while in bed on pillow. Protective boot at all times. This was the second nurse progress note in the electronic health record that mentioned the pressure wound of the right heel. --The 09/01/17 30-day MDS assessed that she had one unstageable pressure ulcer, and it was not present upon admission or reentry. It was assessed as 3.0 by 3.0. with eschar. --A nurse progress note dated 09/12/17 addressed that the order for Rooke boots to be worn while in bed was discontinued due to the resident now wearing waffle boots. --A physician order [REDACTED]. --A physician order [REDACTED]. This order is still current on the (MONTH) (YEAR) MAR. --A skin wound note from the assistant director of nursing (ADON) dated 10/04/17 described the pressure ulcer to the right heel as unstageable, and measured 3.8 by 2.9 cm. She assessed the wound bed as black eschar with yellow slough edges, moderate amount of serous drainage on the old dressing, and a slight odor noted from the wound. She cleaned it with soap and water, applied Santyl, and covered it with gauze and a bioclusive dressing. --A nursing note dated 10/30/17 addressed the resident went to the wound center this day for debridement of the right heel, and the daughter accompanied the resident. --A nursing note by the ADON on 11/17/17 assessed the wound as a Stage III pressure ulcer to the right heel measuring 2.4 by 3.0 by 0.4 cm. There were two (2) small areas of slough. - -n 12/11/17, the resident returned to the same wound care clinic. The physician at the wound care clinic applied silver [MEDICATION NAME] to the wound due to hypergranulation. The physician termed it a Stage 3 decubitus ulcer to the right heel. She gave new orders to clean with wound cleanser, discontinue Santyl and Dakins dressing, and apply silver alginate to wound and cover with border foam and change every two (2) days. She also ordered to Continue aggressive wound offloading. - A nurse progress note on 12/11/17 addressed that the resident visited the wound center today with (name of doctor). The nurse wrote the new orders into the nursing note, which included to Continue aggressive wound offloading. 2. Interview with Assistant Director of Nursing On 01/09/18, an interview was conducted with the assistant director of nursing (ADON) from 2:15 p.m. to 3:15 PM. Upon inquiry, she said she did not see any treatment orders for the pressure wound of the right heel prior to 08/25/17. She said she could only see the Rooke boots order prior to 08/25/17. Upon inquiry as to when the facility first identified the pressure ulcer to the right heel, she said she assumed the resident came in with it. She acknowledged the 08/03/17 nursing admission assessment and 08/03/17 weekly skin assessment found her skin intact, as did the admission MDS with ARD 08/10/17. She agreed that the nurse who wrote the 08/10/17 weekly skin assessment about the pressure ulcer to the right heel should have described the pressure ulcer's appearance and size. She said had the nurse completed an SBAR, they would have been sure to notify the physician and family and get treatment orders. She agreed that the first mention of necrotic tissue on the right heel occurred during the 08/17/17 weekly skin assessment. Upon inquiry as to whether the medical power of attorney (MPOA) or the physician was notified of the necrosis on 08/17/17, she said she did not see any evidence of those notifications, or evidence of any measurements, and no SBAR was completed by the nurse on 08/17/17. Upon request to observe the wound to the right heel, the ADON said she would first gather the supplies, then dress the wound while observed. 2. Observation of the pressure ulcer Observation of the right heel on 01/09/18 at 3:45 p.m. found a new deep tissue injury was present which had not yet been identified by the facility. The inner right heel had a swollen, reddened area approximately two and one-half inches in diameter. The middle of the wound contained an irregular shaped, maroon discoloration. The ADON measured the darkened, maroon discolored area at 2.0 by 2.3 cms. The DON said this was a brand new deep tissue injury first identified at this time when the old dressing was removed. She said the heel was dressed yesterday morning, and there was no mention of a new suspected deep tissue injury at that time on the inner aspect of the right heel. She surmised it developed between then and now. The ADON said the physician's assistant was in the building and they notified him to look at the new wound. He also wrote new orders. The MPOA was notified of the change in condition. A pair of white boots lined with sheepskin lay in her bed which staff had removed prior to the dressing change. After the dressing change, the resident wore dark colored padded boots on both feet instead of the white Rooke boots. The older pressure ulcer, located on the outer right heel, was similar to the 01/05/18 assessment which was 0.8 by 2.0 by 0.1 cms, with dry yellow/brown wound bed without drainage or foul odor. 3. Interviews On 01/09/18 at 4:15 p.m., an interview was conducted with the physician's assistant, Employee #400. Upon inquiry as to how often he and/or the physician assess the wounds, he said they have no set days to look at pressure ulcers, or conduct scheduled wound care clinics. Rather, they depend on nurses to notify them of changes, as they did just now. An interview was conducted with the director of nursing (DON) on 01/09/18 at 4:30 p.m. A discussion ensued about the lack of evidence of physician or MPOA notification at least when the wound was assessed with [REDACTED]. Also, there was no confirmed date of the initial onset of the pressure wound of the right heel, or measurements/assessments/treatment to show evidence of any ongoing monitoring and assessment. The DON said she addressed that whole issue in (MONTH) related to this resident's pressure ulcer, and she brought it to QA (Quality Assessment and Assurance) in (MONTH) (YEAR). She said at that time, they had a lot of agency nurses, and that was the root of the problem. She said the nurse who first documented the pressure ulcer on 0910/17 lacked long-term experience. She said that nurse no longer works at the facility. She was informed that this would be cited, and a list of copies of needed documents was given to her and the ADON for tomorrow. An interview was conducted with the director of rehab Employee #41, on 01/10/18 at 8:15 a.m. in Resident #10's room. Resident #10 sat in a chair in the hall at this time. Employee #41 found the white boots with the sheepskin in the resident's closet. She said they were Rooke boots. She said the dark colored ones lying in the chair at present, were the ones they put on her after yesterday afternoon's dressing change. She said they are called a Heel Medex. She said the Heel Medex is good for offloading, and is a prevalon type of boot. She said that based on her own experience, the Medex boot is better than the Rooke boot for offloading pressure. Upon inquiry, she said a waffle boot is plastic and filled with air. She said it can become hot and sweaty. She said it is air-filled, and that the air consistency does not remain the same consistently. She then returned to the therapy room. She said therapy treated this resident last fall with various modalities to reduce the pain from the pressure wound of the right heel and to promote its healing. She said they used different things last fall such as diathermy. She said that when the resident was discharged from therapy, that she no longer had pain in the pressure wound, and the wound looked like a skin patch ready to peel off. When asked about the waffle boots, she said she did not recall this resident ever having waffle boots in the past Four (4) other therapy staff personnel were present (no patients at this moment), and when asked, none of them could recall using waffle boots for this resident. Employee #41 said different products have different percentages of off-loading, pressure relief. She showed a picture in a catalogue of an off-loading boot she said she could order that is 100% off-loading. Upon inquiry, she said she has not been asked by nursing to select a pressure relieving boot for aggressive wound off-loading for this resident. She said that generally when the physician gives an order to nursing for pressure relieving foot coverings, that nursing use their own discretion to make selections. A second interview was conducted with Employee #41 on 01/10/18 at 9:15 a.m. for clarification. She said that an off-loading boot is a broad term, as there are different percentages of off-loading ability per boot. She said if she received an order from a physician for an off-loading boot, that she would have to contact the physician and ask for more specifics of what he wanted and needed for a resident. During an interview with the ADON on 01/10/18 at 2:15 p.m., she said she could still find no information on notification of the physician or family of the pressure wound prior to her going out the hospital on [DATE] after the fall. She said she still could find no information or notification of the physician or family of the pressure would on 08/17/17 when the nurse assessed and documented necrotic tissue on the right heel. Upon inquiry, she said both she and the DON informed the administrator yesterday of the pressure ulcer issue that would be cited. Interviews were conducted with the ADON and the DON on 01/11/17 at 8:00 a.m. The ADON clarified the resident has had two (2) debridements of the pressure wound to the right heel, once on 10/30/17 and again on 12/11/17. She clarified that the (name of hospital) on 08/20/17 gave orders for a referral to the (name of wound care clinic), which the resident first attended on 08/25/17. She clarified that the only physician or physician's assistant progress notes that they could find which mentioned a pressure ulcer since admission were the 08/22/17 and the 01/09/18 notes, both of which she made copies of yesterday. She clarified that they were still unable to find any evidence of the facility's physician's treatment orders for the pressure wound to the right heel prior to 08/25/17, other than the Rooke boots. Another interview was completed with the ADON on 01/11/17 at 9:45 a.m. Discussed with her what Employee #41 said about differing amounts of offloading per product, and that she has one she can order that is 100% offloading. The ADON said she does not really know that much about all the particulars for all of the boots. Informed her that the wound care clinic on 08/25/17 wrote that Rooke boot is good for shearing preventions, but no so good for offloading, and they recommended a waffle boot or elevating the feet on pillows. Informed her that the physician ordered a waffle boot for five (5) weeks, but the current recapitulation of physician's orders [REDACTED]. Rather, the order and MAR indicated [REDACTED]. The ADON listened and acknowledged. No further information was provided prior to exit. Following exit, the facility emailed a Rooke product advertisement/brochure, which stated in part that the Classic Rooke offloading boot was designed to protect the healing limb and help prevent pressure ulcers.

