Every finding on record at Mount Vernon Healthcare Center

Based on observation, interview and clinical record review, the facility staff failed to ensure a safe clean, comfortable and homelike environment for all residents of the facility. The findings included: The facility staff failed to ensure the parking lot was free of trash and debris, failed to ensure the entry gate was in good repair and not an accident hazard and failed to ensure that the facility was odor free. The following observations were made throughout the three days of survey: On 6/2/26 at 1p.m, within the parking lot there were two face masks and one pair of used purple latex gloves (used turned inside out as if taken off and thrown down. Litter was throughout the parking lot area and on the grass. The wrought iron gate at the front entrance was wobbly and was not secured in the concrete on one side. During the entrance conference the Administrator notified survey team of one Resident using electronic monitoring. Request was made for the electronic monitoring policy. rooms [ROOM NUMBERS] had signs that deep cleaning was scheduled for 6/4/26, room [ROOM NUMBER] - was cluttered with personal property, shopping bags under bed, a stack of five towels, three wash cloths and two hospital gowns sitting on a chair, room [ROOM NUMBER] has a strong odor of urine.room [ROOM NUMBER] was very cluttered, room [ROOM NUMBER] and 237 are cluttered as well, room [ROOM NUMBER] had a strong odor of urine and body odor. On 6/3/36 at 11:00 AM, the gate to front of facility which was wrought iron and comprised of two side pieces that are supposed to be set in the concrete/ brickwork around porch and the gate itself that swings open. The left side piece was not steady in place it moves and is coming out of the concrete foundation. The surveyor spoke with Administrator about the observations and she stated that she is aware of this being an issue and would now take steps to fix the problem. On 6/3/26 at 3 p.m an interview was conducted with the Administrator, who shared documentation from 3/17/26 QAPI meeting. During the meeting the QAPI team identified Clutter present in resident rooms. The action plan created included pruchasing storage containers, Social Services was to identify highrisk rooms and assist with organizing their belongings. Ambassadors would identify and track progress of residents decluttering on room rounds, reviewed and added clutter to care plans as needed. The QAPI plan revealed that the process was on-going. She also shared that the deep cleaning and decluttering was a process that was ongoing and that they were rotating rooms on the deep cleaning schedule. On 6/4/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided

Based on observation, interview and clinical record review the facility failed to ensure a resident's right to be free from physical restraint for one resident (R1) in a survey sample of ten residents.For R1 the facility staff did not ensure proper the resident had the proper assessment and re-evaluations for continued use of restraints.R1 was admitted to the facility on [DATE] with diagnoses that include but were not limited to dysphagia post stroke, chronic obstructive pulmonary disease, tracheostomy status, gastrostomy tube, dementia, neuromuscular dysfunction of bladder, chronic respiratory failure, generalized anxiety disorder, major depressive disorder, gastro esophageal reflux disease. R1's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/14/26 coded R1 as having a BIMS (Brief Interview of Mental Status) score of 00 out of 15 indicating she could not be evaluated. R1 has dementia and is nonverbal due to her trach status. She used to be able to make needs known, however due to advanced dementia she cannot anymore. R1 is totally dependent on staff for all aspects of ADL care. R1 was bedbound with a contracted left hand. On her right hand she wore a mitten (restraint) due to incidents of pulling out her tracheostomy tube. On 6/2/26 at 2:45 pm, Observations were conducted of R1. R1 was observed laying in bed with no splint to the left hand, right hand has mitten restraint. R1 was dressed in a t-shirt and incontinence brief. Resident has trach with humidified oxygen, emergency supplies, ambu bag trach and inner cannula taped to wall above bed.On 6/3/26 at 10:29 am, R1 was in bed dressed in t shirt and incontinent brief and a sheet not covering legs, right hand mitten in place, R1 eyes closed, right hand is not visible due to mitten restraint. Review of the clinical record revealed the following order:Apply Mitten to right hand Q shift release for ten minutes every 2 hrs. as tolerated every shift for safety for removing Trach monitor for break edges and if dirty removed and replace extra from family supply or call family to replaced new ones. A review of the clinical record and observsations revealed staff following physician orders to remove the restraint every 2 hours for 10 min. A review of the clinical record revealed there were no assessment and reevaluation of continued need of restraint usage. A review of the ADL (Activities of Daily Living) record revealed the following documentation: Behavior Monitoring & Interventions wears right hand mitten for safety Each daily block was documented as NB (No Behavior) for the months of April, May, and June of 2026. On 6/3/26 the Director of Nursing (DON) and Administrator were asked to provide any documentation of initial evaluation and subsequent re-evaluationn of continued need for restraint. On the morning of 6/4/26 the DON reported that R1 has been in the facility since 2019 and they could not locate the initial assessment for the need of a restraint. R1 has documentation in the chart of pulling trach out however there was no documentation of a formal assessment or re-evaluation for continued need of the restraint as required. A review of the facility policy revealed:Policy: It is the policy of this facility that each resident shall attain and maintain his/herhighest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Compliance Guidelines:1. The resident has the right to be treated with respect and dignity, including the right to be free from any physical or chemical restraint imposed for the purpose of discipline or staff convenience, and not required to treat the resident's medical symptoms.2. Physical restraints may be used in emergency care situations for brief periods to permit medically necessary treatment that has been ordered by a practitioner, unless the resident has previously made a valid refusal of the treatment in question. Falls do not constituteself-injurious behavior or a medical symptom that warrants the use of a physical restraint.3. Behavioral interventions should be used and exhausted prior to the application of a physical restraint.4. A physician's order alone is not sufficient to warrant the use of a physical restraint. The facility is responsible for the appropriateness of the determination to use a restraint.5. Before resident is restrained, the facility will determine the presence of a specific medical symptoms that would require the use of restraints, and determine:a. How the use of restraints would treat the medical symptom.b. The length of time the restraint is anticipated to be used to treat the medical symptom, who may apply the restraint, and the time and frequency that the restraint will be released.c. The type of direct monitoring and supervision that will be provided during use of the restraint.d. How the resident will request staff assistance and how his/her needs will be met while the restraint is in place.e. How to assist the resident in attaining or maintaining his/her highest practicable level of physical and psychosocial well-being.6. Medical symptoms warranting the use of restraints should be documented in the resident's medical record. The resident's record needs to include documentation that less restrictive alternatives were attempted to treat the medical symptom but were ineffective, ongoing reevaluation of the need for the restraint, and the effectiveness of the restraint in treating the medical symptom. The care plan should be updated accordingly to include the development and implementation of interventions, to address any risks related to the use of the restraint.7. The resident/resident's representative may request the use of a physical restraint; however, the facility is responsible for evaluating the appropriateness of the request, and must determine if the resident has a medical symptom that must include the practitioner in the review and discussion. If there are no medical symptoms identified that require treatment, the use of the restraint is prohibited. The facility shall explain to the resident/resident's representative, the potential risks and benefits of using a restraint, not using a restraint, and alternatives to restraint use. Potential negative outcomes should also be explained including, but not limited to:a. Decline in physical functioningb. Decreased muscle conditionc. Contracturesd. Increased risk for infectione. Pressure ulcers/injuriesf. Deliriumg. Agitationh. Incontinencei. Accidents such as falls, strangulation, or entrapmentj. Loss of autonomy and dignityk. Withdrawal or reduced social contact8. The resident/resident's representative has the right to refuse the use of a restraint and may withdraw consent to use the restraint at any time. The refusal must be documented in the resident's record. The facility will assess the resident and determine how the resident'sneeds will be met if the resident refuses/declines treatment.9. If a resident is admitted to the facility and a restraint was used in a previous health care setting, the facility must still conduct an assessment to determine the existence of medical symptoms that warrant the continued use of the restraint, that include, but not limited to:a. Interventions, including less restrictive alternatives were attempted to treat the medical symptom but were ineffective.b. The resident/resident's representative was informed of potential risks and benefits of all options under consideration including using a restraint, not using a restraint, and alternatives to restraint use.10. A device that is utilized by the resident that was placed by the facility and has been determined by the facility that the resident can remove requires demonstration by the resident of removal of the device without staff providing specific instructions for theremoval. On 6/4/26 during the end of day meeting the Administrator was made aware of the concern, and no further information was provided.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure residents receive the necessary services to maintain good grooming, and personal hygiene, for one resident (R1) in a survey sample of ten residents.For R1 the facility staff failed to ensure the resident had adequate grooming to include nail care. R1 was admitted to the facility on [DATE] with diagnoses that include but were not limited to dysphagia post stroke, chronic obstructive pulmonary disease, tracheostomy status, gastrostomy tube, dementia, neuromuscular dysfunction of bladder, chronic respiratory failure, generalized anxiety disorder, major depressive disorder, gastro esophageal reflux disease. R1's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/14/26 coded R1 as having a BIMS (Brief Interview of Mental Status) score of 00 out of 15 indicating she could not be evaluated. R1 has dementia and is nonverbal due to her trach status. She used to be able to make needs known, however due to advanced dementia she cannot anymore. R1 is totally dependent on staff for all aspects of ADL care. R1 was bedbound with a contracted left hand. On her right hand she wore a mitten (restraint) due to incidents of pulling out her tracheostomy tube. The following observations were made of R1: On 6/2/26 at 2:45 pm, R1 was observed laying in bed with no splint to the left hand, right hand has mitten restraint. Lef hand fingernails are observed to be long. R1 was dressed in a t-shirt and incontinent brief. R1 has trach with humidified oxygen, emergency supplies, ambu bag trach and inner cannula taped to wall above bed. On 6/3/26 at 10:29 am, R1 was again observed in bed dressed in a t-shirt and incontinent brief and a sheet not covering legs, right hand mitten in place, R1 eyes were closed, and there was an odor in room. R1's left hand does not have splint as stated in care plan and orders. The left hand nails are long more than 1/4 inch over nail bed, right hand is not visible due to mitten restraint. On 6/3/26 at 2:10 pm, the DON (Director of Nursing) donned [put on] gloves, isolation gown and carefully opened R1's left hand which was contracted, to view the palm. There was no visible injury from nails however the DON stated he believed podiatry cuts her nails. When asked how often podiatry comes to the building he stated monthly. The DON released restraint from right hand and examined palm nails also long on the right hand however no damage to the hand from nails. On 6/3/26 at 3:30 pm, the DON notified the surveyor that podiatry cuts R1 toenails and the unit manager is the one who cuts the resident's fingernails. On 6/3/36 a review of the ADL policy revealed the following: Definitions: Nail hygiene services: refers to routine trimming, cleaning, filing but not polishing of undamaged nails, and on an individual basis, care for ingrown or damaged nails. Hair hygiene services: refers to the routine combing, brushing, shampooing, trimming and simple haircuts Policy:It is the policy of this facility to promote resident centered care by attending to the physical emotional, social, and spiritual needs and honor resident lifestyle preferences while in the care of this facility. This facility will provide routine care for the resident for hygienic purposes and for the psychosocial well-being of the resident including but not limited to hair hygiene that includes combing, brushing, shampoo, trimming and simple haircuts. Routine care also includes nail hygiene services including routine trimming, cleaning and filing. Routine Nail hygiene and hairhygiene may be performed in conjunction with bathing or performed separately. Care for ingrown or damaged nails will be provided on an individual care need basis. These services are provided by the facility as part of regular grooming care. Nail care for diabetic residents will be completed by a licensed nurse. Procedure: I. Routine Nail Hygiene a. Residents will have routine nail hygiene and hair hygiene as part of the bath or shower i. Nails should be trimmed immediately after bathing or alternatively, soaking nails in warm soapy water prior to trimming or filing to reduce tearing and provide ease of trimming and filing. A review of the clinical record revealed the documentation on the ADL (Activities of Daily Living) record of R1 receiving 2 bed baths per week for the months of April, May and June of 2026, there was no documentation of hair being washed, nor nails being trimmed. On 6/4/26 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure receive asppropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one resident (R1) in a survey sample of ten residents.The findings include: For R1 the facility staff failed to ensure the left hand splint was applied as ordered by the physician for the express purpose of preventing worsening of contractures. R1 was admitted to the facility on [DATE] with diagnoses that include but were not limited to dysphagia post stroke, chronic obstructive pulmonary disease, tracheostomy status, gastrostomy tube, dementia, neuromuscular dysfunction of bladder, chronic respiratory failure, generalized anxiety disorder, major depressive disorder, gastro esophageal reflux disease. R1's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/14/26 coded R1 as having a BIMS (Brief Interview of Mental Status) score of 00 out of 15 indicating she could not be evaluated. R1 has dementia and is nonverbal due to her trach status. She used to be able to make needs known, however due to advanced dementia she cannot anymore. R1 is totally dependent on staff for all aspects of ADL care. R1 was bedbound with a contracted left hand. On her right hand she wore a mitten (restraint) due to incidents of pulling out her tracheostomy tube. A review of the clinical record revealed the following order: Device: wear left resting hand splint 6 hours per day. Donn at 10:00AM and doff at 4:00 PM . every day and evening shift Complete Skin Checks and remove for hygiene. The following observations were made regarding R1's use of splint. On 6/2/26 at 2:45 pm, R1 was observed laying in bed with no splint to the left hand, the right hand had a mitten restraint. R1 was dressed in a t-shirt and incontinent brief. R1 was noted to have a trach with humidified oxygen, emergency supplies, ambu bag trach and inner cannula taped to wall above bed. On 6/3/26 at 10:29 am, R1 was again observed in bed, dressed in a t-shirt and incontinent brief with a sheet not covering legs, right hand mitten was in place, R1's eyes were closed. The right hand was not visible due to mitten restraint. On 6/3/26 at 1pm an interview was conducted with a certified nursing assistant (CNA 2) who stated The nurse is supposed to put the splint on because she has to sign it off in her documentation. On 6/3/26 at 1:25 pm an interview with a licensed practical nurse (LPN 1) was conducted and LPN 1 stated that nurses put the splints on and off since they are responsible for the documentation in the chart. On 6/3/26 at 2:10 pm, an interview was conducted with the DON (Director of Nursing) who stated that it is the expectation of the facility that physician orders are followed and splints are put on as ordered by the physician. On 6/4/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure that tracheostomy care was provided in accordance with standards of practice for one resident (Resident 1 (R1)) in a survey sample of ten residents. The findings included: For R1the facility staff failed to use proper procedure and documentation of tracheal care and suctioning, R1 was admitted to the facility on [DATE] with diagnoses that include but were not limited to dysphagia post stroke, chronic obstructive pulmonary disease, tracheostomy status, gastrostomy tube, dementia, neuromuscular dysfunction of bladder, chronic respiratory failure, generalized anxiety disorder, major depressive disorder, gastro esophageal reflux disease. R1's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/14/26 coded R1 as having a BIMS (Brief Interview of Mental Status) score of 00 out of 15 indicating she could not be evaluated. R1 has dementia and is nonverbal due to her trach status. She used to be able to make needs known, however due to advanced dementia she cannot anymore. R1 is totally dependent on staff for all aspects of ADL care. R1 was bedbound with a contracted left hand. On her right hand she wore a mitten (restraint) due to incidents of pulling out her tracheostomy tube. On 6/3/26 observations were conducted of licensed practical nurse #1 (LPN 1) providing tracheostomy care and suctioning on R1 On 6/3/26 at 12:00pm, LPN 1 was again observed performing trach care and suctioning LPN 1 assembled equipment, performed hand hygiene, donned [put on] personal protective equipment (ppe), proceeded to set up and turn on suction, removed the inner cannula, placed it in saline solution to clean, attached suction cannula and introduced it 4-6 inches in trach, withdrew cannula applying suction on withdrawal, cleared cannula using normal saline, repeated procedure several times. LPN 1 did not explain procedure, assess lung sounds prior to or post suctioning, nor did LPN 1 check R1's oxygen saturation (pulse ox). On 6/3/26 at approximately 3:30 pm an interview was conducted with the DON (Director of Nursing) who stated it is the expectation of the facility that nurses follow the trach and suction policy and procedure of the facility each time they suction and provide trach care. The DON stated that the professional standard used by the facility is [NAME]. Per [NAME] lww.comLippincott procedures. Tracheostomy Suctioning. November 28, 2022. Lippincott procedures -Tracheostomy suctioning (lww.com)Policy: Residents may require suctioning by a licensed, competent nurse or respiratory therapist to clean the throat and upper respiratory tract of secretions that may block the airway. Process steps may be performed using a different sequence and does not imply incorrect procedure. Each resident's care will be based upon an assessment of their medical needs, and the resources available at the time of the procedure in consideration of emergency needs.Procedure:A. Open Suctioning System:1. Gather equipment and set up, attach suction tubing to canister.2. [NAME] appropriate PPE3. Explain the procedure to the patient and screen for privacy.4. Auscultate pre procedure lung sounds5. Suctioning can be a frightening experience; allow the patient an opportunity to catch his/herbreath between episodes of suctioning.6. Position patient semi to high fowler's, if tolerated7. Wash hands.8. Place sterile towel (paper) on table.9. Place cup on sterile area, pour approximately 50-100cc sterile water or saline into cup.10. Put on sterile gloves.11. Attach suctioning tip to the connecting tubing.12. Turn on suction source. Remembering to keep one hand sterile. Set the pressure between 80-120mmHg for adults.13. Insert catheter into tracheostomy tube opening gently during inspiration until resistance is felt or patient starts to cough. DO NOT apply suction while inserting.14. Withdraw catheter about inch15. Place finger over catheter suction port approximately 10-12 seconds.16. Rotate and withdraw catheter smoothly. Rinse tubing by suctioning the sterile water or saline through the suction tubing to clear the tubing if necessary.17. Repeat tracheostomy suctioning if necessary.18. Clean the trach site and position patient comfortably.19. Post Procedure:a. After completion of suctioning, wrap the suction catheter around the gloved hand; pull the glove over the coiled catheter and discard both into the designated container.b. Replace a disposable suction collection canister, as necessary (at least weekly).c. Rinse and clean a non-disposable suction collection canister, as necessary ifsecretions are adhered to the container, discard or disinfect, as appropriate.d. Remove PPE and perform hand hygienee. Auscultate lung sounds and obtain oxygen saturation reading Documentation:1. Document the procedure and resident tolerance in the medical record2. Document pre and post lung sounds, oxygen saturation level and any significant findings. On 6/4/26 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observation, interview, and facility documentation the facility staff failed to prepare, food in accordance with professional standards for food service safety for all residents who recieve food from the kitchen. For all residents receiving food from the kitchen, other employee one did not wear a beard guard while preparing salads in the kitchen to reduce the risk of food contamination. On 6/3/26 at 9:00 a.m. a dietary aide (other employee 1) was observed packaging/dating the salads without a hair net or beard guard on. At 9:05 a.m., an interview was conducted with other employee 1 who stated that he forgot to put on the beard guard. At 9:15 a.m., an interview was conducted with the Dietary Manager who stated that it is the expectation of the facility that all staff use appropriate head and beard covering at all times in the kitchen. A review of the facility policy revealed the following excerpt: Authorized Kitchen Personnel Policy: .2. All authorized personnel must wear appropriate head covering while i the kitchen or production area (e.g. hair off the shoulders, confined in a hair net or cap and facial hair properly restrained.) . On 6/4/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview, and facility policy review, the facility to ensure food was labeled, dated, and discarded when beyond the use by date per the facility's policy. This failure had the potential to create an environment for food-borne illnesses which could affect 123 of 123 residents who consumed food prepared from the facility's kitchen.Findings include:During a tour of the kitchen on 04/20/26 at 10:30 AM with the Regional District Dietary Supervisor (RDDS), the main refrigerator revealed the following: 18 uncovered cucumbers with white spots and soft to the touch were inside an uncovered and undated cardboard box. Cut green peppers in a one-pound plastic bag. The peppers had visible white spots and were dated 04/07/26. Cut red peppers in a one-pound plastic bag. The peppers had visible white spots and were dated 04/07/26. One half pound of butter in an open wrapper on the shelf. There was no date on the package. Six pork chops in a plastic bag inside a cardboard box. The cardboard box was wet in the corner with what appeared to be leaking from the pork chop bag. The date on the package was 04/12/26. During an interview on 04/20/26 at 11:15 AM, the RDDS confirmed the above observations and stated the dates on the food items were the dates the food was stored. The RDDS stated that butter product should have been in closed packaging and dated by staff. The RDDS confirmed that all products should have been used before they were expired. The RDDS also stated that there was no procedure or a schedule for dietary staff to check the stored foods' expiration dates. Review of the facility's policy titled, Dining Services Policy and Procedure Manual specifically the section titled Food Storage: Cold Foods, dated 02/2003 revealed that all food will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility's policy Food Storage and Retention Guide, dated 2017 revealed that animal and plant food was to be kept up to seven days; butter dairy products could be kept for one to three months.