Based on medical record review and staff interview, the facility failed to immediately notify the physician of significant changes in Resident #10's skin integrity, and/or to commence a new form of treatment. This delay in treatment resulted in actual harm to Resident #10 who developed necrotic tissue in a heel pressure ulcer injury. Because of conflicting medical record information, it is unclear when the pressure wound originated. After the facility assessed necrotic changes in a heel wound fourteen (14) days after admission to the facility, it was another eight (8) days before a new form of treatment commenced. Additionally, the facility also failed to notify the medical power of attorney when the necrotic tissue was first assessed. This affected one (1) of thirty (30) sampled residents. Resident identifier: #10. Facility census: 79. Findings include: a) Resident #10 1. Record review The following details conflicting dates concerning the inception and status of the pressure wound: --Review of the medical record on 01/09/18 found the lack of accurate, ongoing monitoring of a pressure injury to the right heel initially, and conflicting assessments as follows: --The Nursing Admission Data Collection, dated 08/03/17, assessed under section L that the resident had no skin issues. The nurse at admission assessed she was dependent on staff for eating, toileting, chair/bed-to-chair transfer. The nurse assessed that her body appearance was well-nourished; cognition with short -term memory loss; confusion; primary [DIAGNOSES REDACTED]. --The weekly nursing Skin Review by licensed practical nurse #6, dated 08/03/17, assessed that her skin was intact, with no redness, no bruising, no open areas. --The Physical Therapy Plan of Care, with start date 08/04/17, stated Skin Integrity: Bilateral posterior heels - slow rebounding tissue with depression L (Left heel) = 0.6 cm (centimeters); R (Right heel) = 0.5 cm. Therapy's goal date of 08/17/17 was for the patient to demonstrate improved skin integrity of bilateral heels with delayed tissue rebound to depression as follows: L (Left heel) = 0.4 cm; R (Right heel) = 0.3 cm. --The Order Summary Report for August, (YEAR) included a physician's orders [REDACTED]. The start date of this order was 08/07/17, which was four (4) days after she came to the facility. --The admission minimum data set (MDS), with assessment reference date (ARD) of 08/10/17, assessed under section M that the resident had no stage 1 or greater pressure ulcer and no unhealed pressure ulcers. --The weekly nursing Skin Review assessment by registered nurse #200, dated 08/10/17, stated pressure sore on R (right) heel, rook boots while in bed. There was no description of the wound as to its size or appearance or staging or other type of identification. Review of the medical record found no corresponding nurse progress notes or assessments related to this skin review assessment entry. --The weekly nursing Skin Review assessment by licensed nurse #300, dated 08/17/17, stated (typed as written) Resident has a 3 by 3 necrotic area to outside of right heal. Treatment ordered. Review of the medical record found no treatment ordered beyond the Rooke boots. --Review of the medical record found no situation, background, assessment, request (SBAR) for this change of condition of necrotic 3.0 by 3.0 cm area of tissue on the right heel, which was first identified on 08/17/17. --Review of a (name of hospital) emergency room encounter for an unwitnessed fall at the facility was reviewed. She sustained a laceration to the right hand, and a skin avulsion to the right forearm. She was non-verbal at baseline with history of altered mental status secondary to dementia. She would follow up within the next two (2) days with her primary physician for wound check, and with wound care as scheduled. Discharge instructions included a consult with the wound care clinic for complex right forearm wound. The wound care clinic appointment was scheduled for 08/25/17. --Review of physician progress notes [REDACTED]. He wrote has a heel wound as well, which included no descriptions, staging, or measurement. --Review of a (name of wound care center) Comprehensive Wound Center History and Physical, dated 08/25/17, addressed that the resident's daughter reports concerns of wound to the right heel. States she noticed a dark area to heel over six (6) weeks ago. Daughter unsure what wound is being dressed with. Wears Rooke boots while in bed. Patient is immobile and dependent for transfers. Daughter reports patient is in bed or wheelchair. The Wound Center physician on 08/25/17 assessed the presence of a right calcareous (heel) deep --tissue injury (DTI) pressure ulcer, 2.5 by 3.5. The physician described the wound base as soft eschar firmly attached without fluctuance.with no undermining/tunneling. There was no drainage. The peri wound skin was clean, absent of [DIAGNOSES REDACTED]//warmth. A picture of the wound revealed it was located on the outer part of the right heel. --The 08/25/17 report of consultation from (name of wound care clinic) assessed a DTI pressure ulcer to the right heel. The clinic recommended to clean the wound with wound cleanser; cover with border silver foam, change it every other day; keep dry. --The Wound Center also stated to Elevate heels when in bed or use offloading waffle boots. Rooke boots for shearing prevention but does little help for pressure. F/U (follow-up) 5 (five) wks (weeks) for R (right) heel. --Review of the medical record found the resident's physician order, dated 08/25/17, to clean the right heel pressure ulcer with wound cleanser; keep dry; cover with border silver foam every two (2) days. --A physician's orders [REDACTED]. --The first nurse progress note in the electronic health record that mentioned the pressure wound of the right heel occurred on 08/28/17 at 12:33 p.m. In this note, the nurse addressed that the resident went to an appointment at the (name of wound care clinic) on 08/25/17. The consultation report states .3. Pressure ulcer to R (right) heel. Cver with border silver foalm, change QOD (every other day). Clean w/ (symbol for with) wound cleaner. Keep dry. DO NOT apply any ointments to wound. If area opens and begins to dry please callw/new orders. Elevate heels when in bed or use offloadin gwaffle boots. Rooke boots for shearing prevnetion but does little help for pressure. Follow-up in five (5) weeks for right heel. --A skin/wound note dated 09/01/17 by the director of nursing stated (typed as written) Resident admitted to facility with unstageable pressure ulcer to outer aspect of right heel. Wound 3 by 3 cm black necrotic area. No drainage. No discomfort noted during dressing change. Heels elevated while in bed on pillow. Protective boot at all times. This was the second nurse progress note in the electronic health record that mentioned the pressure wound of the right heel. --The 09/01/17 30-day MDS assessed that she had one unstageable pressure ulcer, and it was not present upon admission or reentry. It was assessed as 3.0 by 3.0. with eschar. --The current care plan contained a focus for being at risk for further skin breakdown, as she has a history of pressure ulcers, impaired mobility, and incontinence. The date of initiation was 08/08/17. Interventions include a full body check weekly and document. Another intervention directed to inform the family of any new area of skin breakdown. It did not mention the pressure reducing boot. It did not mention any description of any type of current pressure ulcer that she may potentially have had. --The current care plan also contained a focus for an unstageable pressure ulcer to the right heel. The date this focus was initiated was 08/28/17. Interventions included pressure relieving boots on at all times while in bed, with initiation date of 10/04/17. (As a note, it did not specify which or what type of boot.) Another intervention included weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, with initiation date of 08/28/17. --A nurse progress note dated 09/12/17 addressed that the order for Rooke boots to be worn while in bed was discontinued due to the resident now wearing waffle boots. --A physician order [REDACTED]. --A physician order [REDACTED]. This order is still current on the (MONTH) (YEAR) MAR. --A skin wound note from the assistant director of nursing (ADON) dated 10/04/17 described the pressure ulcer to the right heel as unstageable, and measured 3.8 by 2.9 cm. She assessed the wound bed as black eschar with yellow slough edges, moderate amount of serous drainage on the old dressing, and a slight odor noted from the wound. She cleaned it with soap and water, applied Santyl, and covered it with gauze and a bioclusive dressing. --A nursing note dated 10/30/17 addressed the resident went to the wound center this day for debridement of the right heel, and the daughter accompanied the resident. --A nursing note by the ADON on 11/17/17 assessed the wound as a Stage III pressure ulcer to the right heel measuring 2.4 by 3.0 by 0.4 cm. There were two (2) small areas of slough. --On 12/11/17, the resident returned to the same wound care clinic. The physician at the wound care clinic applied silver [MEDICATION NAME] to the wound due to hypergranulation. The physician termed it a Stage 3 decubitus ulcer to the right heel. She gave new orders to clean with wound cleanser, discontinue Santyl and Dakins dressing, and apply silver alginate to wound and cover with border foam and change every two (2) days. She also ordered to Continue aggressive wound offloading. --A nurse progress note on 12/11/17 addressed that the resident visited the wound center today with (name of doctor). The nurse wrote the new orders into the nursing note, which included to Continue aggressive wound offloading. 2. Interview with the Assistant Director of Nursing On 01/09/18, an interview was conducted with the assistant director of nursing (ADON) from 2:15 PM to 3:15 PM revealed the following: --Upon inquiry, she said she did not see any treatment orders for the pressure wound of the right heel prior to 08/25/17. She said she could only see the Rooke boots order prior to 08/25/17. --Upon inquiry as to when the facility first identified the pressure ulcer to the right heel, she said she assumed the resident came in with it. She acknowledged the 08/03/17 nursing admission assessment and 08/03/17 weekly skin assessment found her skin intact, as did the admission MDS with ARD 08/10/17. She agreed the nurse who wrote the 08/10/17 weekly skin assessment about the pressure ulcer to the right heel should have described the pressure ulcer's appearance and size, but she did not do so. --She said had the nurse completed an SBAR, they would have been sure to notify the physician and family and get treatment orders. --She agreed that the first mention of necrotic tissue on the right heel occurred during the 08/17/17 weekly skin assessment. Upon inquiry as to whether the medical power of attorney (MPOA) or the physician was notified of the necrosis on 08/17/17, she said she did not see any evidence of those notifications, did not see any evidence of measurements, and no SBAR was completed by the nurse on 08/17/17. She provided a copy of the facility's policy on Changes in Resident Condition. 3. Review of facility policy Review of the facility's policy in Changes in Resident Condtion (revised (MONTH) (YEAR)) stated: --The nursing staff, the resident, the attending physician and the resident's legal representative are notified when changes in the resident's condition occur. Communication with the Interdisciplinary Team and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit. --Guideline #2 in this policy stated Prompt notification is required when . a signficant change in the resident's attending physical, mental , or psychosocial status, including a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications; or a need to alter treatemnt signficantly. --Guideline #4 in this policy stated The SBAR Communication Form and the Progress not are used to: a. Assess and document changes in condition in an efficient and effective manner; b. Provide assessment information to the physicain, and c. Provide clear comprehensive documentation. --Guideline number #4 this policy also stated Changes in the resident status that affect the problem (s)/goals(s) or approaches(es) on his or her care plan are documented as revisions and communicated to the interdisciiplinacy caregivers. --Under Documentation requirements, this policy listed the SBAR Communication Form, Progres Note, and 24-Hour Report. 4. Observation of the wound Observation of the right heel on 01/09/18 at 3:45 p.m. found a new deep tissue injury was present which had not yet been identified by the facility. The inner right heel had a swollen, reddened area approximately two and one-half inches in diameter. The middle of the wound contained an irregular shaped, maroon discoloration. The ADON measured the darkened, maroon discolored area at 2.0 by 2.3 centimeters (cm). The ADON said this was a brand new deep tissue injury first identified at this time when the old dressing was removed. She said the heel was dressed yesterday morning, and there was no mention of a new suspected deep tissue injury at that time on the inner aspect of the right heel. She surmised it developed between then and now. The ADON said the physician's assistant was in the building and they notified him to look at the new wound. He also wrote new orders. The MPOA was notified of the change in condition. A pair of white boots lined with sheepskin lay in her bed which staff had removed prior to the dressing change. After the dressing change, the resident wore dark colored padded boots on both feet instead of the white Rooke boots 5. Interview with Director of Nursing (DON) and ADON An interview was conducted with the director of nursing (DON) on 01/09/18 at 4:30 PM. A discussion ensued about the lack of evidence of physician or MPOA notification at least when the wound was assessed with [REDACTED]. Also, there was no confirmed date of the initial onset of the pressure wound of the right heel, or measurements/assessments/treatment to show evidence of any ongoing monitoring and assessment. The DON said she addressed that whole issue in (MONTH) related to this resident's pressure ulcer, and she brought it to QA (Quality Assessment and Assurance) in (MONTH) (YEAR). She said at that time, they had a lot of agency nurses, and that was the root of the problem. She said the nurse who first documented the pressure ulcer on 09/10/17 lacked long-term experience. She said that nurse no longer works at the facility. She was informed that this would be cited, and a list of copies of needed documents was given to her and the ADON for tomorrow. During an interview with the ADON on 01/10/18 at 2:15 PM, she said she could still find no information on notification of the physician or family of the pressure wound prior to her going out the hospital on [DATE] after the fall. She said she still could find no information or notification of the physician or family of the pressure would on 08/17/17 when the nurse assessed and documented necrotic tissue on the right heel. Upon inquiry, she said both she and the DON informed the administrator yesterday of the pressure ulcer issue that would be cited. Interviews were conducted with the ADON and the DON on 01/11/17 at 8:00 AM. The ADON clarified the resident has had two (2) debridements of the pressure wound to the right heel, once on 10/30/17 and again on 12/11/17. She clarified that the (name of hospital) on 08/20/17 gave orders for a referral to the (name of wound care clinic), which the resident first attended on 08/25/17. She clarified that the only physician or physician's assistant progress notes that they could find which mentioned a pressure ulcer since admission were the 08/22/17 and the 01/09/18 notes, both of which she made copies of yesterday. She clarified that they were still unable to find any evidence of the facility's physician's treatment orders for the pressure wound to the right heel prior to 08/25/17, other than the Rooke boots. The lack of documentation to support the notification of the physician that Resident #10 had a pressure ulcer with necrotic tissue, lack of evidence to support when the pressure ulcer developed, and lack of physician treatment orders all contributed in actual harm to Resident #10.

During the investigation of a complaint and based on record review, staff interview, policy review, and review of the facility's investigation of a fall with injury reported to the state; the facility failed to provide the supervision needed by two (2) cognitively impaired residents, who had been assessed and identified as cognitively impaired and having behavioral problems, to prevent them from sustaining falls with injuries. Those were two (2) of six (6) residents who had a history of [REDACTED]. Resident identifiers: #88 and #92. Facility census: 91. Findings include: a) Resident # 88 A review of the clinical record of Resident #88 at 3:00 p.m. on [DATE], revealed he was an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His assessments by his physician included hallucinations, paranoia, delusions, and physical and verbal aggression. He had been determined by a physician to lack the capacity to form medical decisions. Resident #88 had been totally dependent on staff for all activities of daily living for over a year. He required use of a mechanical lift for transfers. Due to his poor cognition, he was unable to communicate his needs in an understandable manner. The resident exhibited almost daily behaviors, which included being easily agitated during personal care and hitting, shouting, and cursing during personal care. Because of restlessness, and no self - safety awareness due to his cognitive impairment he had been assessed to be High Fall Risk and several safety interventions were included in his Care Plan, including: --[DATE] - Bed in low position --[DATE] - Landing mats beside bed --[DATE] - Bed alarm when resident is in bed to alert staff for when resident needs assistance --[DATE] - Mechanical Lift for transfers --[DATE] - Padding to side rails --[DATE] - When resident is out of bed and in his wheelchair at seatbelt with be utilized to assist with body positioning complicated by decreased safety awareness and inability to comprehend verbal safety prompts when given by staff and others. During independent interviews with Registered Nurse (RN) #82 at 8:40 a.m. on [DATE], and RN #11 at 12:30 p.m. on [DATE], both nurses verified the resident frequently struck out at caregivers and flailed out when touched. They said the interventions listed above were needed and followed daily. Nurse Aide (NA) #5, when interviewed at 1:15 p.m. on [DATE], said the aides tried to work in pairs for transfers and personal care of Resident #88. At 10:00 a.m. on [DATE], Resident #88 fell from a shower gurney in the shower room approximately three (3) feet onto a tile floor sustaining a laceration to his forehead and a head injury later diagnosed as an acute displaced type II odontoid fracture and fractures through the posterior archy of C1. The fall was observed and the resident received immediate emergency care, 911 was called, and the resident was transferred to an acute care hospital. The facility immediately reported the incident to the appropriate state offices, suspended the aide involved, and began an investigation. The Immediate Fax Report to the Nurse Aide Registry stated the following: --Allegation: CNA was showering this resident, she put the rail down on the shower gurney and turned to get the hoyer pad and the resident rolled off the gurney hitting the floor sustaining a head laceration. All staff working at the time of the incident were interviewed during the investigation and the Five Day Follow-up report was sent to the Nurse Aide Registry on [DATE]. The Five Day Follow-up report stated, Resident did sustain a neck fracture after his fall. After investigation this facility determined this was an accident, however this CNA did fail to follow safety rules and was terminated for such. She was also in her probationary period. In a signed statement from the aide present in the shower room and assigned to care for Resident #88 at the time of the incident she stated: .On this day [DATE] I was assigned to shower (Resident #88). While showering (Resident) he was being combative @ times. (CNA #5) another CNA was also in the shower room with me showering another male resident also (LPN #11) the treatment nurse came in to change his bandage. I had finished (Resident #88's) shower had him dressed and a lift under him for he was being showered on a shower bed. (CNA #5) had left to transport her resident and was coming back to assist and I had turned my back for a minute to reach for (Resident's) Chair which was in arms length reach and he had rolled himself off of the shower bed. A signed written statement from CNA #5 validated the behavior of the resident during his shower and that she left the room with her resident intending to return to assist with Resident #88. Seven (7) staff members completed written statements (LPN#11, CNA#5, RN#34, RN#82, CNA#69, CNA#89, and NA#115). All seven (7) staff members confirmed the resident was aggressive and not cooperative with care. After review of the investigation completed by the facility and interviews with LPN#11 at 12:30 p.m. on [DATE] and NA #5 at 10:30 a.m. on [DATE], who were both present shortly prior and immediately after the incident, it was apparent NA #115 was negligent in her care of Resident #88. This resulted in the decision that the facility had failed to provide supervision to prevent the fall with harm. During an interview with the director of nurses (DON) and assistant director of nurses (ADON) at 11:30 a.m. on [DATE], the DON agreed the aide should not have lowered the rail or turned her back on any resident on a shower gurney and she had made the decision NA #115 had neglected her supervision responsibility to Resident #88 when she lowered the siderail and turned her back allowing him to fall and because of this neglect she was terminated. The ADON agreed with her. b) Resident #92 On [DATE] at 2:30 p.m., a review of the accident/incident log revealed Resident #92 had a total of two (2) unwitnessed falls without injury. One (1) fall occurred