Based on record review, interview, and document review, the facility failed to provide an opportunity for residents who were registered to vote to exercise their right to vote for three of 66 residents identified by the facility as being registered voters (Resident (R) 3, R21, and R79). On 04/21/26 a special state election was held; however, the residents were not informed of the election nor aided to vote. This failure caused the residents not to be able to exercise their right to vote. Findings include:1. Review of R2's admission Record located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R2's significant change in status Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/19/26 located in the resident's EMR under the MDS tab revealed the resident had a Brief Interview for Mental Status (BIMS) Score of 15 out 15 which indicated the resident was cognitively intact. An interview on 04/21/26 at 12:37 PM with R2 revealed the resident was aware that voting was occurring on this date and he had been waiting for his absentee ballot, but he never received it. The resident stated that the facility had not offered any information about the election prior to today. The resident stated he had voted in every election and felt his right to vote was being denied. 2. Review of R67's admission Record located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R67's significant change in status MDS with an ARD of 03/19/26 and located in the resident's EMR under the MDS tab revealed the resident had BIMS score 14 out 15 which indicated the resident was cognitively intact. An interview on 04/22/26 at 12:16 PM with R67 revealed the resident was a registered voter and had seen the commercials about the upcoming elections but no one had approached him about voting. The resident further stated if the staff asked him, he would have voted. 3. Review of R79's admission Record located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R79's Annual MDS with an ARD of 01/30/26, located in the resident's EMR under the MDS tab revealed the resident had BIMS score of 14 out of 15 which indicated the residents was cognitively intact. An interview on 04/21/26 at 9:38 AM revealed R79 was not made aware of voting occurring in Virginia today. R79 stated that she would like to have voted. A review of facility's list of registered voters dated 4/21/26 revealed R2, R67, and R79 were listed as registered voters. An interview on 04/21/26 at 9:44 AM with Activity Leader (AL) revealed she was unsure if any election was occurring today. At 9:55AM the AL returned and stated there was a Virginia election occurring today and to her knowledge no information had been given to the residents. An interview on 04/21/26 at 3:55 PM with the Activities Director (AD) revealed that since she did not live in Viriginia, she was not sure if there was an election occurring. The AD stated that she maintained a list of residents that were registered to vote and most of the residents voted via absentee ballots. The AD stated no absentee ballots were issued to the residents or any other opportunity to vote was offered. The AD stated voting activity was the responsibility of the Social Service Director (SSD). During an interview on 04/22/26 at 3:50 PM with the Administrator revealed that none of the residents that were registered to vote expressed an interest in participating in the election. The Administrator acknowledged no arrangements were made to inform the residents of the upcoming election. During an interview on 04/23/26 at 11:30 AM, the SSD stated the AD was responsible for resident voting.

Based on observations, record review, interviews, and review of facility policy, the facility failed to provide a program of activities to support two of three sampled residents reviewed for activities (Resident (R) 67 and R79) out of 31 sampled residents. This failure has the potential to negatively impact quality of life for the affected residents. Findings include:1. Review of R67 admission Record located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility with diagnoses that included cerebrovascular infraction with hemiplegia, and hemiparesis affecting the right side, diabetes mellitus, neuromuscular dysfunction of the bladder, and major depression. Review of R67's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 01/08/26, located in the resident's EMR under the MDS tab revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out 15 points which indicated the resident was cognitively intact. Review of R67's Activity Preferences Interview dated 03/19/26 located in the resident's EMR tab Assessments revealed the resident preferred to attend activities in the afternoon in his room, day/activity room. The interview indicated that the resident was interested in audio books/ reading/writing, watching television or movies, listening to the radio, computer, keeping up with the news, religious activities and bible study. Review of R67's Care Plan with a revision date of 04/14/26 located in the resident's EMR tab Care Plans revealed the resident was self-directed for activities in and out of his room. The care plan indicated the resident would participate in activities of choice or one-to-one. During an interview on 04/22/26 at 12:16 PM, R67 stated he did not attend activities outside of his room since he was bed bound. The resident stated there is an activities calendar posted on the wall, but he could not read it. The resident stated that no activity staff had ever come to his to offer one to one activities. The resident stated that he would like to have someone play chess with him or read to him; the only time staff come into the room was to provide care and no one really spent time with him. 2. Review of R79 's admission Record located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility 02/14/25 with diagnoses that include end stage renal disease with dialysis, peripheral vascular disease, right above the knee amputation and major depressive disorder. Review of R79's annual MDS with ARD of 01/20/26 located in the resident's EMR under the MDS tab revealed the resident had a BIMS score of 14 out of 15 points which indicated the resident was cognitively intact. Review of R79's Activity Preferences Interview dated 2/17/26 located in the resident's EMR tab Assessments revealed the resident preferred music, television watching and movies, radio, reading books, cooking, computers, religious studies, keeping up with the news, talking and conversing with others. Continued review revealed that the resident preferred to attend activities in the morning or afternoon. Review of R79's Care Plan with a revision date of 02/26/26 located in the resident's EMR under the Care Plans tab documented the resident preferred to stay in her room for activities; and the resident would engage in one-to-one activities with staff. An interview on 04/21/26 at 9:38 AM revealed R79 was bedbound and did not like to attend activities, especially Bingo. R79 stated that no one had ever come to her room and offered to engage her in one-to-one activities. Observations on 04/20/26 through 04/23/26 revealed both residents had activities calendars posted on the wall in their room. The calendars were posted across the room out of the residents' view. The following activities were posted: 04/20/26 Morning puzzles, trivia, chips and chat social and word scramble 04/21/26 Jewelry making, bingo, gaming hour, activities cart, 04/22/26 morning painting, grilled cheese social, hangman, activities cart 04/23/26 activities book club, bowling, rosary, the great outdoors, freestyle activities Observation on 04/20/26 at 10:43 AM revealed an activity staff member going to residents' room asking if they wanted to participate in the morning puzzle activity. However, the staff member did not ask R69 if he was interested in attending the activity. Observation for 04/21/26 at 10:45 AM revealed an activity staff member encouraged a few residents to attend jewelry making activity scheduled for 11:00 AM; however, the activity staff member did not invite R67 or R79. Observation on 04/21/26 at 3:30 PM revealed an activity in progress in the main dining room; however, R67 and R79 were not present. Continued observation revealed there was no activity being provided to either resident in their room. An interview on 04/23/26 11:10 AM with the Activities Director (AD) revealed that she maintained a list of residents that required one-to-one activities. Those residents would receive one-to-one visits at least twice a week. The AD stated the one-to-one visits were supposed to last at least 30 minutes. Each resident had a log sheet on which the staff documented the visit (type of activity performed) and the length of the visit. The AD was unable to provide any activity documentation for R67 and R79. Review of the facility's undated policy titled, Activities Program reads as follows: .The activity program is designed to encourage restoration to self-care and maintenance of normal activity that is geared to the individual resident's needs.consists of individual and small and large group activities which are designed to meet the needs and interests of each resident.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure a medication was given as ordered by the physician for one of six residents observed during medication administration out of 31 sampled residents (Resident (R) 31). Specifically, R31 was ordered by his physician to be administered a chewable aspirin tablet; however, the resident was administered an extended-release aspirin. Additionally, the aspirin was crushed prior to being administered to the resident even though the manufacturer's recommendations indicated the aspirin should not be crushed. These failures had the potential to cause the resident adverse side effects.Findings include:Review of R31's Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R31 was originally admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following unspecified cerebrovascular disease, gastro-esophageal reflux disease without esophagitis. Review of R31's Physician Orders provided by the facility revealed an order dated 02/12/22 for aspirin table chewable 81mg, (milligram) to be given by mouth one time a day. On the bottom of the order sheet the Physician wrote order, may crush meds unless contraindicated/ During an observation of medication administration on 04/22/26 at 8:42 AM, Licensed Practical Nurse (LPN) 1 crushed a delayed release aspirin 81 mg tablet, placed it in apple sauce, and administered it to R31. During an interview on 04/22/26 at 2:36 PM, the Director of Nursing (DON) was asked if a delayed release aspirin tablet should be crushed. The DON stated, No, there are meds [medications] that can be [crushed] but not that one. During the interview on 04/22/26 at 8:56 AM, LPN1 was asked why R31 was administered a delayed released aspirin tablet that was crushed and not the physician ordered chewable aspirin tablet, LPN1 stated, I thought the regular aspirin was better to crush than the chewable, and it's easier to get him to swallow. Review of the facility's policy titled, Policies and Standard Manual, References UHS Berkely. (2013), indicated, .t. crushing medications. iii. Follow manufacturer's recommendations for medications that note do not crush. Manufacturers recommend not crushing an enteric-coated (a delayed release coating mechanism) , aspirin 81 mg tablets. The coating is designed to protect your stomach from irritation by allowing the tablet to pass through and dissolve later. Crushing destroys this protection and may cause stomach issues, from [NAME] Enteric Coated Aspirin company.

Based on observations, interviews, record review, and policy review, the facility failed to ensure the urinary catheter tubing and collection bag were not in contact with the floor for one (Resident (R)67) of three residents reviewed for catheters and urinary tract infection. This failure placed the residents at risk for transmission of infection to the urinary tract.Findings include:Review of R67Resident (R)67 's admission Record located in the resident's electronic medical records tab Profile revealed the resident was admitted to the facility on [DATE] with diagnosis that included neuromuscular dysfunction of the bladder. Review of R67's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date of 03/19/26 revealed the resident had an external catheter to a urinary drainage bag. Observation on 04/22/26 at 12:16 PM revealed R67's urinary drainage bag dragging on the floor. Certified Nursing Assistant (CNA)1 had finished providing care to the R67. Observation on 04/22/26 at 12:45PM revealed R67 urinary drainage bag continued to drag on the floor. An additional observation on 04/22/26 at 2:40PM revealed the resident urinary drainage continued to drag on the floor. The drainage bag contained approximately 300 milliliters amber colored urine During an interview on 04/22/26 at 2:50PM, Licensed Practical Nurse (LPN)1 was asked to inspect the resident to see if he was positioned properly. The resident's urinary drainage bag continued to drag on the floor. LPN1 felt the resident was properly positioned. LPN1 was asked about the resident's urinary drainage bag on the floor. LPN1 picked up the drainage bag and held it above the level of the resident's bladder. The urine in the tubing back up towards the resident's bladder. LPN1 then laid the drainage bag full of urine on bed with the resident and proceeded to pull the resident up in bed. As the resident was being pulled up in bed the urinary drainage fell on the floor and LPN1 was stepping on the drainage bag while positioning the resident in bed. Afterwards LPN 1 realized the drainage was on the floor and instructed the CNA to place the drainage bag in a basin so it would not touch the floor. Interview with LPN1 on 04/22/26 at 3:05PM, revealed that he could not explain the concern about the drainage bag touching the floor and being held above the resident's bladder area. During an interview with the Infection Preventionist (IP) on 04/23/26 at 10:45AM the scenario with R67 urinary drainage bag was discussed. The IP stated that it looked like she would have to do more training on how to position urinary drainage bags. Review of the facility's undated policy titled Condom Care External Catheter Application and Removal directs staff to .Collection bag should remain dependent of the bladder preventing urine flowing back to the resident

Based on observation interview, facility policy review, the facility failed to ensure medications were maintained in accordance with expiration date requirements for one of two medication storage rooms. A total of five medication units were identified as expired and remained in active storage within the medication room refrigerator, and one Tuberculin vial that had been open and used out of and not dated, creating the potential for administration beyond pharmacy's expiration dates. This indicates a failure to ensure proper monitoring, removal, and disposal of expired medications in accordance with facility policy and regulatory standards.Findings include:During an observation on 04/22/26 at 4:03 PM with Licensed Practical Nurse (LPN) 1 of the first-floor medication storage room, revealed the medication storage refrigerator contained five bags of expired Fetroja, (an intravenous (IV) antibiotic) 2 GM, (gram)/100mg (milligram). One bag had a use by date of 04/16/26 and four bags had a use by date of 04/19/26. Continued observation of the medication storage refrigerator revealed an opened box which contained a vial of Tuberculin. The vial's top had been removed. The vial nor the box was dated to indicate the opening of the vial. LPN1 sated he did not open it and did not know when the expiration would be. During an interview with Licensed Practical Nurse, (LPN),1 on 04/22/26 at 4:05 PM, revealed that he was to remove the bags when the new medication came in which was on the 16th and the 19th and he did not remove them and send them back to the pharmacy as the policy notes too. LPN1 stated, I did not do that. It should have been dated when it was opened. During an interview with Director of Nursing, (DON), on 04/22/26 at 4:35 PM, it was revealed, the medication should have been removed and not in the medication room. When asked about the Tuberculin vial not dated, DON stated, They are to put the date on it when it is opened, the first time it is used. Review of the facility's titled, policies and standard procedures dated 2013, revealed that .aa. For medications that expire, label the date open on the label) insulin, irrigation solutions etc.) . There was nothing in the policy about expired medications on replacing or sending back to the pharmacy.