on [DATE] at 0245 (2:45 a.m.), and two falls on [DATE] at 6:00 p.m. and 7:00 p.m. Copies of the accident/incident reports were provided on [DATE] at 3:30 p.m. and found not to match the accident/incident log. The accident/incident reports identified an unwitnessed fall without injury on [DATE] at 0245 (2:45 a.m.) and one (1) report for [DATE] for unwitnessed falls without injury at 6:00 p.m. and 7:00 p.m. (this was found to be inaccurate, the resident only had one fall at 7:00 p.m.). On [DATE] at 09:30 a.m., a record review revealed Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Transfer/Discharge Report, by an unknown author dated ,[DATE] 5:30 p.m. states, . Resident fell several times today. unable to calm, possible head injury . A review of the nursing progress notes on [DATE] at 09:45 a.m., revealed the following documentation: ---[DATE] at 17:15 (6:15) of Resident had been having increased agitation . Notified MD. received order for Ativan 1 mg IM (intramuscular) x 1 dose now repeat in 1 hr. if needed . ---[DATE] at 17:59 (7:59 p.m.) IM Ativan given as ordered at 1800 (6:00 p.m.) to (L) arm . ---[DATE] at 01:58 (1:58 a.m.) Resident is alert and verbal with increased confusion. Resident received IM Ativan 1 mg at 6p, resident continued to have behaviors and was found on floor beside bed IM Ativan 1 mg administered at 7P per MD orders . Resident continued to flail around and was unconsolable and was found on floor after second dose of Ativan. Resident found with head against bottom bed bar, no visible injuries noted . Redness noted to back of head . Respirations even and labored . PA ordered to send resident to Mon Gen for eval . Resident left facility via Star city EMS (Emergency Medical Service) at appox 8 P (8:00 p.m.) . (Note was made after Resident was transported to the hospital on [DATE].) There is no evidence in the record of the incident being reported to the appropriate state agencies or of an investigation by the facility of the unwitnessed fall which required medical intervention, nor of the resident being monitored and/or supervised following the administration of either doses of the injectable medication Ativan. During an interview with Licensed Practical Nurse (LPN) #11 on [DATE] at 11:40 a.m. she commented that she was the nurse going off shift on [DATE]. Resident #92 was aggressive on [DATE] and was trying to destroy the furnace in his room. LPN #11 had notified the Physician and received an order for [REDACTED].#11 stated, he (Resident #92) did calm down five (5) minutes after the Ativan was given. Two (2) nurses aides (NA) assisted him back to bed and I went to the desk to give report to the on coming nurse and update his (Resident #92) daughter. I walked past as I was leaving about 6:30 p.m. and peeked in the room, he was in bed and no one was in his room with him. The Director of Nursing (DON) was interviewed on [DATE] at 12:20 p.m. and asked to explain the procedure for a resident following an aggressive episode that would require medical intervention. She stated, call the doctor, call the family, keep a close eye on for the next few hours and someone should stay in the room for the first (1st) hour after giving Ativan or any emergent medication. On [DATE] at 3:45 p.m., in the company of the Director of Nursing (DON), the Administrator and the Assistant Director of Nursing (ADON), a speaker phone interview was conducted with LPN #95 (who was the on coming nurse on [DATE]). The DON asked LPN #95 if the resident had fallen twice during her shift as was recorded on the accident/incident report. LPN #95 stated, no just the once at 7:00 p.m . no it is incorrect (the accident/incident report documentation), he only had one fall. I did give the IM Ativan but did not sign it out, it was very busy and I was worried about caring for the resident. After further discussion LPN #95 stated, I stayed with him for about 15 minutes after I gave the second (2nd) dose of Ativan and then went out because I was in the middle of medication pass. It is not documented but now I know to document that in the notes. A review of the company HOSPIRA manufacture's package insert for the injectable medication Ativan (lorazepam), (obtained at the acute care hospital pharmacy) on [DATE] at 8:45 a.m. revealed, Elderly patients .do not operate machinery or motor vehicle during the first 24 hours .monitor for possible respiratory distress's in elderly patients .monitor for falls related to sedation On [DATE] at 9:00 a.m., a review of the community hospital records revealed Resident #92 was admitted to the hospital on [DATE] with the chief complaint of agitation and combativeness, multiple falls and respiratory failure. Resident #92 expired on [DATE] at 2:15 p.m. The cause of death on the Death Certificate was listed as: a. Acute hypercapnic respiratory failure. b. Benzodiazepines overdose. During the review of the facility reference Nursing 2015 Drug Handbook showed the following information regarding the medication Ativan (lorazepam): CONTRAINDICATIONS & CAUTIONS .use cautiously in elderly, acutely ill or debilitated patients. PATIENT TEACHING .Warn patient to avoid hazardous activities that require alertness or good coordination until effects of drug are known. Due to the resident being newly admitted to the facility, having unwitnessed falls with the latest fall needing medical intervention, expiring in less than 24 hours of being transferred to the community hospital and due to the listed causes of death, the facility should have reported this to the appropriate State agencies and thoroughly investigated the fall. Also the resident should have been monitored and/or supervised following the administering of the emergent newly prescribed injectable anti-anxiety medication Ativan. b) Resident #88 A review of the clinical record for Resident #88 at 3:00 p.m. on [DATE] revealed he was an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His assessments by his physician included hallucinations, paranoia, delusions, and physical and verbal aggression. He had been determined by a physician to lack the capacity to form medical decisions. Resident #88 was totally dependent on staff for all activities of daily living for over a year. He required use of a mechanical lift for transfers. Due to his poor cognition, he was unable to communicate his needs in an understandable manner. The resident exhibited almost daily behaviors which included being easily agitated during personal care and hitting, shouting, and cursing during personal care. Because of restlessness, and no self-safety awareness due to his cognitive impairment he had been assessed to be High Fall Risk and several safety interventions were included in his Care Plan including: --[DATE] - Bed in low position --[DATE] - Landing mats beside bed --[DATE] - Bed alarm when resident is in bed to alert staff for when resident needs assistance --[DATE] - Mechanical Lift for transfers --[DATE] - Padding to side rails --[DATE] - When resident is OOB (out of bed) and in his WC (wheelchair) a seatbelt will be utilized to assist with body positioning complicated by decreased safety awareness and inability to comprehend verbal safety prompts when given by staff and others. During independent interviews with RN #82 at 8:40 a.m. on [DATE], and RN #11 at 12:30 p.m. on [DATE], both nurses verified that the resident frequently struck out at caregivers and flailed out when touched. They said the interventions listed above were needed and followed daily. Nurse Aide (NA) #5, when interviewed at 1:15 p.m. on [DATE], said the aides tried to work in pairs for transfers and personal care of Resident #88. At 10:00 a.m. on [DATE], Resident #88 fell from a shower gurney in the shower room approximately three (3) feet onto a tile floor sustaining a laceration to his forehead and a head injury later diagnosed as an acute displaced type II odontoid fracture and fractures through the posterior archy of C1. The fall was observed and the resident received immediate emergency care, 911 was called, and he was transferred to an acute care hospital. The facility immediately reported the incident to the appropriate state offices, suspended the aide involved, and began an investigation. The Immediate Fax Report to the Nurse Aide Registry stated the following: Allegation: CNA was showering this resident, she put the rail down on the shower gurney and turned to get the hoyer pad and the resident rolled off the gurney hitting the floor sustaining a head laceration. All staff working at the time of the incident were interviewed during the investigation and the Five Day Follow-up Report sent to the Nurse Aide Registry on [DATE], stated, Resident did sustain a neck fracture after his fall. After investigation this facility determined this was an accident, however this CNA did fail to follow safety rules and was terminated for such. She was also in her probationary period. In a signed statement from the aide present in the shower room and assigned to care for Resident #88 at the time of the incident she stated: On this day [DATE] I was assigned to shower (Resident #88). While showering (Resident) he was being combative @ times. (CNA #5) another CNA was also in the shower room with me showering another male resident also Licensed Practical Nurse (LPN #11) the treatment nurse came in to change his bandage. I had finished (Resident #88 ' s) shower had him dressed and a lift under him for he was being showered on a shower bed. (CNA #5) had left to transport her resident and was coming back to assist and I had turned my back for a minute to reach for (Resident's) Chair which was in arms length reach and he had rolled himself off of the shower bed. A signed written statement from NA #5 validated the behavior of the resident during his shower and that she left the room with her resident intending to return to assist with Resident #88. Seven (7) staff members completed written statements (LPN#11, NA#5, Registered Nurse (RN) #34, RN#82, NA#69, NA#89, and NA#115. All confirmed the resident was aggressive and not cooperative with care. After review of the investigation completed by the facility and interviews with LPN#11 at 12:30 p.m. on [DATE] and NA #5 at 10:30 a.m. on [DATE], who were both present shortly prior and immediately after the incident, it was apparent NA #115 was negligent in her care of Resident #88. During an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) at 11:30 a.m. on [DATE], the DON acknowledged she had made the decision that NA #115 had neglected her supervision responsibility to Resident #88 when she lowered the side rail and turned her back allowing him to fall and because of this neglect she was terminated. The ADON agreed with her. A review of the personnel file for NA #115 revealed she had been trained and licensed in another state in 1991 and her license in that state was in good standing when transferred to West Virginia. Her background checks were done on [DATE] and were returned as satisfactory. She had been hired on [DATE], and completed her required orientation which included training on transfers and Alzheimer's training. The Alzheimer's training reviewed the safety and care of cognitively impaired residents.