Based on record review, observations, interview and review of facility policy, the facility failed to ensure that staff members were donning the appropriate personal protective equipment (PPE) for two of four residents (Resident (R)2 and R67) reviewed for enhanced barrier precautions (EBP) and contact isolation from a sample of 31 residents. The facility also failed to ensure the correct signage was posted for one resident (R2) with Methicillin Resistant Staphylococcus Aureus (MRSA). These failures had the potential to promote the spread of infectious diseases. Findings include:1. Review of R2's admission Record located in the electronic medical records (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included left hip open wound, resistance to multiple antimicrobial drugs, congestive heart failure, extended spectrum beta lactamase (ESBL) resistance, resistance to carbapenem, and cutaneous abscess of the left leg. Review of R2's Physician Orders for month of April 2026 located in the EMR under the Orders tab revealed the resident was on EBP related to wound and peripheral inserted central line placement (PICC). Observation on 04/20/26 at 10:30 AM revealed the signage indicated R2 was on contact isolation and EBP was posted on the resident's door. Also, directions for donning and doffing PPE which included wearing a face mask was posted on the resident's door. There was an isolation cart outside the resident room which contained face masks, gowns, gloves, and hand sanitizer. Observation on 04/20/26 at11:27 AM, revealed Licensed Practical Nurse (LPN) 1 entered R2's room without wearing a gown or gloves. LPN1 remained in the resident's room approximately five minutes with the door closed. During an interview on 04/20/26 at 11:42 AM, LPN1 revealed he did not go all the way in the resident's room, and he just wanted to remind R2 about his appointment later in the afternoon. LPN1 acknowledged R2 was on contact isolation for MRSA but since he did not go completely in the room it was not necessary for him to wear PPE. During an interview on 04/22/26 at 1:10 PM, the Director of Nursing (DON) revealed R2 should be on contact isolation for MRSA and staff should be wearing gowns and gloves when entering the room according to the signage on the door. The DON verified the EBP signage did not apply to this resident; it was incorrect signage for this resident. 2. Review of R67's admission Record located in the EMR Profile tab revealed the resident was admitted to the facility with diagnoses that included cerebrovascular infraction with hemiplegia, and hemiparesis affecting the right side, diabetes mellitus, neuromuscular dysfunction of the bladder, and major depression. Review of R67's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/08/26 located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 14 out 15 points which indicated the resident was cognitively intact. Review of R67's Physicians Orders for the month of April 2026 located in the EMR under the Orders tab revealed the resident was on EBP related to the use of the condom catheter. Observation on 04/20/26 at 12:50 PM revealed signage was posted on R67's door for EBP that directed staff to wear gowns and gloves while providing direct care. Certified Nursing Assistant (CNA) 1 was assisting the resident with dressing. CNA1 wore only gloves and no gown while providing direct care. Observation and interview on 04/22/26 at 12:24 PM revealed CNA1 had finished providing peri-care to R67. CNA1 was wearing only gloves and no gown. CNA1 stated he forgot to don the gown this afternoon. Interview on 04/23/26 at 10:15 AM, the Infection Preventionist (IP) stated that EBP should never have been placed on R2's door since he was diagnosed with MRSA, other antimicrobial organisms and intravenous antibiotic therapy. The IP also stated it was an expectation that staff would wear gowns and gloves for those residents that are on EBP when providing direct care. Review of the facility undated policy for Enhanced Barrier Precautions directs staff as follows . Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs hand hygiene, targeted gown and glove use during high contact resident care activities that include; Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing.

Based on clinical record review, staff interview, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards for 1 resident, Resident #1, in a sample size of 3 residents. The findings included: For Resident #1, facility staff failed to utilize proper turning/repositioning technique while providing care. Resident #1 was discharged from the facility on 9/22/23 and therefore not available for observation and direct interview. On 11/14/23, a telephone call was placed to the last known number for Resident #1 and there was no answer. On 11/14/23, Resident #1's clinical record was reviewed in its entirety. A progress note dated 8/19/23 at 13:30 read, Resident is alert and verbally responsive and complained of pain in his right shoulder, he stated that the aid [certified nursing assistant-CNA] from last night pulled his right shoulder when she tried to turn him while doing the ADL [activities of daily living] care, upon assessment pain was rated 6/10, vital signs were stable . Resident #1 received Tylenol which relieved his pain. The physician ordered a right shoulder xray which resulted as negative for dislocations and fractures. On 11/14/23 at approximately 3:30 PM, an interview was conducted with the Facility Administrator and Director of Nursing (DON). The Facility Administrator verbalized awareness of the occurrence and stated that re-education on proper repositioning and turning of residents was conducted for all clinical staff. The Facility Administrator provided copies of the inservice education and staff sign-in sheets for verification. The DON stated, Pulling on extremities, arms or legs, is not an accepted practice for assisting with repositioning or turning, especially with the elderly, because it can cause injuries like dislocated joints or even fractures. The Facility Administrator identified CNA C as the person who was providing care to Resident #1 and additional education for CNA C was verified through the documentation provided. CNA C was not available for interview. According to an article located on MedlinePlus, an online health information resource provided by the National Library of Medicine (NLM) which is part of the National Institutes of Health (NIH), subtitle, Avoiding Injury, item 1 read, You must move or pull someone up in bed the right way to avoid injuring the patient's shoulders and skin . and item 4 read, Never move patients up by grabbing them under their arms and pulling. This can injure their shoulders. URL as follows: //medlineplus.gov/ency/patientinstructions/000429.htm On 11/15/23 at approximately 3:00 PM, the Facility Administrator and DON were updated on the findings. No further information was provided.

Based on Resident interview, staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to protect Resident's confidential records, to include Protected Health Information (PHI) and Protected Private Information (PPI), for 4 Residents (#101, 102, 188, and 116) in a survey sample of 33 Residents. The findings included; This access was given to an individual who was an alleged physiatrist (in sports medicine) who was not in contract with the facility to provide services. The individual was not in contract nor known by the Rehab Department for services, and not ordered to consult with the Residents by the physician. The individual was not known by the Residents nor their responsible parties, and had not received consent to this access the medical record from them. 1. For Resident #101, the facility allowed disclosure of PPI, and PHI, by way of access to the electronic clinical record. Resident #101's most recent Minimum Data Set assessment (a federal assessment protocol) was a discharge assessment dated [DATE]. The document denoted the Resident as fully cognitively intact. A review Resident #101's physician's orders in the clinical record, revealed Physical Therapy (PT), and Occupational Therapy (OT) orders but there were no orders for Physiatry consult. Resident #101 was interviewed via telephone on 1-9-23 and stated that she had never met, nor been seen by the alleged Physiatrist. Resident #101 further stated the medical doctor's name, the nurse practitioners name, the OT staff names, and the PT staff names, indicating she had seen all of them and could describe them. The Resident was oriented, and a good historian to include dates given during the interview. Research in the clinical record revealed that the Resident's account of her stay was exactly accurate. On 1-9-23 initially multiple interviews, with multiple surveyors present for each interview, were conducted with Employee C (Therapy manager), and Employee F (OT) in regard to the physiatrist specifically. The interviews with the therapy department continued throughout the course of the survey from 1-4-23 through 1-11-23. Both employees C, and F, stated that no one in the Rehab department knew the alleged physiatrist and further never met and am unaware if (name) is a woman or a man. Employees C and F stated that the therapy department (Rehab) did not have any contract nor any business agreement with the physiatrist, nor was the physiatrist consulted by them to see the Residents on their case load. They stated that the rehabilitation department (Rehab) did not bill the residents for the physiatrist alleged visits. They stated the physiatrist would not have been needed as the medical doctor saw the residents for their medical needs and for orders to be issued for therapy, then they treated the residents. Employee C, and F, stated that the operating standard for therapy was for OT, PT, and Speech Therapy (ST), to evaluate the Residents first, then make recommendations to the doctor for treatment needs. After the doctor received the evaluations, the doctor would issue therapy orders, and finally, they as therapists would follow the doctors orders to treat the residents, document and report to the doctor the Residents progress, or lack thereof. Licensed Practical Nurses (LPN) B unit 2, and (LPN) D unit 1 manager, were interviewed and stated they had not seen, and did not know the physiatrist. Progress notes were reviewed and revealed that the physiatrist had documented in the clinical record as type of note Rehab progress note. The physiatrist documented 40 notes stating he was providing Physiatry follow up and seeing the Resident approximately every two days, with weekends off, in a 124 day stay. The notes revealed that all of them were late entry notes and were placed in the medical record 4-5 weeks after alleging to have seen the Resident. The notes would not have been available to the physician nor the rehab department for 4-5 weeks which made them unnecessary to the facility for use in care of the Resident. The notes were all essentially identical as though they were copied and pasted into the record with only 1 or 2 words changed of no significance to findings. All of the notes indicated that the physiatrist documented the visits had occurred during daytime business hours. The National Institutes of Health define a physiatrist as Physical Medicine and Rehabilitation physicians. The Resident was discontinued from Physical Therapy on 9-28-22, as having plateaued and not a further candidate for therapy services, however, the physiatrist continued to write Rehab progress notes as having seen the Resident, on 9-29-22, 10-1-22, 10-4-22, 10-6-22, 10-8-22, and 10-11-22. The last note on 10-11-22 was put into the clinical record by the physiatrist on 11-16-22, (5 weeks late) and 2 days after the Resident was discharged . On 1-9-23 at 11:00 a.m., the Administrator and Director of Nursing (DON) were interviewed and stated the physiatrist was unknown to them, and they had no contract with him to provide services in the facility. They further stated they would check with corporate and get back to surveyors if one could be found. On 1-9-23 at 4:00 p.m., the Administrator stated there was no corporate contract with the physiatrist, and that the facility did not bill for him. She stated she had contacted the medical director and he said he would call and talk to the physiatrist and tell him that he was revoked from the building, and was not to enter. The Administrator had no contact information for the physiatrist, and she was not aware of how the physiatrist was able to access the clinical record. She stated that she was investigating. On 1-10-23 at 10:00 a.m., the Administrator told surveyors that she had spoken to the physiatrist and notified him she was conducting an investigation into the matter and that state surveyors were conducting an investigating as well. Surveyors asked for the contact information of the physiatrist and she stated that she didn't have a number for him as he had contacted her and told her he had been coming there for more than 6 years. She stated his business office was in Florida and he billed through his own office. She further stated his office was listed as a Post Office box. The Administrator was notified at that time that online search had proven he had listed his business office as this facility, and at this facility address, and that he did bill insurances to include Medicare. Policy and procedure was requested for a physiatry program, and the DON stated we don't have a physiatry program. Facility billing records were reviewed and revealed that no resident billing for this physiatrist had been conducted from this facility. At an end of day meeting on 1-10-23 the Administrator, and DON were made aware of the failure of staff to protect residents records. The alleged physiatrist accessed Resident protected private information (PPI), and protected health information (PHI) without Resident nor responsible party consent. On 1-11-23 at the end of day meeting at 5:00 p.m., the facility Administrator and DON were again notified by the survey team of the deficient practice, and they stated they had no further information to provide the survey team. 34894 2. For Resident #102, the facility failed to protect the resident's right to privacy and confidentiality of personal, health and medical records. For Resident #102, the facility failed to protect the resident's right to privacy and confidentiality of personal, health and medical records. The facility allowed access of PPI (Protected Personal Information) and PHI (Protected Health Information) through the electronic clinical record Resident # 102 most recent Minimum Data Set (MDS) was an Admission assessment with an Assessment Reference Date (ARD) of 7/13/2022. The MDS coded Resident # 102 with a BIMS (Brief Interview for Mental Status) Score of 14 out of 15 indicating no cognitive impairment. Review of the closed electronic clinical record was conducted on 01/04/2023-01/06/2023 and 01/09/2023-01/11/2023. Thorough review revealed no Physician's Order for a Rehab Consultation by the Physiatrist. The dates of the alleged Physiatrist encounters and the dates the note were created were documented as follows: 7/12/2022 15:01:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 8/15/2022 13:02:24 7/14/2022 15:05:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 8/17/2022 13:05:26 7/16/2022 15:29:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 8/19/2022 13:30:12 7/21/2022 15:39:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 8/24/2022 13:39:53 7/23/2022 15:01:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 8/26/2022 14:02:11 7/26/2022 15:15:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 8/29/2022 13:15:27 7/28/2022 15:14:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 8/31/2022 13:14:15 7/30/2022 15:23:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/2/2022 09:23:53 8/2/2022 15:21:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/5/2022 15:21:16 8/4/2022 16:31:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/7/2022 16:31:38 8/6/2022 14:20:00 Department: Physician Position: Physician Created By: (name redacted)Created Date : 9/9/2022 14:20:25 8/9/2022 15:01:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/12/2022 12:01:46 8/11/2022 15:49:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/14/2022 12:49:14 8/13/2022 15:19:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/16/2022 13:19:18 8/18/2022 15:26:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/21/2022 12:26:22 8/20/2022 15:22:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/23/2022 12:23:03 8/23/2022 15:16:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/26/2022 15:17:00 8/25/2022 15:55:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/28/2022 15:55:34 8/27/2022 17:11:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/30/2022 17:11:32 8/30/2022 15:59:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 10/3/2022 07:00:15 9/1/2022 13:39:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 10/5/2022 13:40:05 9/3/2022 14:19:00 Department: Physician Position: Physician Created By: (name redacted)Created Date : 10/7/2022 14:19:27 Review of the Progress notes revealed the notes appeared to be essentially the same verbiage during every encounter. The Assessment and Plan section addressed 8 areas. All of the notes had the narratives written in the 8 areas. On 1/5/2023 at 4:01 p.m., an interview was conducted with Resident #102's family member who stated she visited Resident # 102 daily and stayed for all waking hours for weeks. The family member stated she did not see a Rehab doctor visit Resident # 102. Interviews by another surveyor with another alert resident (with a BIMS score of 15/15 indicating no cognitive impairment) in the survey sample revealed that particular Resident stated she had never met the Physiatrist, never consented to receive services from the Physiatrist and was certain to not have ever heard that name (when asked about the name of the Physiatrist). The interviews with the therapy department continued throughout the course of the survey from 1-4-23 through 1-11-23. Both employees C, and F, stated that no one in the Rehab department knew the alleged physiatrist. They also stated they never met the Physiatrist and were unaware if [Physiatrist] is a woman or a man. Employees C and F stated that the therapy department (Rehab) did not have any contract nor any business agreement with the Physiatrist, nor was the Physiatrist consulted by them to see the Residents on their case load. They stated that the rehabilitation department (Rehab) did not bill the residents for the Physiatrist alleged visits. They stated the Physiatrist would not have been needed as the medical doctor saw the residents for their medical needs and for orders to be issued for therapy, then they treated the residents. Employee C and Employee F stated that the operating standard for therapy was for the Medical Doctor to give the order for OT, PT, and Speech Therapy (ST), to evaluate the Residents first, then make recommendations to the doctor for treatment needs. After the doctor received the evaluations, the doctor would issue therapy orders, and finally, they as therapists would follow the doctor's orders to treat the residents, document and report to the doctor the Residents progress, or lack thereof. Licensed Practical Nurses (LPN) B unit 2, and (LPN) D unit 1 manager, were interviewed and stated they had not seen, and did not know the Physiatrist. Progress notes were reviewed and revealed that the Physiatrist had documented in the clinical record as type of note Rehab progress note. The physiatrist documented 22 notes stating he was providing Physiatry follow up and seeing the Resident approximately every two days, with weekends off. The notes revealed that all of them were late entry notes and were placed in the medical record 4-5 weeks after alleging to have seen the Resident. The notes would not have been available to the physician nor the rehab department for 4-5 weeks which made them unnecessary to the facility for use in care of the Resident. The notes were all essentially identical as though they were copied and pasted into the record with only 1 or 2 words changed of no significance to findings. All of the notes indicated that the physiatrist documented the visits had occurred during daytime business hours. According to the Physical Therapy records, Resident # 102 was discharged from therapy on 9/2/20222. The last note from the Physiatrist on 9/3/22 was put into the clinical record by the physiatrist on 10/16/22, (over 5 weeks late) and 6 weeks after the Resident was discharged on [DATE]. There were a total of 14 late entry notes entered into the clinical record by the Physiatrist after Resident # 102 was discharged . On 1/9/23 at 11:00 a.m., the survey team conducted interviews with the Administrator and Director of Nursing (DON) who both stated the physiatrist was unknown to them, and they had no contract with him to provide services in the facility. They stated they would check with their corporate office and get back to surveyors if one could be found. Further, they could not say if he was an MD (medical doctor), DO (Doctor of Osteopathic Medicine) or a PHD (Doctor of Philosophy.) The Administrator stated she would check and let the survey team know the next day On 1/9/23 at 4:00 p.m., the Administrator stated there was no corporate contract with the physiatrist, and that the facility did not bill for him. The Administrator had no contact information for the physiatrist, and she was not aware of how the physiatrist was able to access the clinical record. The Administrator stated she did not know the credentials of the individual and that she talked with the Medical Director who stated he knew him and that he was a Physiatrist. She stated the medical director and he said he would call and talk to the physiatrist and tell him that he was revoked from the building, and was not to enter. The Administrator stated she deactivated him from seeing residents and was going to launch an investigation. The Administrator stated she asked the therapy staff if they knew the Physiatrist and they did not. The Administrator stated she did not know how this happened and how the Physiatrist was able to see so many residents. When asked exactly how many residents were being seen by the Physiatrist, the Administrator stated she did not know for sure but would check. The Administrator was informed that the Electronic Medical Record System had two specific tabs designated for documentation by this particular Physiatrist. One tab was for (Dr. name redacted) initial Rehab consultation and the other was for (Dr. name redacted) Rehab progress notes. The Administrator stated she did not know how it happened that this Physiatrist had access to electronic health records. On 1/10/23 at 10:00 a.m., the Administrator told surveyors that she had spoken to the physiatrist and notified him she was conducting an investigation into the matter and that state surveyors were conducting an investigating as well. Surveyors asked for the contact information of the physiatrist and she stated that she didn't have a number for him as he had contacted her and told her he had been coming there for more than 6 years. She stated his business office was in Florida and he billed through his own office. She further stated his office was listed as a Post Office box. The Administrator was notified at that time that online research had proven the Physiatrist had listed his business office as this facility, and at this facility address, and that he did bill insurances to include Medicare. Surveyors also notified her that his license to practice was only 5 years old. Policy and procedure was requested for a physiatry program, and the DON stated we don't have a physiatry program. Facility billing records were reviewed and revealed that no resident billing for this physiatrist had been conducted from this facility. During the end of day meeting on 1/10/23, the Administrator, and DON were made aware of the failure of staff to protect residents from access to their person and protected records. This was in regard to the potential for unsupervised visits in the private rooms of vulnerable Residents by a person who was unknown by staff, Residents, and Residents' responsible parties. Resident #102 was not afforded the right to privacy nor the right to deny the Physiatrist access to confidential personal and medical records. The protected health and private information was disclosed to the Physiatrist without Resident # 102's knowledge or consent. For Resident # 102, the facility failed to ensure protected health and protected private information. According to the facility staff including administrative staff, the facility had no business relationship with the physiatrist who was allowed to view the personal and protected information for every resident in the facility. On 1/11/23 at the end of day meeting at 5:00 p.m., the facility Administrator and DON were again notified by the survey team of the findings and they stated they had no further information to provide the survey team. 40026 3. For Resident #188 the facility staff failed to ensure privacy of Protected Health and Protected Private Information For Resident #188 the facility staff failed to ensure privacy of Protected Health and Protected Private Information by physiatrist, who did not have contract, or agreement with the facility or rehab department and who was not referred by the medical director or Nurse practitioner working under him. Resident #188 was not available for interview as he was out of the facility. On 1/11/23 during clinical record review it was discovered that Employee G (a physiatrist) had entered progress notes in the Residents chart including the time period when the Resident was not receiving therapy. Many of the physiatrist notes were identical as if copied and pasted to include typos. The notes do not reflect any services provided by the physiatrist they only give history and physical as input by the medical director and list of diagnoses the notes do not reflect any changes in patient status, any recommendations for patient care or therapy modalities. All progress notes placed in the system were at minimum 1 month after the alleged visit and maximum 2 1/2 months after the alleged visit. All of the notes from 9/24/22 - 10/7/2 (4 in total) were while this Resident was not receiving therapy. On 1/11/23 at approximately 3:00 PM an interview was conducted with employee C (Physical Therapy Manager) who stated that she did not know who this doctor was and she had asked around in the department and no one was aware of him working with therapy patients. On 1/11/23 at approximately 4:30 PM an interview was conducted with the Administrator who stated that she was not aware of the physiatrist but stated that she had suspended services in the building and had spoken to the medical director about him. She stated that some of the nurses recall him but said They have not seen him lately. When asked if the facility has a contract with this physiatrist or if the medical director has consulted him to see residents she stated that he had not. On 1/11/23 at approximately 2:00 PM an interview was conducted with the business office manager who stated that she does not bill for the physiatrist she bills for in house therapy providers. On 1/11/23 during the end of day meeting the Administrator was made aware of the concerns and she stated that she was going to launch a formal investigation. The Administrator then submitted a copy of the document she sent to the state agency reporting the investigation of the physiatrist. No further information was provided. 40452 4. For Resident #116, the facility allowed disclosure of PPI, and PHI by way of access to the electronic clinical record. During the survey, Resident #116's clinical record was reviewed. There were three progress notes (05/26/2020, 06/02/2020, and 06/09/2020) written by Employee G, an alleged physiatrist (in sports medicine) who was not in contract with the facility to provide services. All three progress notes were written as late entries over two months after the dates of service. All three progress notes were identical and included the following excerpt: Patient is in therapies working towards functional goals as noted in the functional status updates in the chart. Plan is to continue intensive skilled nursing rehabilitation including PT/OT [Physical Therapy/Occupational Therapy] and if needed SLP [Speech Language Pathology] to work toward functional goals which include improvement in mobility, ADLs [Activities of Daily Living], transfers, cognition, safety awareness, balance, selfcare, and hygiene. Continue 5-6 days a week of therapy to achieve the above-mentioned goals. A review of the physician orders revealed that there were no therapy orders nor a physiatry consult in 2020. On 01/11/2023 at 4:20 P.M., the Therapy Manager was interviewed. The Therapy Manager verified that Resident #116 did not receive any therapy services in 2020. On 01/11/2023 at approximately 4:45 P.M., the Administrator was notified of findings. The Administrator stated she would be launching a formal investigation into the matter.

Based on interview, clinical record review, facility documentation and in the course of an investigation the facility staff failed to ensure the Resident's right to participate in the development and implementation of his person centered care process for one Resident (Resident #168) in a sample size of 33 Residents. The findings included: For Resident #168 the facility staff failed to allow the Resident to identify individuals or roles to be included, and failed to inform him of meeting to discuss care plan. On 1/6/23 a review of the clinical record revealed that the Resident was seen by the Psychiatrist (Employee J) on 12/1/22 and the Psychiatrist entered the following orders in Resident #168's clinical record. Physicians Progress Note 12/1/22 -Continue same meds. -PT [patient] needs to attend treatment plan with facility Administration to address behavioral concerns. -Pt will be referred to psychotherapy On 12/2/22 the following nursing note was entered: 12/2/2022 10:13 Nurses Note : Resident refused to be seen by MD [Psychiatrist name redacted] psychogeriatric services. PSG [sic] [PGS=Psychogeriatric Services] recommendation, Pt. needs to attend treatment plan meeting with facility administration to address behavioral concerns, Pt. will be referred for psychotherapy. resident self RP/mother [name redacted] notify [sic] all risk and benefit explained with verbalization of understanding consented all question answered at this time. On 12/6/22 the social worker entered the following note: 12/6/2022 4:13 PM Social Services Note : This writer made aware on Thursday 12/8 at 2pm psychogeriatric doctor requesting a IDT meeting to be held with resident. There is no documentation stating that the Resident or family member was made aware of this meeting. The next note in the Resident record is 12/8/22 was recorded in the progress note as follows: 12/8/2022 16:00 Social Services Note: This writer, psych doctor, resident, unit manager and social services assistant met with resident. Psych-doctor advise resident he don't require a 1:1 due to him not being suicidal, fall risk etc. Resident became upset stating I'll call the state. Psych-doctor suggest speaking to i.e. unit manager, social services director or the supervisor if the staff he is reaching out to are not responding timely and to not assume the staff is ignoring him. Resident proceeded to call the state and spoke to a person via phone in front of the IDT and verbalize he is being bombarded by his psych doctor, unit manager and 4 or 5 other people. Patient also verbalize he want it to be known he is being harrassed [sic] and he is willing to meet with the state and do not want the psych-doctor to be his doctor. Meeting concluded with the psych-doctor recommending the IDT to meet with resident weekly. On 1/5/23 at 11:00 AM, an interview was conducted with Resident #168 who stated that on 12/1/22 he had a meeting with the psychiatrist and they really didn't talk about much. After the meeting with the psychiatrist he told the nursing staff he did not want to see him (the psychiatrist) again. He stated he wanted talk therapy and did not need the psychiatrist for that. The nurse entered that information into the clinical record on 12/2/22. The Resident stated that on 12/8/22 the social worker told him he would be meeting with the psychiatrist that day at 2 pm. He stated that he was under the impression it would be a therapist not the psychiatrist he had told them he did not want to see. Resident #168 stated that when 6 people walked into his room he was feeling like They were ganging up on me. Resident #168 stated that he felt like it was harassment and he called the State Agency (OLC) to complain. He stated that he called the OLC while everyone was in his room. He said They look at me as a problem because I will call state and the Ombudsman. Its my life its my care; and my health should be a priority. It is my right to complain if there is a problem. On 1/6/23 a telephone interview was conducted with the Psychiatrist and he was asked about the meeting on 12/1/22 he stated that he introduced himself got background information and medication information and his history and physical, and spoke with the Resident. He told him they would be having psychotherapy services starting soon and the Resident seemed interested in those services. He stated that he did not make any changes to his medications because he seemed stable on the meds and dosages he was currently on. When asked how the second meeting came about he said, I was told by the nursing home staff that they are having a lot of challenges dealing with him, it is difficult to address all of his needs, for that reason, they have put a care giver across from his room, like 1:1 so his needs can be met. Usually 1:1 is placed when the patient is actively suicidal or may hurt someone or have physical disability that if they were to stand they would fall. [Resident name redacted] gets upset if he rings the bell and there is a delay he gets upset calls the Dept of Health and Ombudsman, so therefore my impression that the nursing home was trying their best to make sure his needs are met right away with no delay. The nursing home was feeling overwhelmed and didn't know how to meet his needs, what should be the treatment plan, etc. therefore I suggested a meeting, because I can't prescribe a medication and he will magically become pleasant. I told them it is not going to be an easy fix, I am not a magician, I can't come and immediately find a fix and everyone will be happy. He is someone you can have a meaningful conversation with, he understands what is happening around him. You have to sit down with them and have a dialogue. The nursing home admin was very apprehensive, it was like they have a [NAME] hanging on their heads, they are afraid because of the complaints, and they are very scared. I said we have to do something, we can have a treatment plan and that is why the treatment plan conference was scheduled. When I arrived the DON was there, the social worker was there, unit manager and we all went into his room, it was a scheduled meeting. After seeing us he became apprehensive and asked why we were ganging up on him. We said just a conference where we can all meet. He said he wanted to complain and asked if we were going to stop him from complaining and we said no, he picked up the phone and called and talked to someone, said he was in [the facility]; they seemed to know him by name, there was not too much introduction. He said they are all in my room I want to make this complaint. The Psychiatrist was asked if Resident #168 had bipolar disorder and he confirmed the diagnosis. He was asked if it was possible the Resident felt threatened by so many people in the room at once? The Psychiatrist said, My impression was he that he was not afraid or threatened, he might have been surprised, he might not have been expecting this conference take place. A review of the clinical record revealed the following entry by the social worker: 11/29/2022 12:07 PM -SocialServicesNote: This writer spoke with resident to remind him of his care plan meeting schedule for 11/30 at 2:30pm. Resident thanked this writer for stopping by. On the afternoon of 1/6/23 a telephone interview was conducted with the social worker, who was asked if it was usual practice to document patient notification of IDT meetings as she did on 11/29/22 and she stated that it was. She stated that she found out about the meeting on 12/6/22 and she verbally notified the Resident. When asked if she notified his mother she stated that she did not. On 1/10/22 during the end of day meeting the Administrator was made aware of concerns and no further information was provided.

Based on staff interview, clinical record review and financial record review, the facility staff failed to convey within 30 days following discharge Resident funds that were deposited within the facility for one Resident (Resident #105) in a survey sample of 33 Residents. The findings included: For Resident #105, who discharged from the facility on 2/1/22, the facility staff didn't convey the funds to the Resident within 30 days of discharge. On 1/4/23, the regional mobile business office manager (BOM) (Employee E) provided Surveyor C with a listing of Resident trust account balances on 11/13/22, and on 1/4/22. Review of this document revealed that on 11/13/22, Resident #105 had a trust fund account balance of $2,560.55. Review of the clinical record revealed Resident #105 discharged from the facility on 2/1/22. On 1/5/23, the BOM was asked to provide a transaction history of the Resident's trust fund account. Review of this document revealed that the trust account was not closed until 11/29/22. A copy of the check written revealed that the check was not written until 12/5/22. The check was then mailed to this same facility, where the Resident was no longer a Resident. On 1/5/23 at 11:51 AM, an interview was conducted with the BOM. When asked she indicated that accounts are to be closed and funds sent to the Resident or their estate within 30 days of discharge. When asked why Resident #105's account funds were not disbursed until 10 months after discharge, she said she was not aware of why the delay. The Regional Business office manager was able to confirm that the check was initially mailed to this facility and then had to be forwarded to the facility where he was a current resident. The envelope was post marked 12/14/22. When the facility mailed it to the other nursing facility where the Resident was, it got returned to this facility. As a result, as of 1/5/23, the Resident was still not in receipt of the funds. On 1/5/23 at approximately 2:30 PM, the business office manager reported to Surveyor C that she had called the other nursing facility and confirmed that the Resident lives there and would be mailing the check out again. On 1/10/23 at 9:45 AM, an interview was conducted with the Regional Business office manager. She stated, When residents leave we should be closing their account within 30 days of their discharge. Review of the facility policy titled Resident Trust Fund was reviewed. This policy did not address the timing of closing a Resident's account following their discharge from the facility. On the morning of 1/10/23, the facility Administrator was made aware of the findings. No further information was provided.