Based on record review, staff interview and policy review, the facility failed to ensure each resident was free of neglect. The facility failed to fully operationalize procedures to ensure residents received adequate supervision and/or monitoring to prevent a fall with harm. The facility failed to monitor Resident #92 after the resident had received two (2) doses of a newly prescribed emergent injectable anti-anxiety medication [MEDICATION NAME] ([MEDICATION NAME]). After receiving the second dose of [MEDICATION NAME], Resident #92 had an unwitnessed fall with injury requiring medical intervention at an acute care hospital where he expired in less than 24 hours of transfer. There was no evidence the resident was monitored and/or supervised after receiving either dose of the medication [MEDICATION NAME]. Resident #88 did not receive adequate supervision/monitoring during a shower and had a fall from a shower gurney causing harm with a severe injury requiring medical intervention and continued use of an immobilizing cervical collar. This practice was found for two (2) of six (6) sample residents who were reviewed for falls. This practice had the potential to affect all residents in the facility. Resident identifiers: #92 and #88. Facility census: 91. Findings include: a) Resident #92 On [DATE] at 2:30 p.m., a review of the accident/incident log revealed Resident #92 had a total of two (2) unwitnessed falls without injury, one (1) on [DATE] at 0245 (2:45 a.m.) and two falls on [DATE] at 6:00 p.m. and 7:00 p.m. Copies of the accident/incident reports were provided on [DATE] at 3:30 p.m. and found not to match the accident/incident log. The accident/incident reports identified an unwitnessed fall without injury on [DATE] at 0245 (2:45 a.m.) and one (1) report for [DATE] for unwitnessed falls without injury at 6:00 p.m. and 7:00 p.m. (This was found to be inaccurate; the resident only had one fall at 7:00 p.m.). On [DATE] at 9:30 a.m., a record review revealed Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Transfer/Discharge Report, by an unknown author dated ,[DATE] 5:30 p.m. stated, . Resident fell several times today. unable to calm, possible head injury . A review of the nursing progress notes on [DATE] at 09:45 a.m., revealed the following documentation: ---[DATE] at 17:15 (6:15) of Resident had been having increased agitation . Notified MD. received order for [MEDICATION NAME] 1 mg IM (intramuscular) x 1 dose now repeat in 1 hr. if needed . ---[DATE] at 17:59 (7:59 p.m.) IM [MEDICATION NAME] given as ordered at 1800 (6:00 p.m.) to (L) arm . ---[DATE] at 01:58 (1:58 a.m.) Resident is alert and verbal with increased confusion. Resident received IM [MEDICATION NAME] 1 mg at 6p, resident continued to have behaviors and was found on floor beside bed IM [MEDICATION NAME] 1 mg administered at 7P per MD orders . Resident continued to flail around and was unconsolable and was found on floor after second dose of [MEDICATION NAME]. Resident found with head against bottom bed bar, no visible injuries noted . Redness noted to back of head . Respirations even and labored . PA ordered to send resident to Mon Gen for eval . Resident left facility via Star city EMS (Emergency Medical Service) at appox 8 P . (Note was made after Resident was transported to the hospital on [DATE].) There is no evidence in the record of the incident being reported to the appropriate state agencies or of an investigation by the facility of the unwitnessed fall which required medical intervention, nor of the resident being monitored and/or supervised following the administration of either doses of the injectable medication [MEDICATION NAME]. During an interview with Licensed Practical Nurse (LPN) #11 on [DATE] at 11:40 a.m. she commented that she was the nurse going off shift on [DATE]. Resident #92 was aggressive on [DATE] and was trying to destroy the furnace in his room. LPN #11 had notified the Physician and received an order for [REDACTED].#92) daughter. I walked past as I was leaving about 6:30 p.m. and peeked in the room, he was in bed and no one was in his room with him. The Director of Nursing (DON) was interviewed on [DATE] at 12:20 p.m. and asked to explain the procedure for a resident following an aggressive episode that would require medical intervention. She stated, Call the doctor, call the family, keep a close eye on for the next few hours and someone should stay in the room for the first (1st) hour after giving [MEDICATION NAME] or any emergent medication. On [DATE] at 3:45 p.m., in the company of the Director of Nursing (DON), the Administrator and the ADON, a speaker phone interview was conducted with LPN #95 (who was the oncoming nurse on [DATE]). The DON asked LPN #95 if the resident had fallen twice during her shift as was recorded on the accident/incident report. LPN #95 stated, no just the once at 7:00 p.m . no it is incorrect (the accident/incident report documentation), he only had one fall. I did give the IM [MEDICATION NAME] but did not sign it out, it was very busy and I was worried about caring for the resident. After further discussion LPN #95 stated, I stayed with him for about 15 minutes after I gave the second (2nd) dose of [MEDICATION NAME] and then went out because I was in the middle of medication pass. It is not documented but now I know to document that in the notes. A review of the company [MEDICATION NAME] manufacture's package insert for the injectable medication [MEDICATION NAME] ([MEDICATION NAME]), (obtained at the acute care hospital pharmacy) on [DATE] at 8:45 a.m. revealed, Elderly patients .do not operate machinery or motor vehicle during the first 24 hours .monitor for possible respiratory distress's in elderly patients .monitor for falls related to sedation On [DATE] at 9:00 a.m., a review of the community hospital records revealed Resident #92 was admitted to the hospital on [DATE] with the chief complaint of agitation and combativeness, multiple falls and [MEDICAL CONDITION]. Resident #92 expired on [DATE] at 2:15 p.m. The cause of death on the Death Certificate was listed as: a. Acute hypercapnic [MEDICAL CONDITION]. b. Benzodiazepines overdose. A review of the facility reference, Nursing 2015 Drug Handbook revealed the following information regarding the medication [MEDICATION NAME] ([MEDICATION NAME]): CONTRAINDICATIONS & CAUTIONS .use cautiously in elderly, acutely ill or debilitated patients. PATIENT TEACHING .Warn patient to avoid hazardous activities that require alertness or good coordination until effects of drug are known. Due to the resident being newly admitted to the facility, having un-witnessed falls with the latest fall needing medical intervention, the resident expiring in less than 24 hours of being transferred to the community hospital and due to the listed causes of death, it should have been reported to the appropriate state agencies and thoroughly investigated by the facility. Also the resident should have been monitored and/or supervised following the administering of the emergent newly prescribed injectable anti-anxiety medication [MEDICATION NAME]. . b) Resident #88 A review of the clinical record for Resident #88 at 3:00 p.m. on [DATE] revealed he was an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His assessments by his physician included hallucinations, paranoia, delusions, and physical and verbal aggression. He had been determined by a physician to lack the capacity to form medical decisions. Resident #88 was totally dependent on staff for all activities of daily living for over a year. He required use of a mechanical lift for transfers. Due to his poor cognition, he was unable to communicate his needs in an understandable manner. The resident exhibited almost daily behaviors which included being easily agitated during personal care and hitting, shouting, and cursing during personal care. Because of restlessness, and no self-safety awareness due to his cognitive impairment he had been assessed to be High Fall Risk and several safety interventions were included in his Care Plan including: --[DATE] - Bed in low position --[DATE] - Landing mats beside bed --[DATE] - Bed alarm when resident is in bed to alert staff for when resident needs assistance --[DATE] - Mechanical Lift for transfers --[DATE] - Padding to side rails --[DATE] - When resident is out of bed and in his wheelchair a seatbelt will be utilized to assist with body positioning complicated by decreased safety awareness and inability to comprehend verbal safety prompts when given by staff and others. During independent interviews with RN #82 at 8:40 a.m. on [DATE], and RN #11 at 12:30 p.m. on [DATE], both nurses verified that the resident frequently struck out at caregivers and flailed out when touched. They said the interventions identified in the care plan were needed and followed daily. Nurse Aide (NA) #5, when interviewed at 1:15 p.m. on [DATE], said the aides tried to work in pairs for transfers and personal care of Resident #88. At 10:00 a.m. on [DATE], Resident #88 fell from a shower gurney in the shower room approximately three (3) feet onto a tile floor sustaining a laceration to his forehead and a head injury later diagnosed as an acute displaced type II odontoid fracture and fractures through the posterior archy of C1. The fall was observed and the resident received immediate emergency care, 911 was called, and he was transferred to an acute care hospital. The facility immediately reported the incident to the appropriate state offices, suspended the aide involved, and began an investigation. The Immediate Fax Report to the Nurse Aide Registry stated the following: Allegation: CNA was showering this resident, she put the rail down on the shower gurney and turned to get the hoyer pad and the resident rolled off the gurney hitting the floor sustaining a [MEDICAL CONDITION]. All staff working at the time of the incident were interviewed during the investigation and the Five Day Follow-up Report sent to the Nurse Aide Registry on [DATE], stated, Resident did sustain a neck fracture after his fall. After investigation this facility determined this was an accident, however this CNA did fail to follow safety rules and was terminated for such. She was also in her probationary period. In a signed statement from the aide present in the shower room and assigned to care for Resident #88 at the time of the incident she stated: On this day [DATE] I was assigned to shower (Resident #88). While showering (Resident) he was being combative @ times. (CNA #5) another CNA was also in the shower room with me showering another male resident also Licensed Practical Nurse (LPN #11) the treatment nurse came in to change his bandage. I had finished (Resident #88's) shower had him dressed and a lift under him for he was being showered on a shower bed. (CNA #5) had left to transport her resident and was coming back to assist and I had turned my back for a minute to reach for (Resident's) Chair which was in arms length reach and he had rolled himself off of the shower bed. A signed written statement from NA #5 validated the behavior of the resident during his shower and that she left the room with her resident intending to return to assist with Resident #88. Seven (7) staff members completed written statements (LPN#11, NA#5, Registered Nurse (RN) #34, RN#82, NA#69, NA#89, and NA#115. All confirmed the resident was aggressive and not cooperative with care. After review of the investigation completed by the facility and interviews with LPN#11 at 12:30 p.m. on [DATE] and NA #5 at 10:30 a.m. on [DATE], who were both present shortly prior and immediately after the incident, it was apparent NA #115 was negligent in her care of Resident #88. During an interview with the director of nurses (DON) and assistant director of nurses (ADON) at 11:30 a.m. on [DATE], the DON acknowledged she had made the decision that NA #115 had neglected her supervision responsibility to Resident #88 when she lowered the side rail and turned her back allowing him to fall and because of this neglect she was terminated. The ADON agreed with her. A review of the personnel file for NA #115 revealed she had been trained and licensed in another state in 1991 and her license in that state was in good standing when transferred to West Virginia. Her background checks were done on [DATE] and were returned as satisfactory. She had been hired on [DATE], and completed her required orientation which included training on transfers and Alzheimer's training. The Alzheimer's training reviewed the safety and care of cognitively impaired residents.