Based on staff interview, Resident record review, financial record review and facility documentation review, the facility staff charged the Resident and deducted from their patient trust account funds more than what were due to the facility for two Residents (Resident #170 and #1111), in a survey sample of 33 Residents. The findings included: 1. For Resident #170 the facility staff withdrew $82 more than what was due towards the cost of care for January 2023. On 1/4/23, Surveyor C met with the regional business office manager and obtained a trust account transaction history and the patient liability verifications for Resident #170 dating November 2022-January 2023. Review of these documents revealed the following: On 1/3/23, the facility withdrew funds in the amount of $920 and indicated this was a Care Cost withdrawal. The Virginia Medicaid Web Portal had indicated Resident #170 owed $838 towards the cost of care for the month of January. This was $82 more than the owed amount that the facility withdrew. 2. For Resident #1111, the facility staff withdrew more than what was due to the facility for the cost of care and services for December and January. Review of the patient trust account transaction history revealed the following: On 12/2/22, the facility staff withdrew $1,436 from Resident #1111's trust account. On 12/5/22, an additional withdrawal in the amount of $54 was made. Review of the Virginia Medicaid Web Portal for December 2022, Resident #1111 only owed $1,463 for the month of December and a total of $1,490, was taken from Resident #1111's trust account, which was an overpayment of $27. On 12/7/22, Resident #1111 received a refund check from the facility in the amount of $4,041, for prior instances where the facility withdrew funds more than what was due for the cost of care. On 1/3/23, the facility staff withdrew funds in the amount of $1,597 from Resident #1111's trust account and noted with transaction as a Care Cost Auto Withdrawal. The Medicaid web portal showed Resident #1111 only owed $1,463 for the month of January, therefore the facility withdrew an excess of $134. On 1/4/22, in the afternoon an interview was conducted with the Regional Business office manager. She was asked about the above transactions and said, Per the Medicaid portal he should have paid $1,463 for December and when I made the withdrawal, I transposed the numbers and only took $1,436. So, we went back and took the balance which is where the $54 withdrawal on 12/5/22, came in. On the afternoon of 1/4/22, the Regional Business Office manager was asked about the money that was withdrawn from Resident #170 and #1111's trust accounts in the month of January that were more than what was due to the facility. The business office manager said, I will have to do a refund back for January and everyone will have to be reviewed because of the cost-of-living increase in January, I'm sure they are all wrong. On 1/10/23 at 9:45 AM, an interview was conducted with the Regional business office manager. When asked to explain the process regarding trust funds and payments to the facility the following explanation was given. When a resident sets up a RFMS (Resident Fund Management System) agreement we set up for it to transfer their PL (patient liability). We look at their deposit and make sure what we transfer matches the Medicaid portal. Review of the facility policy titled; Resident Trust Fund was conducted. This policy read, Purpose: To hold, safeguard, manage, control and reconcile the personal needs funds deposited with the facility by the residents, as authorized, in a manner and in compliance with all laws and regulations to provide the residents with accurate and timely information regarding their personal funds .B. Withdrawals .8. Withdrawals are not made from a resident trust funds account for items or services that are reimbursed by Medicare and/or Medicaid. On the morning of 1/11/23, the facility Administrator was made aware of the above findings. No further information was provided.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to provide a SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice) to 2 Residents (Resident #109, 110) in a survey sample of 2 Residents reviewed for such notices. The findings included: On 1/4/23, the facility Administrator was asked to provide a listing of Residents who were discharged from Medicare Part A services. From this listing a sample was selected which consisted of Resident #109 and 110. The notices issued to these Residents were reviewed and revealed the following: 1. For Resident #109, the facility staff failed to provide a SNF ABN notice prior to skilled care services ending. Resident #109 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services. Review of the clinical record revealed that Resident #109 was readmitted to the facility on [DATE], for skilled care, Medicare part A services. When skilled services were scheduled to end on 12/25/22, the Resident remained in the facility. The facility staff issued a NOMNC (Notice of Medicare Non-Coverage) form on 12/23/22. The facility staff failed to provide Resident #109 with the second required notice, a SNF ABN, which allows the resident an option to continue to receive services, be notified of the expected cost, and have Medicare make the coverage determination once a bill is submitted to Medicare. 2. For Resident #110, the facility staff failed to provide a SNF ABN notice prior to skilled care services ending, therefore eliminating the Resident's opportunity to have Medicare make the coverage determination. Review of the clinical record for Resident #110 revealed that the Resident was readmitted to the facility on [DATE], under skilled care/Medicare part A benefits. Skilled care ended on 12/23/22, and the Resident remained in the facility for long-term care. The facility staff issued Resident #110 a NOMNC on 12/21/22 but had no evidence that the SNF ABN was issued. 1/9/23 at 9:38 AM, an interview was conducted with Employee M, a facility social worker. Employee M was asked to explain the NOMNC and ABN forms and explain when they are issued. Employee M stated, The ABN is a waiver of liability. The provider gives it to let them know Medicare coverage rules. It lets them know where expenses will incur. Our policy is that we issue it 2 days prior that way if they appeal, they can do that. The social work department issues the notices, but the business office tells us which form to provide. The facility policy titled, Non-coverage and Advanced Beneficiary Notices Policy was reviewed. It read, .4) SNFABN (Part A Traditional Medicare only). a) Regulations mandate that Medicare Part A beneficiaries be notified in advance when the Skilled Nursing Facility (SNF) makes a determination that the SNF stay may not be covered by Medicare. b) This usually happens on two occasions, either upon admission, or at the end of a Medicare covered stay. c) The SNFABN is based on not meeting the skilled level of care criteria. d) The SNFABN is not REQUIRED (but recommended) if noncoverage is related to a technical denial (no 3-day hospital stay, no benefits available). e) The facility will issue the SNFABN prior to Medicare A services ending to inform them that there will potentially be a cost incurred to the resident as a result of the Med A coverage ending. i) Typically, the facility will make every effort to issue this notice at the same time as the NOMNC . CMS gives the following guidance to skilled nursing facilities regarding ABN notices in the Medicare Claims Processing Manual Chapter 30 - Financial Liability Protections. An excerpt from Page 72 read, .70.2 - Situations in Which a SNF ABN Should Be Given .In the situation in which a SNF proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF must provide a SNF ABN to the beneficiary before it terminates such extended care items or services . Accessed online at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c30.pdf On 1/11/23 at approximately 9 AM, the facility administrator was made aware of the above findings. No further information was provided.

Based on observation, staff interview and facility documentation review, the facility staff failed to provide a clean and homelike environment for two Residents (Resident #103, 1111) in a survey sample of 33 Residents. The findings included: 1. For Resident #103 the facility staff failed to provide a clean and homelike environment as evidenced by a significant amount of splatters and drips of a tan colored substance on the wall behind the head of the bed. On 1/5/23 at 2:23 PM, Surveyor C made observations of Resident #103's room. The wall behind the head of the bed had a tan colored substance splattered all over the wall with drips running from the over bed light to the baseboard. The splattered substance was on a photo that was hanging on the wall over the Resident's head of the bed. There was a tube feeding pole that had the same-colored substance with drips on the entire length of the pole. Resident #103 was non-verbal and unable to be interviewed about the findings or with regards to the cleaning frequency of her room. On 1/6/23 at approximately 11:40 AM, an additional observation was made of Resident #103's room with the same findings noted. On the afternoon of 1/9/23, Surveyor G made observations of the same in Resident #103's room. On 1/9/23 at 9:47 AM, an interview was conducted with Employee L, the housekeeping supervisor. The housekeeping supervisor described the facility housekeeping process to be that Resident rooms are checked three times daily. Employee L said, in the morning they prepare their carts, go to every Resident room and get trash and sweep the floor. After breakfast, we start a full cleaning of every room. He described this process to be, cleaning the floor, sweeping and mopping, wiping down all surfaces, and cleaning the bathroom. Employee L then went on to say, After lunch we go back to every Resident room and sweep, mop and clean the room again. When asked about cleaning of the entire room and walls, the housekeeping supervisor said, We call that a terminal clean, we do 5 rooms a day, so that all rooms are done monthly. On 1/10/23 at 9:30 AM, a video call was held with the facility Administrator. The Administrator was made aware of the observations. The Administrator stated that Resident #103's room had been brought to her attention that morning and had been cleaned. The Administrator went to the room and showed Surveyor C that it had been cleaned. The Administrator confirmed the Surveyor's prior observations and stated she was very upset when she saw the condition of the room prior to the cleaning. Review of the Terminal Cleaning Schedule provided by the facility staff revealed that Resident #103's room was scheduled for a terminal cleaning on 11/4/22, 12/8/22, 1/5/23. The facility policy titled Occupied Patient/Resident Room Cleaning was reviewed. This policy read, .5. Disinfecting: Beginning at the door, using a germicide-soaked microfiber cloth, disinfect all touch points and areas that have a high probability of carrying infections including: doorknobs, edges of furniture, bed rails, the phone, nurse call button, needle box, and sink by the patient/resident, not in the bathroom. Work in a single direction around the room to ensure that no key areas are missed. Fold your cloth using a clean surface as needed . On 1/11/23 at 9:00 AM, the facility administrator was made aware of the above findings. No further information was provided. 2. For Resident #1111, the facility staff failed to provide a homelike environment as evidenced by missing sections of wallpaper and peeling wallpaper in the Resident's bathroom. On 1/5/23 at 2:20 PM, observations were made of Resident #1111's bathroom. The observation revealed there was a large section of wallpaper missing below the paper towel dispenser. The missing area measured approximately 6 inches long and approximately 16 inches wide. Additionally, there was a significant amount of wallpaper throughout the bathroom which was peeling and was not adhered to the wall. On 1/6/23 at approximately 11:40 AM, observations revealed the same findings in Resident #1111's bathroom. Resident #1111 was interviewed and had no knowledge as to how long the bathroom had been in this condition. On 1/9/23 at 3:40 PM, Surveyor G observed the same findings in Resident #1111's bathroom, which included the missing wallpaper and peeling wallpaper. Review of the maintenance work orders from November 13, 2022, until the time of survey revealed no listing of Resident #1111's room being communicated to maintenance. On 1/10/23 at 9:40 AM, during a video call with the facility Administrator, the Administrator was made aware of the observations. The Administrator went to Resident #1111's room and confirmed the findings. No further information was provided prior to the conclusion of the survey. Complaint related deficiency.