Based upon record review, staff interview, physician interview, and observation, the facility failed to ensure resident to resident mistreatment and abuse by failing to identify residents whose personal histories rendered them at risk for abusing other residents. The facility failed to develop and implement intervention strategies to prevent occurrences, failed to monitor for changes that would trigger abusive behavior, and failed to reassess interventions on a regular basis. The facility also failed to protect residents from potential abuse and/or neglect by failing to conduct an investigation of an injury of unknown source that constituted harm. The absence of investigation prevented the facility from considering any corrective action to prevent similar injuries to residents. Resident #13 had a tender swollen area on her thigh which was not reported to the physician in a timely manner. When she continued to complain of pain, an x-ray was ordered, followed up by a computerized tomography (CT) scan. The CT scan identified the resident had bilateral [MEDICAL CONDITION] with impaction. Between the initial identification of the tender swollen area, therapy provided passive range of motion (PROM) to the lower extremities. Furthermore, the facility failed to attempt to identify the cause of the fractures for this nonambulatory resident. The failure to communicate the resident's tender, swollen, painful thigh to the physician in a timely manner in conjunction with the failure to communicate this finding to the therapists, and the failure to attempt to identify the cause of the injury resulted in a determination of immediate jeopardy. The Administrator was notified of the immediate jeopardy situation at 2:45 p.m. on 06/11/14. A written notice of the findings was provided to the administrator. At 5:12 p.m., the administrator provided a written plan for the immediate removal of the immediate jeopardy situation. The interventions outlined in the facility's plan were observed to be in place during a brief tour. The abatement plan of correction was prepared and sent to the State Survey Agency at 5:20 p.m. The plan of correction was accepted by the State agency at 5:40 p.m. and the administrator was informed that the Immediate Jeopardy was lifted. Resident #71 was known to hit other residents with her power wheelchair. The facility failed to ensure implementation of effective measures to ensure the resident did not pose a risk to other residents. These concerns were found for two (2) of sixteen (16) sampled residents, but had the potential to affect all residents living in the facility. Resident identifiers: #71 and #13. Facility census: 97. Findings include: a) Resident #13 On 06/04/14 at 3:45 p.m., record review found this [AGE] year-old woman was admitted to the facility on [DATE]. She had a chronic deformity with her hips in a flexed position. 1. The facility notified applicable state agencies of an "unusual occurrence" involving Resident #13 on 04/04/14. The notice was signed by the assistant director of nursing, #51. This notice stated (typed as written): "I am reporting an unusual occurrence that initially happened Monday, March 31, 2014 involving one resident Ms. (#13), her DOB is 9/15/1937. She currently has a [DIAGNOSES REDACTED]. (Resident #13) was noted by staff to be having increased amounts of pain in areas of her left hip, resident was made comfortable in bed with positioning and administration of pain medication prior to her being assessed by Nurse Supervisor who noted no [MEDICAL CONDITION] or deformity of left hip with assessment. The resident was continuously monitored for pain and interventions were continued to assist with diminishing resident's pain level. (Resident #13) did receive an x-ray of her left hip which reflected left femoral head/neck fracture. Nurse Supervisor was then given a verbal order for a CT scan of left hip. This resident was ordered an orthopedic consultation and was continued on non weight bearing status until given the verbal ok via consult and facility doctor. After results of CT scan were received which reflected bilateral [MEDICAL CONDITION] resident was directly admitted to hospital for further evaluation and treatment. . . ." 2. Review of progress notes found Resident #13 was sent to the local acute care hospital on [DATE] where she was admitted with a [DIAGNOSES REDACTED]. Upon her return to the facility on [DATE], it was noted, (typed as written) ". . . resident arrived to facility @1500 from (local hospital) via EMS (emergency medical services) to room (room number). Pleasant and cooperative. Alert to self only, speech clr (clear) hearing and vision intact, makes some needs known to staff, Lng (lung) sounds clr non labored no cough . . . skin warm pink intact, Sara lift for transfers, Diet mech soft, no c/o (complaints of) pain, (physician's assistant) aware of arrival confirmed all meds (medications) as per d/c (discharge) summary cont (continue) [MEDICATION NAME] 500 mg (milligrams) BID (two times a day) x (times) 5 days for Resp inf. (respiratory infection)." -- A progress note dated 03/29/14 at 5:30 stated (typed as written), "Situation: Resident has guarding, crying and c/o pain in left leg....Assessment: Resident has tender, swolen (swollen) area to her left thigh. Resident afebrile, VS (vital signs) WNL (within normal limits). cries out when area is touched. No evidence of bruising or injury. Response: Currently monitor, will notifiy MD for further instructions." -- Continued complaint of pain was documented on 03/30/14 at 12:50 (typed as written): "Resident was in her bed crying, saying her back hurt." -- Continued complaint of pain was documented on 03/31/14 at 12:50 (typed as written): "Situation: Recent left hip xray d/t c/o pain.... Assessment: resident moaning, @x's (at times), went asked to locate pain, resident changing answer with each question, c/o (complained of) R (right) hip, abd (abdomen), r (right) leg, and l (left) hip, no [MEDICAL CONDITION] or instability noted. @x's moving BLE (bilateral or both lower extremities) without discomfort. Response: Notified MD (physician) of results, orders to obtain CT (computerized tomography) scan of left hip outpatient, Hoyer lift and bedrest until further notice. . . ." -- A progress note of 04/01/14 at 13:43 stated (typed as written): "Resident placed on complete bedrest following possible left hip Fx. (fracture) C/O pain to hip, unable to verbalize pain level, but continued to moan, facial grimacing and guarding during care. . . ." X-ray results showed an examination completed 03/31/14 at 14:48:59 suggested left [MEDICAL CONDITION] with impaction. A CT evaluation was recommended. The results of the CT scan, completed on 04/02/14 at 14:39:12, showed a subcapital fracture right femoral neck, and impacted subcapital left femoral neck fracture. 3. On 06/09/14 at 3:30 p.m. an interview was conducted with physical therapist, contracted Employee #108, and head of the therapy department. She provided therapy progress notes. Resident #13 received physical therapy on 03/27/14, 03/28/14, and 03/29/14. She was discharged from therapy on 04/02/14. Her therapy also included training staff with use of Sara lift, chair positioning and bed positioning. The notes documented Resident #13 sat with her legs flexed most of the time due to her bilateral contractures. The treatment provided on 03/29/14 took place from 5:07 to 5:33 p.m., for a total of 26 minutes. The note stated (typed as written): "PROM (passive range of motion) with end range (the furthest a joint moves) stretch to bilateral LE's (lower extremities) for improved positioning. Deep tendon pressure and light soft tissue massage provided to increase resident's tolerance during stretch. Res (resident) with occasional complaints of discomfort that were alleviated with release from stretch position. Upon conclusion of treatment, res resting in approximately 45 degrees of hip and knee flexion bilaterally." 4. On 06/11/14 at 11:40 a.m. an interview was conducted with the registered nurse (RN) supervisor, RN #50. She commented she was the supervisor on duty. She said she was not made aware of the left hip being swollen on 03/29/14. She said the day shift nurse should have followed up on the swollen tender left hip. She said she contacted the doctor and got an order because of the pain on 03/30/14 for the x-ray to be done on 03/31/14 because it was not considered an emergency. She said the director of nursing told her to do a pain evaluation on the 31st and she did evaluate her then. She agreed this was a delay in care and notification of the physician. She said she was not aware therapy treated her on 03/29/14, they should not have because of the documented change in her condition. 5. During an interview on 06/11/14 at 11:04 a.m., the Director of Nursing #24 said she was not aware of the therapy treatment because she could not see what therapy charted because the two (2) electronic medical record (EMR) systems were different. She said the contracted therapy department did not have access to the facility's EMR, and the facility did not have access to the contracted therapy department's EMR. She acknowledged that the treatment was contraindicated for Resident #13, and could have caused injury or exacerbated any existing injury. 6. During an interview on 06/12/14 at 1:20 p.m., the attending physician for Resident #13 said he was unaware of the therapy treatments after Resident #13 returned from the hospital. He said based upon the documentation of onset of pain and swelling, and crying out when the area was touched, the therapy treatment of [REDACTED]. 7. A confidential interview was conducted with a nursing assistant (NA) on 06/10/14 at 10:30 a.m. She said communication between the nurses and the aides was not good. She was concerned when Resident #13 came back from the hospital on [DATE] because they were still being told to use the sit to stand (Sara) lift on her, even with her contractures and her confusion. She said therapy did training on how to use the lift, but said the Sara lift was unsafe for Resident #13. According to the NA, they had a lot of trouble due to her contractures. The resident would yell and cry out when they used it. The aides told the nurses. Then, after the x-rays showed fractures, they changed her to a Hoyer lift for all transfers. 8. An interview was conducted with NA #68 on 06/10/14 at 11:20 a.m. She said staff had difficulty using the Sara lift with Resident #13 due to her contracted position. 9. During the interview on 06/12/14 at 1:20 p.m., the attending physician for Resident #13 said use of the Sara lift for Resident #13 was contraindicated due to her contractures. He said he was unsure of how the fractures happened, but due to the impaction, it would have been from impact and pressure from an up and down movement. 10. Review of physician orders [REDACTED]. Medical Records Coordinator #22, confirmed this during an interview on 06/10/14 at 12:10 p.m. 11. The review found therapy had treated the resident immediately after her readmission of 03/26/14. They treated her on 03/27/14 and, 03/28/14, and even after the onset of "guarding, crying and c/o pain in left leg.... has tender, swollen area to her left thigh...cries out when area is touched" as documented by nursing on 03/29/14 at 5:30 a.m., the therapy department treated her with "endrange stretch to bilateral LE's for improved positioning. Deep tendon pressure and light soft tissue massage provided to increase resident's tolerance during stretch." The director of nursing, nurse supervisor, and the attending physician stated this treatment was contraindicated, and could have caused injury or exacerbated existing injury. The aides continued to follow their instructions to use a Sara lift for all transfers until her bilateral [MEDICAL CONDITION] with impaction were identified, even though they had difficulty doing so and the resident was in apparent pain during these attempted transfers. The attending physician said use of a Sara lift was contraindicated for Resident #13 due to her bilateral hip contractures. It was not possible to categorically state when and how Resident #13 sustained her injuries, but the facility's documentation was that she had no complaints of pain upon her readmission on 03/26/14 and she was to use the Sara lift for transfers. The facility conducted no investigation of these injuries in an attempt to determine the cause. This resulted in a determination of an immediate jeopardy to the well-being of residents. The Administrator was notified of the immediate jeopardy situation at 2:45 p.m. on 06/11/14. A written notice of the immediate jeopardy was provided and a plan of correction requested for the amelioration of the immediate jeopardy. At 5:12 p.m., the administrator provided a written plan of correction for the immediate removal of the immediate jeopardy. The interventions were observed to be in place during a tour. The abatement plan of correction was prepared and sent to the State Survey Agency at 5:20 p.m. The plan of correction was accepted by the State agency at 5:40 p.m. and the administrator was informed the immediate jeopardy was lifted. . b) Resident #71 Record review on 06/03/14 at 2:42 a.m. found Resident #20 was injured 05/26/14 at 2:30 p.m., when Resident #71 propelled her power wheelchair into him, knocking him out of his wheelchair. He fell to the floor striking his head. Additional review of Resident #71's medical record found this [AGE] year-old woman was admitted to the facility on [DATE], and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. She was determined by a physician to lack the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score as assessed on 05/12/14 was "08", indicating moderate cognitive impairment. The review of the record began on 06/03/14 at 2:42 p.m. A review of the resident's medical record found documentation indicating the resident had been identified by the facility as being at risk for dangerous, impulsive behavior since 2009. There were three (3) documented episodes of Resident #71 deliberately striking other residents with her power wheelchair. There was no evidence of any systematic effort to address this ongoing concern until the most recent accident resulted in Resident #20's injury. Progress notes following the incidents were noted as follows (typed as written): 1. On 02/15/13 at 13:52, a general note text included: "Resident was given blank paper as she had asked for and had laying on desk at nurses station. When pt moved away from desk briefly, another female resident came to the desk and lifted papers to look at them, then laid them back down on the desk and moved away. Pt had noted this and ran her electric w/c into back of other female residents w/c. Back up and bumped into her again. Spoke w/ (with) resident and was warned of consequences of being removed from her w/c for rest period if it occurred again. Pt (patient) calm at this time. Attempted to explain but pt was not listening." 2. On 08/18/13 at 14:02, a general note text included: "Alert, able to make needs known at times. Medicated per orders. Resident attempted to jam her electric w/c (wheelchair) into another resident's w/c this shift b/c (because) she was angry with him, easily redirected. Distance provided between two and no further occurrences noted. . . ." 3. On 01/16/14 at 21:17 (9:17 p.m.), a Behavior Charting included: "Resident was arguing with (initials of another resident), who was in her room going through her things. Resident used her motorized wheelchair to hit into (initials of other resident) which prompted (initials of other resident) to bite her foot." Prior to the incident, the resident was sitting at the desk and saw the other resident going into her room. After the residents were separated, the other resident was taken to activities. Resident #71 remained at the desk with staff. Resident had visible bite mark c/o pain at bite site and was given Tylenol. 4. On 02/20/14 at 13:49, it was noted the resident was doing things to agitate her roommate like sitting in front of television, or blocking the bathroom so the roommate could not get in or out. 5. 04/28/14 at 22:21, a behavior charting entry noted the resident was upset because (name of other resident) wandered over and ate some of Resident #71's fruit. Resident #71 ran her wheelchair into the other resident's wheelchair three (3) times. Neither resident was injured during this event. 6. On 05/26/14 at 16:38, another behavior entry noted the resident was angry that another resident had bumped into her wheelchair. She rammed her wheelchair into his wheelchair knocking him over causing him to hit his head on the ground. According to the note, there was no time for interventions because Resident #71 had rammed the other resident's wheelchair too quickly. An interview was conducted with the Administrator, Employee #38, on 06/03/14 at 4:40 p.m. He said there was no incident report completed for the resident to resident incident documented in nurses' notes on 04/28/14, but agreed there were three (3) deliberate power chair ramming incidents documented for 01/16/14, 04/28/14, and 05/26/14. He was asked for evidence of assessments, consultations, discussions with the family, or policy and procedure for screening for safe operation of power wheelchairs. On 06/05/14 at 1:10 p.m., the Administrator advised the facility had no policy and procedure for assessing whether residents were safe to physically control and operate, or psychologically appropriate to operate, power wheelchairs prior to permitting their use in the facility. He said they had written a policy following the incident of 05/26/14, but had to give thirty (30) days notice to residents prior to implementing it. He said there were psychological consultations for Resident #71, but these had been for self-injurious behavior and not to address aggression with her power chair. Earlier evidence of behavior issues were found when requests were made for screening for safe use of power chairs. The evaluating physical therapist concluded on 10/12/09 that Resident #71 was deemed safe to control the functionality of the power chair based upon apparent observations by therapy staff for 5 times for one hour. There was an additional note that stated (typed as written): "No episodes of impulsive, dangerous behavior." There was no explanation as to why this was so documented. The administrator confirmed, during an interview on 06/09/14 at 9:00 a.m., there must have been some prior concern related to impulsive dangerous behavior, although there were no references found in the record. He also agreed that Physical Therapy would not be the appropriate professional to evaluate the risk for impulsive dangerous behavior. A care plan focus item for behaviors was found, which stated (typed as written): "I sometimes have behaviors which include Bumping into other people with the power and door/walls wheelchair." Date Initiated: 5/22/2012. The goal associated with this item was: "My behavior will stop with staff intervention to decrease my episodes to less than monthly thru the next review." Interventions implemented were (date initiated: 6/2/2014) : 1. Attempt interventions before my behaviors begin such as reminding me that I could hurt someone or talk to me about things that interest me such as my family. 2. Do not seat me around others who disturb me. 3. Give me my medications as my doctor has ordered. 4. Help me to avoid situations or people that are upsetting to me. 5. Keep resident from middle of hallways and middle of lobbies to ensure other patient safety . 6. Encourage resident to utilize bell on her WC to alert staff that she needs assistance. Whan a potential confrontation may occur to staff to redirect her behavior and staff will intervene to ensure residents are kept safe. 7. Keep my family involved with my care and any behaviors that I am displaying with my motorized WC so they can help ensure my safety and safety of others around me. (Date Initiated: 5/30/2014) 8. Turn down speed of w/c to medium. On 06/04/14 at 9:30 a.m., both Resident #20 and Resident #71 were observed in the lobby adjacent to the South nurses' station. Resident #71, who was in her power chair drove by Resident #20, then turned and drove in front of him, turned and passed by him a third time. She backed her chair against a wall about three (3) feet from Resident #20 and watched him as he moved slowly around the area, sometimes bumping into other residents who occasionally pushed him away or verbally rebuffed him. He moved toward Resident #71, but never got close enough to touch her. There was no confrontation between the two (2) residents, but Resident #71 watched him intently the entire time. Virtually the same scenario was repeated on the morning of 06/05/14. Again, there was no actual confrontation between the two (2) residents, but they were in very close proximity for a period of at least 20 minutes. Staff made no effort to redirect or relocate any of the residents assembled in the area. During the interview of 06/05/14 at 1:10 p.m., the Administrator confirmed there was long-term evidence of ongoing concern regarding safety issues related to aggressive behavior towards other residents by Resident #71. He agreed the record showed staff were aware of these concerns, but no systematic assessment, consultation, or dialogue with outside professionals or the family was attempted in order to ensure other residents' safety until the injury to Resident #20 on 05/26/14. He agreed many of the care plan interventions were simply impractical or inconsequential. He acknowledged that the power wheelchair was Resident #71's only means of independent ambulation, and that efforts toward ensuring her continued safe use of this equipment should have begun as early as 2009. He confirmed the facility had no means of assessing safe use of power wheelchairs in place for the four (4) residents currently using them. .