Based on observation, Resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to protect 5 Residents from abuse (Resident #63, #322, Resident #70, #52, #21 ) and failed to protect 2 residents from neglect (Resident #35, Resident #217) in a sample size of 60 Residents. Immediate Jeopardy was called on 09/16/2022 at 4:34 P.M. On 9/21/22 at 12:15 P.M., the survey team verified the implementation of the removal Plan submitted by the facility and the scope and severity was lowered to E at that time. The findings included: Resident #68's quarterly Minimum Data Set with an Assessment Reference Date of 08/02/2022, Resident #68's medical diagnoses included but were not limited to Bipolar disorder. Resident #68's Brief Interview for Mental Status was coded as 10 out of possible 15 indicative of moderate cognitive impairment. Functional status for walking in room and corridor were coded as requiring supervision from staff without a mobility device. The facility staff provided a copy of two Resident-to-Resident Facility-Reported Incidents (FRI) involving Resident #68 and his roommates: 1) For Resident #63, the facility staff failed to protect Resident #63 from Resident #68, a Resident with known aggressive behaviors, resulting in Resident #68 verbally assaulting Resident #63 with a threat of physical harm on 09/15/2022 According to Resident #63's quarterly Minimum Data Set with an Assessment Reference Date of 08/03/2022, Resident #63's medical diagnoses included but were not limited to depression and schizoaffective disorder. Resident #63's Brief Interview for Mental Status was coded as 11 out of possible 15 indicative of moderate cognitive impairment. Functional status for bed mobility, dressing, and personal hygiene were coded as requiring extensive assistance from staff. On 09/15/2022 at 5:30 P.M., the Ombudsman entered the conference room to speak with the survey team. In the course of the conversation, the ombudsman stated that about 20 minutes ago she heard (Resident #68) tell his roommate (Resident #63) he was going to come over there (in a threatening tone). The ombudsman stated that she told nursing staff. On 09/16/2022 at approximately 8:40 A.M., Resident #63's progress notes were reviewed. An excerpt of a nurse's note dated 09/15/2022 at 8:45 P.M. documented, At around 6:15 pm assigned CNA [Certified Nursing Assistant] for [Resident #63] in room [number] told charge nurse on unit, ombudsman reported to her both residents in room [number] were having verbal altercation. Writer immediately went into residents [sic] room, asked what was the problem. [Resident #63] stated his roommate stepped into his personal space and always have his door closed, he feels so lonely in his corner [B bed] and no fresh air coming into his room and his roommate does not want him to turn his radio on, his roommate always tell him to shut up when he wants to speak. On 09/16/2022 at approximately 8:50 A.M., Resident #68's progress notes were reviewed. An excerpt of a provider note dated 09/15/2022 at 8:48 P.M. documented, Resident had altercation with roommate, roommate transferred [sic] to another floor and room. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recommendations: separation of residents, psych evaluation ordered in [electronic health record]. An excerpt of a nurse's note dated 09/15/2022 at 11:08 P.M. documented, At around 6:15 pm assigned CNA for [Resident #68] told charge nurse on unit, ombudsman reported to her both residents in room [number] were having altercation. Writer immediately went into residents room, asked what was the problem. [Resident #68] stated earlier during dinnertime, he was talking to the CNA, [Resident #63] had accused him of breaking into his home, and would call the cops on him, and [Resident #63] has his radio on loud all day and night, whenever he asks him to lower his radio, they get into an argument. On 09/16/2022, the facility staff provided a copy of the FRI of the incident. A handwritten statement dated 09/15/2022 from CNA P documented, To my knowledge, I was delivering dinner trays to [Resident #68]'s room he began complaining about his tray and asked for the top to keep his food hot. Bed B [Resident #63] assumed he was talking to him, and began telling me that he wanted to call the police because Bed A [Resident #68] had broken into his home. Bed A [Resident #68] told Bed B [Resident #63] 'Hey she was not talking to you!' Bed B [Resident #63] said, 'Shut up', Bed A [Resident #68] said 'You shut the hell up you S.O.B.' I intervened, changing the subject. Both people calmed down. 2) For Resident #322, the facility staff failed to protect Resident #322 from Resident #68, a Resident with known aggressive behaviors, resulting in Resident #68 hitting Resident #322. FRI #1) Incident date 09/13/2020 with Resident #322. According to the incident description, there was a loud exchange of words heard by staff between Resident #68 and Resident #322 about whether or not to close the room door resulting in Resident #68 hitting Resident #322 on the back of his head. According to the 5-day follow-up report dated 09/17/2020, an excerpt documented, Education was provided to each resident about respecting other individuals' space and no physical contact without consent from the other individual. 3) For Resident #70, the facility staff failed to protect Resident #70 from Resident #68, a Resident with known aggressive behaviors, resulting in Resident #68 physically assaulting Resident #70 on 06/01/22. According to Resident #70's quarterly Minimum Data Set with an Assessment Reference Date of 08/05/2022, Resident #70's medical diagnoses included but were not limited to cerebral infarction, hemiplegia, and hemiparesis. Resident #70's Brief Interview for Mental Status was coded as 14 out of possible 15 indicative of intact cognition. Functional status for bed mobility and transfers were coded as requiring extensive assistance from staff. Functional limitations in range of motion were coded as 1 meaning impairment on one side for upper and lower extremities. Urinary and bowel continence were coded as 3 meaning always incontinent. FRI #2) Incident date 06/01/2022 with Resident #70. An excerpt of an Activity staff member handwritten statement documented, I went into [room number] to see [Resident #68]. I asked [Resident #70] who was in (Bed A) where is [Resident #68] and [Resident #70] stated that he was in the bathroom-he always in the bathroom. I asked [Resident #68] how long will he be in the bathroom so [Resident #68] came flying out of the bathroom and rushed toward [Resident #70] saying I'm sick and tired of him. I tried to hold [Resident #68] back and he pushed me out of the way and put his hands in [Resident #70]'s face and then pushed his face and [Resident #70]'s head went to the edge of the bed. An excerpt of the Follow-Up Report written by the Director of Nursing dated 06/03/2022 under the section entitled Conclusion documented the following excerpt pertaining to Resident #68: behavior problems of being verbally abusive to staff and other residents, and he is receiving treatment to manage his health conditions. Resident has also been seen by the psychiatric NP [nurse practitioner] related to this behavior problems [sic]. Staffs [sic] will continue to monitor him closely, assist with care as needed, assess for pain, skin and will report any abnormal findings or behavior symptoms to the MD/NP. On 09/16/2022, Resident #70's clinical record was reviewed. An excerpt of a nurse's note dated 06/01/2022 at 10:00 A.M. documented, At around 10:00 am staff member called this writer's attention, staff member stated that she witnessed [Resident #70]'s roommate pushed [Resident #70]'s face while he was lying in a bed. When this writer arrived at the room I observed [Resident #70] lying in bed. Immediately separated them. Head-to-toe assessment done on [Resident #70]. No skin issues were observed, and no bruise or skin discoloration was noted. [Resident #70] denies any pain or discomfort. Resident #68's clinical record was reviewed. A nurse's note dated 06/01/2022 at 4:53 P.M. documented, Note Text: Writer was called to resident [#68] room by activity staff that the resident pushed his roommate's [Resident #70] face. Immediately writer went to the resident's room and the activity staff said she came to the resident's room to do an assessment on the resident's roommate at about 10:20 am. While the activity staff was conducting her UDA assessment on the resident's roommate who was lying on his bed, the activity staff asked the roommate about the resident, meanwhile, the resident was in the bathroom and he heard the activity staff asking about him. The resident's roommate then said to the activity staff Resident was in the bathroom and he's been there for too long. The resident while in the bathroom came out of the bathroom and started saying he is tired of his roommate and rushed toward roommate and pushed his face. The activity staff tried to stop him and resident rushed to the roommate who was lying on the bed and pushed his face. The resident was accompanied out of the room by the nurse. Head to toe assessment done on the resident's roommate and upon assessment, no bruises, no swelling, no skin tear, no discoloration, no injury, no s/s [signs/symptoms] of trauma noted. The resident also was assessed and no s/s of trauma noted and denies pain. The resident was immediately moved to another room and was separated from the roommate. The resident was asked why he pushed the roommate's face and the resident said 'I am tired of my roommate talking about me.' Resident was calmed at this time and was educated not to put his hand on any resident. Resident [#68] with history and diagnoses of Behavioral with major depressive disorder, bipolar disorder, yelling, complaining and using abusive language. MD [medical doctor] and RP [responsible party] made aware, new ordered [sic] for psych consult and evaluation. 911 was called spoke with officer [name], case number [number] Resident was separated and room changed to another wing on same unit. Resident is been monitored closely for any further behavior. The social worker was called and also spoke with the resident regarding his behavior. The resident remain calmed [sic] and in his new [sic] adjusting well with no complaints at this time. Resident was moved with all his belongings and the resident checked and made sure all his belongings were moved. We will continue with the plan of care. On 09/20/2022 at 10:40 A.M., Resident #70 was interviewed. When asked about the experience of being a roommate with [Resident #68], Resident #70 stated, It was terrible. Resident #70 also stated, He would yell at me plenty of times. When asked about the incident on 06/01/2022, Resident #70 explained that a staff member entered the room and asked where [Resident #68] was and he told the staff member that [Resident #68] was in the bathroom. Resident #70 added, He was usually in the bathroom. Resident #70 then stated that after he said that, Resident #68 came over and hit me. On 09/15/2022 at 6:15 P.M., the Administrator, the Director of Nursing, and the Social Worker were interviewed. When asked about Resident #68's altercations with roommates, the Social Worker stated Resident #68 was moved into a room with Resident #70. The social worker stated that there was an altercation between Resident #68 and Resident #70 so Resident #68 was then moved into a room with Resident #63. When asked how the facility staff determines which Resident would be a compatible roommate with Resident #68, the social worker stated that Resident #68 prefers to have a bathroom to himself so they opted to pair him with a roommate that is non-ambulatory and does not use the bathroom. 4) For Resident #52, the facility staff failed to identify and implement measures to protect Resident #52 from staff verbal abuse. On 09/14/2022, Resident #52's clinical record was reviewed. Resident #52's Minimum Data Set with an Assessment Reference Date of 07/27/2022 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 10 out of possible 15 indicative of moderate cognitive impairment for that 7-day look-back period. On 09/15/2022, the facility staff provided a document dated 09/13/22 entitled, Concern Form for Resident #52. Under the header Description of Concern it was documented, Resident verbalize [sic] staff yells at her. Under the header Actions to resolve the concern documented, Social Services interviewed all residents w/a [with a] BIMS [Brief Interview for Mental Status] score of 12 and above with no concerns voiced of verbal, physical, or sexual abuse. The document was signed by the Social Worker on 09/14/2022 and the Administrator on 09/15/2022. On 09/15/2022 at 1:00 P.M., a copy of the Facility-Reported Incident (FRI) related to Resident #52's allegation of abuse on 09/13/2022 was requested from the administrator. The Administrator stated a grievance form was filed and an investigation was started. There was no evidence in the packet that the allegation of abuse reported on 09/12/2022 by Resident #52 was reported to the state agency or an investigation initiated. On 09/13/2022 at 11:00 A.M., a Resident Council meeting with 6 Residents was conducted. Resident #52 stated that the aides appear angry, not giving good service. Resident #52 also stated staff was yelling at me. Resident #52 also indicated she didn't want to provide names. Resident #52 also stated she had experienced retaliation for reporting issues and did not want to elaborate further at the time of the meeting. On 09/15/2022 at approximately 5:30 P.M., the ombudsman entered the conference room to speak with surveyors. When asked if Residents expressed fears of retaliation, the Ombudsman stated, Yes and went on to explain that at least three very cognitively intact Residents said that they didn't want to say anything because they will get yelled at or they [the staff] will be mean or not respond to the call light. When asked if this information was passed along to Social Services or Adult Protective Services, the ombudsman stated No, that's a gray area for me. On 09/15/2022 at 6:25 P.M., the Administrator was interviewed. When asked about the process for allegations of verbal abuse, the Administrator stated that staff would put a note in the system and it would be investigated and reported initially to the state agency within 2 hours and a follow-up report would be sent to the state agency in 5 days. When asked about a FRI regarding Resident #52's allegation of verbal abuse, the administrator stated a FRI was not done. The facility staff provided a copy of their policy entitled, Abuse, Neglect, and Exploitation. In Section VII, part viii, entitled, Reporting and Response an excerpt documented, Residents who are abusive to other residents must be monitored and must have a care plan that addresses the abusive behavior. Those who are victims of abuse must be protected from further injury or mental anguish. 40026 4. For Resident # 21 the facility staff failed to protect the Resident from physical abuse by staff. On 5/1/22 the facility submitted a FRI (Facility Reported Incident) to the OLC (Office of Licensure and Certification) regarding an allegation of abuse of Resident #21 by LPN F. The FRI read: Describe incident, including location, and action taken: CNA [name redacted] reported seeing a male nurse, [name redacted] hit Resident from behind the privacy curtain in room [ROOM NUMBER]. Resident was assessed w/o [without] injury. Employee action initiated or taken - [Employee name redacted] placed on suspension 5/1/22 pending investigation. The investigation contained a statement from the CNA that witnessed the incident. The CNA stated in her witness statement, that she went downstairs upset and was told that they would notify the DON however the CNA stated she did not trust the DON due to hearing her say Stuff like that does not happen on my floor. The CNA went outside and called the police to report the abuse and that the police came and took her statement. A review of the time card punches revealed that the LPN F was never placed on suspension. He continued working and had even been assigned to her unit several times after the incident. LPN F was still an active employee until 9/16/22 when he was terminated during the survey. A review of the employee file included the license verification completed on hire. LPN F's license verification read: Additional Public Information - YES [Please note when YES comes up on a license verification it is indicative of the licensee being brought before the Board of Nursing, and the facility needed to click the Yes to find out what the further information was] The facility had no evidence that they had not checked to see what that further information was until after this incident took place. During the course of their investigation of the incident they found that the nurse had been terminated from 2 previous facilities for negligence and verbal abuse of Residents. The nurse was terminated from employment on 9/16/22. On 9/16/22 the Administrator was made aware of the concerns and no further information was provided. On 09/16/2022 at 4:34 P.M., immediate jeopardy was called. On 09/16/2022 at 4:49 P.M., the Administrator was notified. On 09/21/2022 at 12:15 P.M., the removal plan was accepted by the survey team. The facility presented the following removal plan. 1. Resident #68 placed on 1:1 supervision to ensure other residents are protected from abuse. Resident #68 was moved to a room with no roommate. Attending physician and responsible party informed. Psychiatric evaluation will be completed. Resident #63 assessed by social worker for psychosocial effect from verbal abuse of resident #68. Head to toe assessment done and PTSD screen completed, no new findings. Social worker referral and psych consult will be done. Based on assessment findings appropriate therapeutic measures will be implemented to protect resident. 2. Resident #52 self-report of allegation of abuse completed 9/16/22 by administrator. Resident #52 was assessed by social worker for psychological effect of abuse. Head to toe assessment and PTSD screen, no new findings noted. Resident interviewed by social worker. To identify staff who committed the verbal abuse all staff will be investigated to ensure a thorough investigation is completed. Appropriate action including termination will be taken for any staff identified as committing the alleged abuse. 3. Regional Director of Operations educated facility leadership team on 9/16/22 on organization abuse, neglect and exploitation policy. Facility Staff Development Coordinator is re-in servicing all staff on abuse, neglect and exploitation policy. 4. Facility leadership team is currently interviewing all Interviewable residents for abuse. Head to toe skin assessments will be completed for non-Interviewable residents. Residents' responsible parties will be contacted to gather information on abuse that may have occurred in the past 90 days. 5. LPN F employment terminated on 9/16/22. LPN F last worked in facility 6/15/22. The survey team verified the following items listed in the removal plan: A FRI dated 09/16/2022 was completed for Resident #52. Resident #52 was assessed by the social worker. Resident #68 was placed 1:1; staff stationed outside his room, and no roommate. Psychiatric evaluation for Resident #68 was completed. Resident #63 was assessed by the social worker, head-to-toe assessment completed, PTSD screen completed, and psychiatric consult completed. All staff were educated on abuse, neglect, and exploitation policy. All interviewable Residents were interviewed to screen for abuse. Skin assessments were performed on all non-interviewable Residents Responsible Parties were interviewed to gather information on abuse. A head-to-toe assessment and a PTSD [post-traumatic stress disorder] were completed for Resident #52. All staff were educated on abuse, neglect, and exploitation policy. All interviewable Residents were interviewed to screen for abuse. Skin assessments were performed on all non-interviewable Residents. Responsible Parties were interviewed to gather information on abuse. On 9/21/22 at 12:15 P.M., the survey team verified the implementation of the removal Plan submitted by the facility and the scope and severity was lowered to E at that time. 41449 5. For Resident #35 the facility staff neglected to provide a blanket after the surveyor and the Resident made the request to facility staff. On 9/12/22 at 3:26 PM, an interview was conducted with Resident #35. During the interview, when asked about the temperature in the facility, Resident #35 stated he would like another blanket because he gets cold at night. While in the room with Resident #35, Surveyor B observed CNA F at the doorway, in the hall. CNA F had a linen cart, Surveyor B observed blankets on the cart and approached the doorway and said, He [Resident #35] would like another blanket, he says he gets cold at night. CNA F responded, We are making our rounds, I may need them for other people but it will be taken care of. CNA F then entered the room and handed Resident #35 a hospital gown and said, This is for later tonight. Resident #35 said, I like the gown because it keeps my clothes fresher, but it gets cold at night, I don't know if I can wear it all night. May I have a blanket? CNA F said, Let me make my rounds since you already have one. Resident #35 responded, It's a thin blanket. CNA F said again, Let me see if anyone else needs one first, and CNA F exited the room. Resident #35 then told Surveyor B, They say I bother them and they are busy working on reports, they just tell me to go wait in my room, they don't listen to you. On 9/12/22 at approximately 4:00 PM and again at 4:30 PM, Surveyor B went to laundry and knocked on the door without any response. On 9/12/22 at 5:12 PM, during an end of day meeting the facility Administrator and Director of Nursing were made aware of the above findings. The Administrator confirmed that the facility linen supply is good. When asked, if a Resident asks for a blanket what response would you expect. The Administrator said, They have to give it to them immediately. The DON said, You can't do that. The Administrator said he would define this as neglect. Following the end of day meeting, Surveyor B asked the Administrator to provide access to laundry, so the supply of linen could be observed. The Administrator was unable to find any staff to unlock the laundry door and gain access prior to the survey team leaving for the day at 5:45 PM. On 9/13/22, the facility Administrator provided the survey team with a Facility Reported Incident (FRI) that had been submitted that read, Surveyor witnessed Resident being verbally abused by staff employee regarding resident asking for blanket .Resident was immediately provided multiple blankets when brought to the ED's [executive director] attention. The Administrator also indicated that the employee [CNA F] has been suspended pending the investigation. On 9/13/22 at 8:15 PM, Surveyor B observed the 2 linen carts on the second floor, where Resident #35 resided and observed blankets available. The facility abuse policy was reviewed. This policy read, Neglect: means a failure to provide timely and consistent services, treatment or care to a resident or resident's which are necessary to obtain or maintain the resident's health, safety or comfort . No further information was provided. 34894 6. For Resident # 217, the facility staff failed to provide services to protect from neglect on 5/28/2020. Resident # 217 was admitted to the facility on [DATE] for skilled services in nursing and therapy with the diagnoses of, but not limited to, Asthma, Congestive Heart Failure (CHF), Chronic Kidney Disease Stage 3, Hypertension, Atrial Fibrillation, Obstructive Sleep Apnea (OSA), Infection due to Multi-resistant organism and Morbid Obesity with BMI (Body Mass Index) 60-69. Review of the Resident # 217's closed clinical record revealed the most recent MDS (Minimum Data Set) was a Quarterly Assessment with an ARD (Assessment Reference Date) of 9/16/2021. The MDS coded Resident #217 as requiring extensive to total assistance of one to two staff persons with activities of daily living and frequently incontinent of bowel and bladder. Review of the clinical record was conducted on 9/12/2022-9/22/2022. Review of the Progress Notes revealed documentation of a nurses note dated 5/28/2020 at 8:19 a.m. which stated: Resident The CNA (Certified Nursing Assistant) and I transferred (gender redacted) to the wheelchair. At around 10:30 p.m., I asked the CNA to help put (gender redacted) back to bed because it would be difficult if nobody is around to put (gender redacted) to bed. Resident refused to go to bed. (gender redacted) later on asked to be put to bed and I said (Resident # 217's name redacted) not by myself. I will need someone to help me. There was nobody at the moment and (gender redacted) was in the wheelchair for a while until when (Name of CNA redacted) came to help with (name of another resident redacted), then we put (gender redacted) to bed. On 9/20/2022, an interview was conducted with the Regional Nurse Consultant who read the Progress note and stated That's abuse. The Regional Nurse Consultant stated the nurse should have assisted the resident back to bed upon request. Resident # 217 should not have had to wait in the wheelchair for an extended time as documented by the Licensed Practical Nurse (LPN K). There was no documentation of the amount of time the resident waited. There was no documentation of the LPN trying to get another staff member to assist with the transfer from wheelchair to bed. Resident # 217 had a history of Asthma, and Congestive Heart Failure. The MDS coded extensive assistance of two staff persons for transfers and bed mobility. On 9/21/2022 during the end of day debriefing, the facility administrator, Director or Nursing, Regional Nurse Consultant and Regional Consultant were informed of the findings. The Administrative staff stated they were unaware of the incident that was documented on 5/28/2020 in the progress notes by LPN K (Licensed Practical Nurse K) . On 9/21/2022 at 10:45 a.m., an interview was conducted with the Human Resources Director who stated LPN was no longer employed at the facility. She also stated the CNA was no longer employed at the facility. On 9/21/2022 at 11 a.m., the Human Resources Director stated LPN resigned on 10/19/2021. When asked again if there were any disciplinary actions in the record, The Human Resources Director stated she would check the file for any disciplinary actions. Federal regulations describes neglect as: the failure of the facility , it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility's policy on Abuse, Neglect and Exploitation Effective 5/1/2017, Reviewed 11/22/2019, Revised 10/27/2021 revealed the following excerpts about Neglect: Neglect means a failure to provide timely and consistent services , treatment or care to a resident or resident's which are necessary to obtain or maintain the resident's health safety or comfort or a a failure to provide timely and consistent goods and services to avoid physical harm, mental anguish, or mental illness During the end of day debriefing, the facility's administrative staff was informed of the findings that the nurse, LPN (Licensed Practical Nurse) K, failed to assist Resident # 217 back to bed. Resident # 217 had gotten up earlier in the shift due to experiencing Shortness of Breath and difficulty breathing. LPN K was no longer employed at the facility at the time of the survey when the nurses note was discovered. The CNA mentioned in the note also was no longer employed at the facility. No further information was provided. COMPLAINT DEFICIENCY

Based on Resident interview, facility staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to ensure Residents' were free from misappropriation and exploitation for three Residents (Resident #35, 368 and 70) in a survey sample of 60 Residents. The findings included: 1. For Residents #35 and #368, who were married, were victims of financial misappropriation and were exploited of money in excess of $50,000 by a facility employee, which resulted in fear of economic hardship and mistrust, which constituted harm. On 9/12/22 at 3:07 PM, an interview was conducted with Resident #35. Resident #35 said, I had trouble when I first came here, thieves got hold of the books and it was a minor thing to them. I woke up one morning and the checking account was down to zero. It was an inside job, no one cared about how the books were managed. I would rather go home and do the best we can versus stay here and go broke. When asked if he worries about the ability to pay for continued care, Resident #35 said, Yes. On 9/15/22 at 4 PM, a follow-up interview was conducted with Resident #35. He stated, $70,000 was taken. We used a check to pay the facility because it wasn't covered by Medicare, we wrote a check for the amount due and they never paid the business office. Another check was written and they went to a young teller and got the money and we were down to zero. When asked how did this make him feel, Resident #35 said, I will be blunt. My wife is starting to get tarnished in her trust in people. I want to get out of here because of how they run their accounting and they see nothing wrong with it. It all started here, $4,000 my wife paid was charged to us again, and then another $5,000, looks like the hands of thieves are in it again. On 9/21/22 at 9:54 AM, an interview was conducted with Resident #368. When asked about the incident, Resident #368 said, I'm not sure who took it. A lady there released me and she wanted over $5,000 from me and never took it to the business office. They stole all our money. I'm having so much trouble with that business office. Resident #368 confirmed she feels taken advantage of. The interview was terminated because Resident #368 became very upset and tearful and said, I don't like what is going on. A lot of nights I lay awake and can't sleep, it's awful I sit here and cry a lot. Now I have to worry about money all the time. On 9/15/22, an interview was conducted with Adult Protective Services (APS). They were able to provide information regarding their investigation which revealed a preponderance of evidence to substantiate that Residents #35 and 368 were victims of financial exploitation by a facility employee in excess of $50,000. Their investigation was turned over to financial crimes department with the police. On 9/15/22, an interview was conducted with the investigator from the police department. He stated, Based on the evidence of the investigation thus far, we are able to determine it did take place and Residents #35 and 368 were victims of misappropriation and exploitation by an employee of the facility. The facility provided the survey team with a Facility Reported Incident (FRI) that was completed on 5/2/22, regarding this allegation of misappropriation. On 9/13/22, 9/15/22, and again on 9/16/22, the facility Administrator was asked to provide all documentation regarding this FRI, investigation, etc. Review of the facility reported incident/investigation revealed an investigation follow-up letter dated 5/4/22. This letter/report indicated that Resident #35 and 368's bank fraud department is how the concerns of fraud were identified and the bank reported the concerns to Resident #368. The report further stated that the facility was cooperating with the police department's investigation. There was no indication that any conclusion was made in the facility level investigation, nor that any correction/restitution had been made to Residents #35 and #368 to alleviate their duress. In the investigation documents there was evidence of checks written by Resident #35 and #368, drawn on their joint bank account that were endorsed by a facility employee for personal use/gain. The employee was able to coerce Resident #368 to write checks to her and additionally the employee intercepted payments mailed to the facility, endorsed the checks and obtained the money her/himself. Additional documentation received from the facility included collection notes and activity regarding Resident #35. a. The notes dated 4/21/22, read, s/w [spoke with] [Resident #368 name redacted] and she stated that [facility name redacted] had cleaned them out . b. An excerpt from the notes dated 5/2/22 read, I received a call from the wife [name redacted] on Friday, April 29, 2022. She stated that her bank account was wipe out by [facility name redacted]. I asked her does she know if it was for [hospital name redacted]. She said no, it was the nursing home. She stated that it was about $50,000.00 that was stealing out of her account [sic] . The facility staff reported they have been unable to find the employee file of the perpetrator. Therefore, they had no evidence that they had taken appropriate measures prior to hiring the employee to ensure they were not a threat to the residents. The facility policy titled, Abuse, Neglect and Exploitation Policy was received and reviewed. This policy read, .Misappropriation of Property: means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a Resident's belongings or money without the resident's consent . On 9/21/22, during end of day meeting the facility Administrator, Director of Nursing and Corporate staff were made aware the survey team had concerns regarding the Residents being exploited and misappropriation of money by a facility employee. No further information was received. 2. For Resident #70, the facility staff misappropriated money in the amount of $3,580.04. On 9/19/22, Resident #70 disclosed during an interview concerns about a check he received from a prior facility he lived at, not being deposited into his bank account/trust fund. On 9/19/22, Surveyor B asked for a transaction history of Resident #70's account and related documents. The requested items were received and reviewed. The findings were as follows: a. A copy of the check written to Resident #70 from another skilled nursing facility dated 7/15/21, in the amount of $3,580.04, was provided. b. The transaction history showed the above referenced check was deposited into Resident #70's trust account on 8/30/21. c. On 8/30/21, a withdrawal in the amount of $3,580.04 was made and applied towards care costs. Meaning, the funds were withdrawn and paid to the facility. d. Evidence of the Medicaid patient liability did not indicate Resident #70 owed these funds to the facility. On 9/20/22, an interview was conducted with Employee J, the Regional Director of Revenue Cycle who was present in the absence of the facility business office manager. Employee J was asked if she had any significant findings from the review of the documents Surveyor B had requested for Resident #70. Employee J said, yes, she had identified that they were deducting the wrong amount from Resident #70's account for the cost of care and was not certain why this had been done. When asked specifically about the check in the amount of $3,580.04, being withdrawn and paid to the facility. Employee J said, I am not sure why that was done, it wasn't owed to the facility. The facility policy titled, Abuse, Neglect and Exploitation Policy was received and reviewed. This policy read, .Misappropriation of Property: means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a Resident's belongings or money without the resident's consent . On 9/21/22, during an end of day meeting, the facility Administrator, Director of Nursing and Corporate staff were made aware of the above findings. No further information was provided. Complaint related deficiency.