Based on record review, staff interview, and physician interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was found for one (1) of sixteen (16) sampled residents. Resident #13 had a tender swollen area on her thigh which was not reported to the physician in a timely manner. When she continued to complain of pain, an x-ray was ordered, followed up by a computerized tomography (CT) scan. The CT scan identified the resident had bilateral [MEDICAL CONDITION] with impaction. Between the initial identification of the tender swollen area, therapy provided passive range of motion (PROM) to the lower extremities. Furthermore, the facility failed to attempt to identify the cause of the fractures for this nonambulatory resident. The failure to communicate the resident's tender, swollen, painful thigh to the physician in a timely manner, failure to communicate this finding to the therapists, and failure to attempt to identify the cause of the injury resulted in a determination of immediate jeopardy. The Administrator was notified of the immediate jeopardy situation at 2:45 p.m. on 06/11/14. A written notice was presented to document that a plan of correction must be presented for the amelioration of the immediate jeopardy. At 5:12 p.m., the administrator provided written evidence that they felt demonstrated that the immediate jeopardy situation had been abated. The interventions were observed to be in place during a tour. The abatement plan of correction was prepared and sent to the State Survey Agency Director at 5:20 p.m. The plan of correction was accepted by the State agency at 5:40 p.m. and the administrator was informed that the immediate jeopardy was lifted. Resident identifier: #13. Facility census: 97. Findings include: a) Resident #13 On 06/04/14 at 3:45 p.m., record review found this [AGE] year-old woman was admitted to the facility on [DATE]. She had a chronic deformity with her hips in a flexed position. 1. The facility notified applicable state agencies of an "unusual occurrence" involving Resident #13 on 04/04/14. The notice was signed by the assistant director of nursing, #51. This notice stated (typed as written): "I am reporting an unusual occurrence that initially happened Monday, March 31, 2014 involving one resident Ms. (#13), her DOB is 9/15/1937. She currently has a [DIAGNOSES REDACTED]. (Resident #13) was noted by staff to be having increased amounts of pain in areas of her left hip, resident was made comfortable in bed with positioning and administration of pain medication prior to her being assessed by Nurse Supervisor who noted no [MEDICAL CONDITION] or deformity of left hip with assessment. The resident was continuously monitored for pain and interventions were continued to assist with diminishing resident's pain level. (Resident #13) did receive an x-ray of her left hip which reflected left femoral head/neck fracture. Nurse Supervisor was then given a verbal order for a CT scan of left hip. This resident was ordered an orthopedic consultation and was continued on non weight bearing status until given the verbal ok via consult and facility doctor. After results of CT scan were received which reflected bilateral [MEDICAL CONDITION] resident was directly admitted to hospital for further evaluation and treatment. . . ." 2. Review of progress notes found Resident #13 was sent to the local acute care hospital on [DATE] where she was admitted with a [DIAGNOSES REDACTED]. Upon her return to the facility on [DATE], it was noted, (typed as written) ". . . resident arrived to facility @1500 from (local hospital) via EMS (emergency medical services) to room (room number). Pleasant and cooperative. Alert to self only, speech clr (clear) hearing and vision intact, makes some needs known to staff, Lng (lung) sounds clr non labored no cough . . . skin warm pink intact, Sara lift for transfers, Diet mech soft, no c/o (complaints of) pain, (physician's assistant) aware of arrival confirmed all meds (medications) as per d/c (discharge) summary cont (continue) [MEDICATION NAME] 500 mg (milligrams) BID (two times a day) x (times) 5 days for Resp inf. (respiratory infection)." -- A progress note dated 03/29/14 at 5:30 stated (typed as written), "Situation: Resident has guarding, crying and c/o pain in left leg....Assessment: Resident has tender, swolen (swollen) area to her left thigh. Resident afebrile, VS (vital signs) WNL (within normal limits). cries out when area is touched. No evidence of bruising or injury. Response: Currently monitor, will notifiy MD for further instructions." -- Continued complaint of pain was documented on 03/30/14 at 12:50 (typed as written): "Resident was in her bed crying, saying her back hurt." -- Continued complaint of pain was documented on 03/31/14 at 12:50 (typed as written): "Situation: Recent left hip xray d/t c/o pain.... Assessment: resident moaning, @x's (at times), went asked to locate pain, resident changing answer with each question, c/o (complained of) R (right) hip, abd (abdomen), r (right) leg, and l (left) hip, no [MEDICAL CONDITION] or instability noted. @x's moving BLE (bilateral or both lower extremities) without discomfort. Response: Notified MD (physician) of results, orders to obtain CT (computerized tomography) scan of left hip outpatient, Hoyer lift and bedrest until further notice. . . ." -- A progress note of 04/01/14 at 13:43 stated (typed as written): "Resident placed on complete bedrest following possible left hip Fx. (fraccture) C/O pain to hip, unable to verbalize pain level, but continued to moan, facial grimacing and guarding during care. . . ." X-ray results showed an examination completed 03/31/14 at 14:48:59 suggested left [MEDICAL CONDITION] with impaction. A CT evaluation was recommended. The results of the CT scan, completed on 4/2/14 at 14:39:12, showed a subcapital fracture right femoral neck, and impacted subcapital left femoral neck fracture. b) On 06/09/14 at 3:30 p.m. an interview was conducted with physical therapist, contracted Employee #108, head of the therapy department. She provided therapy progress notes. Resident #13 received physical therapy on 03/27/14, 03/28/14, and 03/29/14. She was discharged from therapy on 04/02/14. Her therapy also included training staff with use of Sara lift, chair positioning and bed positioning. The notes documented Resident #13 sat with her legs flexed most of the time due to her bilateral contractures. The treatment provided on 03/29/14 took place from 5:07 to 5:33 p.m., for a total of 26 minutes. The note stated (typed as written): "PROM (passive range of motion) with end range (the furthest a joint moves) stretch to bilateral LE's (lower extremities) for improved positioning. Deep tendon pressure and light soft tissue massage provided to increase resident's tolerance during stretch. Res (resident) with occasional complaints of discomfort that were alleviated with release from stretch position. Upon conclusion of treatment, res resting in approximately 45 degrees of hip and knee flexion bilaterally." c) On 06/11/14 at 11:40 a.m. an interview was conducted with the registered nurse (RN) supervisor, RN #50. She commented she was the supervisor on duty. She said she was not made aware of the left hip being swollen on 03/29/14. She said the day shift nurse should have followed up on the swollen tender left hip. She said she contacted the doctor and got an order because of the pain on 03/30/14 for the x-ray to be done on 03/31/14 because it was not considered a emergency. She said the director of nursing told her to do a pain evaluation on03/31/14 and she did evaluate her then. She agreed this was a delay in care and notification of the physician. She said she was not aware therapy treated her on the 03/29/14. She said they should not have because of the documented change in her condition. d) During an interview on 06/11/14 at 11:04 a.m., the Director of Nursing #24 said she was not aware of the therapy treatment because she could not see what therapy charted because the two (2) electronic medical record (EMR) systems were different. She said the contracted therapy department did not have access to the facility's EMR, and the facility did not have access to the contracted therapy department's EMR. She acknowledged that the treatment was contraindicated for Resident #13, and could have caused injury or exacerbated any existing injury. e) During an interview on 06/12/14 at 1:20 p.m., the attending physician for Resident #13 said he was unaware of the therapy treatments after Resident #13 returned from the hospital. He said based upon the documentation of onset of pain and swelling, and crying out when the area was touched, the therapy treatment of [REDACTED]. f) A confidential interview was conducted with a nursing assistant (NA) on 06/10/14 at 10:30 a.m. She said communication between the nurses and the aides was not good. She was concerned when Resident #13 came back from the hospital on [DATE] because they were still being told to use the sit to stand (Sara) lift on her, even with her contractures and her confusion. She said therapy did training on how to use the lift, but said the Sara lift was unsafe for Resident #13. According to the NA, they had a lot of trouble due to her contractures. The resident would yell and cry out when they used it. The aides told the nurses. After the x-rays showed fractures, they changed her to a Hoyer lift for all transfers. g) An interview was conducted with NA #68 on 06/10/14 at 11:20 a.m. She said staff had difficulty using the Sara lift with Resident #13 due to her contracted position. h) During the interview on 06/12/14 at 1:20 p.m., the attending physician for Resident #13 said use of the Sara lift was contraindicated due to her contractures. He said he was unsure of how the fractures happened, but due to the impaction, it would have been from impact and pressure from an up and down movement. i) Review of physician orders [REDACTED]. Medical Records Coordinator #22, confirmed this during an interview on 06/10/14 at 12:10 p.m. j) The review found therapy had treated the resident immediately after her readmission on 03/26/14. They treated her on 03/27/14 and 03/28/14. They treated her after the onset of "guarding, crying and c/o pain in left leg.... has tender, swollen area to her left thigh...cries out when area is touched" as documented by nursing on 03/29/14 at 5:30 a.m., the therapy department treated her with "endrange stretch to bilateral LE's for improved positioning. Deep tendon pressure and light soft tissue massage provided to increase resident's tolerance during stretch." k) The director of nursing, nurse supervisor, and the attending physician stated this treatment was contraindicated, and could have caused injury or exacerbated existing injury. The aides continued to follow their instructions to use a Sara lift for all transfers until her bilateral [MEDICAL CONDITION] with impaction were identified, even though they had difficulty doing so and the resident was in apparent pain during these attempted transfers. The attending physician said use of a Sara lift was contraindicated for Resident #13 due to her bilateral hip contractures. It was not possible to state when and how Resident #13 sustained her injuries, but the facility's documentation revealed she had no complaints of pain upon her readmission on 03/26/14 and she was to use the Sara lift for transfers. The facility conducted no investigation of these injuries in an attempt to determine the cause of the injuries. .