Based on Resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to investigate allegations of abuse, exploitation and mistreatment, and failed to take measures to protect residents, and failed to make corrections affecting 4 Residents (Resident #35, 368, 52, and 317) in a survey sample of 60 Residents. The failure to make corrections resulted in harm for Residents #35 and #368. The findings included: 1. For Residents #35 and #368, who were married and victims of financial misappropriation and were exploited for an excess of $50,000, the facility staff failed to make corrections/restitution, which resulted in fear of economic hardship and mistrust, which constituted harm. On 9/12/22 at 3:07 PM, an interview was conducted with Resident #35. Resident #35 said, I had trouble when I first came here, thieves got hold of the books and it was a minor thing to them. I woke up one morning and the checking account was down to zero. It was an inside job, no one cared about how the books were managed. I would rather go home and do the best we can versus stay here and go broke. When asked if he worries about the ability to pay for continued care, Resident #35 said, Yes. On 9/15/22 at 4 PM, a follow-up interview was conducted with Resident #35. He stated, $70,000 was taken. We used a check to pay the facility because it wasn't covered by Medicare, we wrote a check for the amount due and they never paid the business office. Another check was written and they went to a young teller and got the money and we were down to zero. When asked how did this make him feel, Resident #35 said, [Expletive], I will be blunt. My wife is starting to get tarnished in her trust in people. I want to get out of here because of how they run their accounting and they see nothing wrong with it. It all started here, $4,000 my wife paid was charged to us again, and then another $5,000, looks like the hands of thieves are in it again. On 9/21/22 at 9:54 AM, an interview was conducted with Resident #368. When asked about the incident, Resident #368 said, I'm not sure who took it. A lady there released me and she wanted over $5,000 from me and never took it to the business office. They stole all our money. I'm having so much trouble with that business office. Resident #368 confirmed she feels taken advantage of. The interview was terminated because Resident #368 became very upset and tearful and said, I don't like what is going on. A lot of nights I lay awake and can't sleep, it's awful I sit here and cry a lot. Now I have to worry about money all the time. On 9/15/22, an interview was conducted with Adult Protective Services (APS). They were able to provide information regarding their investigation which revealed a preponderance of evidence to substantiate that Residents #35 and 368 were victims of financial exploitation by a facility employee in excess of $50,000. Their investigation was turned over to financial crimes department with the police. On 9/15/22, an interview was conducted with the investigator from the police department. He stated, Based on the evidence of the investigation thus far, we are able to determine a crime did take place and Residents #35 and 368 were victims of misappropriation and exploitation by an employee of the facility. On 9/15/22, during an interview with Adult Protective Services (APS), Surveyor B was notified that APS had called the facility and made an on-site visit on 4/29/22, and reported the allegation of misappropriation to the facility's Director of Nursing (DON). The facility provided the survey team with a Facility Reported Incident (FRI) that was completed on 5/2/22, regarding this allegation of misappropriation. On 9/13/22, 9/15/22, and again on 9/16/22, the facility Administrator was asked to provide all documentation regarding this FRI, investigation, etc. Review of the facility reported incident/investigation revealed an investigation follow-up letter dated 5/4/22. This letter/report indicated that Resident #35 and 368's bank fraud department is how the concerns of fraud were identified and the bank reported the concerns to Resident #368. The report further stated that the facility was cooperating with the police department's investigation. There was no indication that any conclusion was made in the facility level investigation, nor that any correction/restitution had been made to Residents #35 and #368 to alleviate their duress. The facility policy titled, Abuse, Neglect and Exploitation Policy was received and reviewed. This policy did not address the facility's obligation to make amends to Residents who are victims of financial exploitation and misappropriation. On 9/21/22, during end of day meeting the facility Administrator, Director of Nursing and Corporate staff were made aware the survey team had concerns regarding the facility not making corrections/restitution to Residents #35 and #368 with regards to the money that was misappropriated, which caused ongoing duress to the Residents. No further information was received. 40452 2. For Resident #52, the facility staff failed to adequately investigate the allegation of abuse on 09/13/2022. On 09/13/2022 at 11:00 A.M., a Resident Council meeting with 6 Residents was conducted. At 11:18 A.M., the Social Worker entered the Resident Council meeting. When this surveyor asked the social worker why she was entering the meeting, Resident #88 stated he invited the social worker to the meeting. When the other Residents were asked about this, the other Residents in attendance also indicated they would like the social worker to be present. The meeting resumed and when the Residents were asked if call bells were answered timely, Resident #52 stated that the aides appear angry, not giving good service. Resident #52 also stated staff was yelling at me. Resident #52 also indicated she didn't want to provide names. Resident #52 also stated she had experienced retaliation for reporting issues and did not want to elaborate further at the time of the meeting. Resident #88 also reported experiencing retaliation due to their loved one advocating for their care. When asked about what happened, Resident #88 stated that when he would ask for something, the staff wouldn't do it. Resident #88 also stated that the staff would say his loved one was mean and they would laugh at her. On 09/13/2022 at 12:10 P.M. following the Resident Council meeting, the administrator was notified of findings. On 09/14/2022, Resident #52's clinical record was reviewed. Resident #52's Minimum Data Set with an Assessment Reference Date of 07/27/2022 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 10 out of possible 15 indicative of moderate cognitive impairment for that 7-day look-back period. On 09/15/2022 at 1:00 P.M., a copy of the Facility-Reported Incident (FRI) related to Resident #52's allegation of abuse on 09/13/2022 was requested from the administrator. The Administrator stated a grievance form was filed and an investigation was started. On 09/15/2022, the facility staff provided a document dated 09/13/22 entitled, Concern Form for Resident #52. Under the header Description of Concern it was documented, Resident verbalize [sic] staff yells at her. Under the header Actions to resolve the concern documented, Social Services interviewed all residents w/a [with a] BIMS [Brief Interview for Mental Status] score of 12 and above with no concerns voiced of verbal, physical, or sexual abuse. The document was signed by the Social Worker on 09/14/2022 and the Administrator on 09/15/2022. There were no other documents provided associated with the allegation of verbal abuse made on 09/13/2022. On 09/15/2022 at 6:25 P.M., the Administrator was interviewed. When asked about the process for allegations of verbal abuse, the Administrator stated that staff would put a note in the system and it would be investigated and reported initially to the state agency within 2 hours and a follow-up report would be sent to the state agency in 5 days. When asked about a FRI regarding Resident #52's allegation of verbal abuse, the administrator stated a FRI was not done. The facility staff provided a copy of their policy entitled, Abuse, Neglect, and Misappropriation. In Section (IV)(2)(a), it was documented, Each occurrence of resident incident, bruise, abrasion, or injury of unknown source; or report of alleged abuse, neglect, or misappropriation of funds will be identified and reported to the supervisor and investigated timely. In Section (V)(1), it was documented, In the event a situation is identified as abuse, neglect, or misappropriation, an investigation by the executive leadership will immediately follow. In Section (VII)(iv)(v), it was documented, A timely and thorough investigation, which is recorded in an investigation report, is critical to substantiate finding of misconduct. An investigative report provides: a record of the facility investigators activities in findings so that nothing is left a memory; a permanent official record of the facility investigators actions, observations and discoveries; a basic reference of the case; information on what is been done concerning the case; a basis for deciding further action; a method to communicate the findings of the case; and information that can be evaluated to detect and identify patterns of misconduct. Investigative reports should contain the following basic elements: individuals involved, i.e. all persons connected in any way with the incident under investigation such as, residents, complainant, suspected individual, witnesses, any other with first-hand knowledge. Individuals should be identified in such a manner that they cannot be confused with any other individuals; description of the incident in a precise and accurate manner; including observable facts and statements from witnesses; time and date of the incident; specific location of all persons and things related to the incident, including room numbers, wing/corridor locations, objects in the space, noise, furnishings, clothing of victim; and effect on the resident or resident's reaction. 3. For Resident #317, the facility staff failed to adequately investigate the allegation of abuse on 12/15/2021. On 09/22/2022 at approximately 8:35 A.M., in the course of a complaint investigation, a Facility-Reported Incident (FRI) for Resident #317 dated 12/14/2021 was requested from the Administrator. The incident was pertaining to an allegation of abuse from Certified Nursing Assist S (CNA S) in December 2021. On 09/22/2022 at 9:15 A.M., the Human Resources Manager was interviewed. The Human Resources Manager verified that CNA S was still an active employee but currently suspended pending an investigation. When asked what the investigation was about, the Human Resources Manager stated that it was a complaint from a Resident of the aide being rough with the Resident. The Resident was identified and placed in the sample as Resident #84. When asked if there were any disciplinary actions in her file, the Human Resources Manager searched through her file and stated that there were no disciplinary actions in her file. On 09/22/2022 at approximately 9:35 A.M., a copy of the current FRI involving CNA S was requested from the administrator. On 09/22/2022 at 11:05 A.M., the Administrator provided a FRI pertaining to Resident #317 dated 12/15/2021 and a document entitled, FRI Investigation Summary. When asked about the investigation supporting documents such has Resident assessment, staff and resident interviews, witness statements, and reporting fax receipts to state agencies, the Administrator that he would look for them but This is all we have here. There were no evidence an adequate investigation was completed. On the FRI document dated 12/15/2021 under the header Describe incident, including location, and action taken: it was documented, Writer was made aware today that resident's daughter had concerns about nursing care and unprofessional behavior of a particular nursing employee. This employee was named on the FRI document and placed in the staff identifier as Certified Nursing Assistant S (CNA S). On the document FRI Investigation Summary dated 12/20/2021 under the header Summary of Investigation documented, Daughter stated during the follow-up meeting that Nursing Assistant (CNA S) displayed negative behavior towards her and the care of her father. During interview with the employee, she reported that she had changed the resident that day but had no interaction with the daughter. Accused employee has been at [facility name] since April 2017 with no record of any conduct or performance issues. Social Services Director conducted interviews with fourteen (14) A&O [alert and oriented] residents assigned to this employee. None shared any negative comments regarding employee conduct. Under the header Conclusion, an excerpt documented, The accused employee conducted herself in an unprofessional and negative manner, toward either the daughter or the resident, could not be substantiated. However, the employee will not be assigned to this resident per daughter's request when she returns to work. On 09/22/2022 at 11:30 A.M., the Administrator provided a copy of the current FRI dated 09/16/2022 involving Resident #84 and CNA S. Under the header, Describe incident, including location, and action taken: it was documented, The resident indicated that the CNA grabbed him aggressively from the behind. The resident does not remember the exact date or time. A head to toe assessment for the resident was conducted and no new findings. Social worker will continue to monitor resident and psych referral made. There was no evidence an investigation was completed, no supporting documents, and no five-day follow-up report. On 09/22/2022 at approximately 11:45 A.M., Resident #84's clinical record was reviewed. Resident #84 was initially admitted to the facility on [DATE]. Resident #84's quarterly Minimum Data Set with an Assessment Reference Date of 08/15/2022 coded the Brief Interview for Mental Status as 15 out of 15 indicative of intact cognition. The facility staff provided a copy of their policy entitled, Abuse, Neglect, and Misappropriation. In Section (IV)(2)(a), it was documented, Each occurrence of resident incident, bruise, abrasion, or injury of unknown source; or report of alleged abuse, neglect, or misappropriation of funds will be identified and reported to the supervisor and investigated timely. In Section (V)(1), it was documented, In the event a situation is identified as abuse, neglect, or misappropriation, an investigation by the executive leadership will immediately follow. In Section (VII)(iv)(v), it was documented, A timely and thorough investigation, which is recorded in an investigation report, is critical to substantiate finding of misconduct. An investigative report provides: a record of the facility investigators activities in findings so that nothing is left a memory; a permanent official record of the facility investigators actions, observations and discoveries; a basic reference of the case; information on what is been done concerning the case; a basis for deciding further action; a method to communicate the findings of the case; and information that can be evaluated to detect and identify patterns of misconduct. Investigative reports should contain the following basic elements: individuals involved, i.e. all persons connected in any way with the incident under investigation such as, residents, complainant, suspected individual, witnesses, any other with first-hand knowledge. Individuals should be identified in such a manner that they cannot be confused with any other individuals; description of the incident in a precise and accurate manner; including observable facts and statements from witnesses; time and date of the incident; specific location of all persons and things related to the incident, including room numbers, wing/corridor locations, objects in the space, noise, furnishings, clothing of victim; and effect on the resident or resident's reaction.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure services were provided that meet professional standards of care for 3 Residents (#'s 217, 88, and 417) in a survey sample of 60 Residents, resulting in harm for Resident #217. The findings included: 1. For Resident #217, the facility staff failed to assess, monitor and treat for Diabetes resulting in Harm. Documentation in the hospital records on Admission to the facility showed orders for a Carbohydrate Controlled Diet and Glucerna Shake. Both of these were indications that Resident # 217 might have been a Diabetic. Resident #217 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Asthma, Congestive Heart Failure (CHF), Chronic Kidney Disease Stage 3, Hypertension, Atrial Fibrillation, Obstructive Sleep Apnea (OSA), Infection due to Multi-resistant organism and Morbid Obesity with BMI (Body Mass Index) ,d+[DATE]. The MDS coded Resident #217 as requiring extensive to total assistance of one to two staff persons with activities of daily living and frequently incontinent of bowel and bladder. Review of the electronic clinical record revealed there was no documentation of a diagnosis of Diabetes listed in the record. There was no documentation of an order for the medication, Metformin. Review of the listed diagnoses did include Hypertension (high blood pressure) and Kidney failure. The Admission face sheet stated short term and D/C (discharge) back home with daughter. Review of the Progress Notes revealed a note written by the Nurse Practitioner on [DATE] at 16:22 (4:22 p.m.) which stated Resident # 217 was seen for complaints of increased edema and blisters. The resident was noted to have wheezing on examination by the Nurse Practitioner. The note included the following excerpt Noted to be having wheezing, SOB and increased work of breathing. Sat 87% on room air with abdominal breathing. The note also included the following Assessment and Plan: Acute Respiratory Failure with Hypoxia, Placed on 5 liters of Oxygen , nebulizers were given , placed on CPAP temporarily. if not improvement in dyspnea may need ER evaluation On [DATE] at 16:50 (4:50 p.m.), nurse documented Resident # 217 was alert and oriented x 3, had 3 + (3 plus) edema on bilateral lower legs, blisters, redness, warmth to the right lower leg, DTI to the sacrum, and redness and rash to the peri area. Wound nurse notified, Nurse Practitioner notified, son notified. Interview conducted on [DATE] with the Director of Nursing who stated she did not see a diagnosis of Diabetes for Resident # 217 in the clinical record. The Director of Nursing stated the facility staff normally would review the hospital records upon admission to the facility. Any diagnoses would be carried over to the Admission Notes. An interview was conducted with the Responsible Party via telephone on [DATE] at 9:31 a.m. Resident # 217's son stated the resident had been a known Type 2 Diabetic for over [AGE] years and had been taking Metformin. He stated the resident was aware of the diagnosis and that she told the staff that she was a Type 2 Diabetic. He stated medications were given by staff who did not explain what each pill was being taken for. Review of the Hospital Discharge Records dated [DATE] for admission to the facility revealed no diagnosis of Diabetes in the list of diagnoses. Further review of the documents revealed documentation of an order for a Carbohydrate Controlled Diet and Glucerna. According to the American Diabetes Association, the Carbohydrate Controlled Diet Helps people with diabetes keep their carbohydrate consumption at a steady level, through every meal and snack. On [DATE] at 11:15 a.m., an interview was conducted with the Director of Nursing regarding Admission History and Physicals. The Director of Nursing stated the doctors come on Mondays and Fridays to review new admissions, review the history and physical, do the initial History and Physical on Admission usually on Mondays or Tuesdays. The Director of Nursing stated the Nurse Practitioners are in the facility Monday through Friday. She stated that there are two Nurse Practitioners who come to the facility and one just started recently. An interview was conducted with the Medical Director via telephone on [DATE] at 6:28 PM. An interview was conducted over the phone with the call on speaker phone with all 6 surveyors present. The Medical Director stated he was aware that the facility was being surveyed during the past week and that the surveyors were back to complete the survey. The Medical Director stated he had been out of town at a meeting in Richmond and was going out of town for the next 10 days. The Medical Director was asked about the process for obtaining history and physical information on new admissions to the facility. The Medical Director stated one of the three physicians who see residents in the facility. The Medical Director stated the facility accepts the patients. We (doctors) don't decide who gets admitted . The facility knows what they can do. The Administrative team makes the decision about who gets admitted . When asked about the process of determining chronic disease diagnoses, the Medical Director stated we look at the records from the hospital. The hospital has their history. It's their responsibility to obtain an accurate history. We have the patient for Physical Therapy. We have them for a short time. If there are signs and symptoms, we would check labs. Then the Medical Director questioned the surveyor Why don't you ask the Hospital why they didn't do it? They are supposed to do a medical history. We review that history. It is not standard of practice to check A1C on residents or check for Diabetes unless they have a history or have medicine for Diabetes. We review the hospital records, examine the patient and look at the medicines. I've worked in the hospital before. The hospital is supposed to check the medical history. They do lab work there routinely. We don't routinely do labs for rehab patients unless they have signs and symptoms. When asked if a Blood Glucose result of 145 was considered an indication of a need for further follow up, The Medical Director stated it depends on whether the resident was fasting or nor. An A1C (Hemoglobin A1C) is not indicated unless there are signs or symptoms of Diabetes. The Medical Director was asked if a resident 5 foot 3 inches tall weighing over 370 pounds was a person that might need close follow up to determine if there was Diabetes. The Medical Director again stated that the facility would check the hospital records to see if there was a previous diagnosis of Diabetes. The Medical Director was asked about Residents with Diabetes who were managed by Diet alone or what if the hospital did not obtain a complete medical history. The Medical Director again stated the hospital was supposed to obtain the medical history and the facility would review those documents to obtain the information. The Medical Director was asked if the facility staff ever contacted the Primary Care Physician to make sure an accurate history was obtained. The Medical Director stated no. When the Medical Director was informed that Resident # 217 had a Blood Sugar of 844 that was obtained at the facility but not resulted out until after the transfer to the hospital., the Medical Director stated that could have been an acute thing. It could have just happened. She had no signs or symptoms. The Medical Director was asked if he thought there was a potential for important diagnoses to be missed if the facility staff was relying on the discharging hospital to provide all of the history and physical information. The Medical Director stated the hospital was supposed to be obtain a complete history and physical and the facility would review that information when the resident was admitted to the facility. He then stated the nursing staff would ask information during the admission assessment but would use the hospital discharge summary. The physician at the facility would examine the resident and interview them about the medical history. On [DATE] at 10:45 a.m., another surveyor interviewed one of the physicians (Employee T) about another resident in the survey sample. Employee T was listed on the hospital discharge Summary (and in the clinical record) as the Primary Care Provider for Resident #217. This surveyor immediately asked the Regional Nurse Consultant to have Employee T to call this surveyor. The Regional Nurse Consultant stated Employee T had already left the facility but a message had been left for her to call the surveyor. The Regional Nurse Consultant stated she spoke with Employee T and that Employee T checked her records mentioned something about Diabetes and noted that Resident # 217 had not been her patient anymore for 3 years but may have been seen by one of the partners in the group. Requests were made to have the physician (employee T) to call this surveyor. The Regional Nurse Consultant stated the physician wanted to make sure the family gave permission for her to talk with the surveyors due to HIPPA. This surveyor informed the Regional Nurse Consultant that the Resident's son was aware and told the surveyor to call the Primary Care Doctor to gather information. Employee T never returned the call to the surveyor. Several attempts to reach the physician (Employee T) were unsuccessful while on survey. On [DATE] at 11:45 a.m., an interview was conducted with the Regional Nurse Consultant who stated she reviewed the clinical record and could not find any documentation that Resident # 217 had Diabetes. She stated she did find evidence of an order for a Diabetic Diet and Glucerna on the hospital discharge records in [DATE] that were used for admission to the facility. The Regional Consultant stated that when the labs were ordered and results came back, Resident # 217 was already in the hospital. The Regional Consultant stated we probably should have been checking the blood sugar due to the Diet Order and the Glucerna which are both used for Diabetes. That was a clue She also stated the facility staff should do a thorough History and Physical to include interviewing the resident, family members and the Primary Care physicians. The family should be asked about past medical history too. Review of the Blood Sugar readings revealed documentation of two elevated Comprehensive Metabolic Profile blood sugar results in [DATE]. There were no other Blood Glucose results noted that were drawn after the level of 145 in [DATE] in the clinical record. According to the lab report, normal range is less than 110. There was no noted follow up to check the Hemoglobin A1C after the documented elevated blood glucose level. [DATE]- CMP-glucose =118 [DATE]-CMP-glucose =145 [DATE]-CMP-glucose =844 There was no documentation of a Hemoglobin A1C being ordered for Resident # 217. The A1C evaluates the amount of glucose in the blood over the last two to three months. Resident # 217 had several risk factors that would indicate a work up or evaluation for Diabetes including age, race, BMI greater than 60 and elevated blood glucose levels on routine lab work while in the facility. Resident # 217 was alert and oriented. According to Resident # 217's son, Resident #217 stated 'that;s a lie, I told them. There was no documentation that the facility staff asked questions about a previous history of Diabetes. The was no was documentation that anyone assessed the clinical picture of told about the diagnosis Based on review of the clinical record, interviews, and facility documentation review, the facility staff failed to assess, monitor and treat Resident # 217. Documentation in the hospital records on Admission to the facility showed orders for a Carbohydrate Controlled Diet and Glucerna Shake. Both of these were indications that Resident # 217 might have been a Diabetic. When Resident # 217 was transferred to the hospital on [DATE], the Blood Sugar was 844. Resident # 217 was immediately taken to the Intensive Care Unit and stayed for a few days. Upon discharge from the hospital, Resident # 217 went to another facility because she refused to return to the facility. He stated Resident # 217 had to have a partial amputation while in the hospital. The numbers were not right. So, they could not do the entire amputation. He stated Resident # 217 had to be hospitalized again and had pneumonia, COVID and 'Kidney Failure. The resident expired in [DATE]. Resident # 217's son stated that during the pandemic, we could not advocate for her. We could not see her. We had to trust what the facility was telling us. That started a lot of the problems. We could not see what was happening. We did not get answers from the staff when we called to express our concerns. During the end of day debriefings on [DATE] and [DATE], the facility Administrator, Director of Nursing and Regional/Corporate Consultants were informed of the findings. No further information was provided. COMPLAINT DEFICIENCY at a HARM level 40026 2. For Resident #88 the facility staff failed to check the physicians order against the medication to ensure the proper dose of medication. On [DATE] at approximately 2:00 PM an interview was conducted with Resident # 88 who stated that he has been getting the wrong dose of medication for his blood clots and just found out this week it was the wrong dose. He stated his doctor that he sees for his blood clot had put him on shots in the stomach and the medication should have been 100 mg every 12 hrs. but that he was only getting 80 mg. A review of the clinical record revealed that Resident #88 had physician's orders that read: [DATE] 8:15 PM Enoxaparin Sodium Injection Solution Prefilled Syringe 100 MG/ML (Enoxaparin Sodium) Inject 1 ml subcutaneously every morning and at bedtime for clotting . [DATE] at 21:00 Medication: Enoxaparin Sodium Injection Solution Prefilled Syringe 80 MG/0.8M Generic: Enoxaparin Sodium Medication Class: ANTICOAGULANTS . Enoxaparin Sodium Injection Solution Prefilled Syringe 80 MG/0.8ML (Enoxaparin Sodium) Inject 100 mg/ml subcutaneously every 12 hours for PE/DVT until [DATE] 12:02 for 8 administrations. (**Please note the prefilled syringe was ordered at 80 mg/ 0.8 ml not the 100 mg/ml that was ordered) A review of the MAR (Medication Administration Record) for the month of [DATE] revealed the record was signed off as being given as follows: Enoxaparin Sodium Injection Solution Prefilled Syringe 100 MG/ML (Enoxaparin Sodium) Inject 1 ml subcutaneously every morning and at bedtime for clotting -D/C Date[DATE] Time:14:13 Please note the Resident received the correct dose for [DATE] and [DATE] the order was then discontinued and the following (incorrect) order was initiated. Enoxaparin Sodium Injection Solution Prefilled Syringe 80 MG/0. 8ML (Enoxaparin Sodium) Inject 100 mg/ml subcutaneously every 12 hours for PE/DVT until [DATE] 12:02 for 8 administrations On [DATE] at 9:30 AM an interview was conducted with LPN C who was asked how she administers Lovenox injections and she stated that she looks at the order and the medication available in the drawer making sure the order and the medication are the same before administering the medication. On [DATE] at approximately 3:00 PM an interview was conducted with the DON who was asked if the nurses should be checking the dosage with the medication and comparing to ensure proper dosage. She stated that this is the expectation for all nurses to perform he Rights of medication administration. When she was asked about the Lovenox order for Resident #88 she stated was aware that this happened but she insisted that the Resident was never given in the wrong dose. She stated that the medication was ordered and received by the pharmacy in the 100 mg / 1 ml prefilled syringes. When asked why the order was changed from the original (correct) ordered dosage to an incorrect dose she stated that the nurse who put the order in the system hit the wrong line on the drop down box and ordered 80 mg/0.8 ml instead of the 100 ml / ml, When asked if anyone clarified the order to see what the correct order should be when comparing the dose ordered with the medication on hand she stated they did not. Guidance for nursing standards for the administration of medication is provided by Fundamentals of Nursing, 7th Edition, Mosby's/ Potter-Perry, p. 705: Professional standards, such as the American Nurses Association's Nursing Scope and Standards of Nursing Practice of (2004), apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation. On [DATE] during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 41450 3. For Resident #417, the facility staff failed to administer 5 medications, Trazadone, Clonazepam, Galantamine Hydorbromide, Lamotrigine, and Pantoprazole as ordered by the physician on [DATE]. On [DATE], in the course of a complaint investigation, the clinical record for Resident #417 was reviewed in its entirety, with particular attention given to physician orders and medication administration. Resident #417 was admitted to the facility on [DATE] at 12:30 PM. The clinical record revealed: A physician's order was placed on [DATE] for Trazadone HCl Tablet 50mg .give 1 tablet by mouth at bedtime for Insomnia. The Medication Administration Record (MAR) indicated the Trazadone was scheduled to be given at 08:00 PM beginning on [DATE], however a chart code, 9=Other/See Progress Notes was documented. The corresponding progress note read, Awaiting pharmacy arrival. Resident #417 did not receive the medication until the next scheduled dose, the following day, on [DATE] at 08:00 PM which constituted 1 missed dose. A physician's order was placed on [DATE] for Clonazepam Tablet 0.5mg .give 0.5 tablet by mouth two times a day for Anxiety. The MAR indicated the Clonazepam was scheduled to be given at 09:00 PM beginning on [DATE], however a chart code, 9=Other/See Progress Notes was documented. The corresponding progress note read, Awaiting pharmacy arrival. Resident #417 did not receive the medication until the next scheduled dose, the following day, on [DATE] at 09:00 AM which constituted 1 missed dose. A physician's order was placed on [DATE] for Galantamine Hydrobromide Tablet 4 mg .give 1 tablet by mouth two times a day for Dementia. The MAR indicated the Galantamine was scheduled to be given at 09:00 PM beginning on [DATE], however a chart code, 9=Other/See Progress Notes was documented. The corresponding progress note read, Awaiting pharmacy arrival. Resident #417 did not receive the medication until the next scheduled dose, the following day, on [DATE] at 09:00 AM which constituted 1 missed dose. A physician's order was placed on [DATE] for Lamotrigine Tablet 150mg .give 1 tablet by mouth two times a day for Mood Disorder. The MAR indicated the Lamotrigine was scheduled to be given at 09:00 PM beginning on [DATE], however a chart code, 9=Other/See Progress Notes was documented. The corresponding progress note read, Awaiting pharmacy arrival. Resident #417 did not receive the medication until the next scheduled dose, the following day, on [DATE] at 09:00 AM which constituted 1 missed dose. A physician's order was placed on [DATE] for Pantoprazole Sodium Tablet Delayed Release 20mg .give 1 tablet by mouth two times a day for GERD [Gastroesophageal Reflux Disease] before meals. The MAR indicated the Pantoprazole was scheduled to be given at 04:30 PM beginning on [DATE], however a chart code, 9=Other/See Progress Notes was documented. The corresponding progress note read, Awaiting pharmacy arrival. Resident #417 did not receive the medication until the following day, [DATE], at 04:30 PM, which constituted 2 missed doses. There was no documentation in the clinical record that the physician was notified that the ordered medications were awaiting pharmacy arrival and not given as ordered. On [DATE], an interview was conducted with the Corporate Clinical Nurse who stated, If meds are not available from pharmacy, I expect the nurse to call the ordering doctor, that would give the doctor options to change the medication orders if needed .I would expect to see a note in the clinical record that the nurse notified the doctor of the situation. The Facility Administrator and Director of Nursing (DON) were updated on the findings. The DON stated that the facility's professional nursing standard reference was Lippincott. A facility policy on medication administration was requested and received. Review of the facility policy entitled, Medication Administration, review date [DATE], heading, Procedure read, I. General Procedures: a. Administer medication only as prescribed by the provider and f. Observe the 'five rights' in giving each medication: the right resident, the right time, the right medicine, the right dose, and the right route. According to Lippincott Nursing Procedures, Seventh Edition, 2016, section entitled, Oral Drug Administration, steps in the implementation of medication administration included but were not limited to: Verify the medication is being administered at the proper time .to reduce the risk of medication errors. No further information was provided. COMPLAINT DEFICIENCY 31199

Based on staff interview, family interview, and clinical record review, the facility staff failed to ensure the highest practicable well being. for two residents ( Residents # 217 and #23) in a survey sample of 60 residents. Findings: 1. For Resident #217, the facility staff failed to ensure the highest practicable well being resulting in Harm. Resident #217 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Asthma, Congestive Heart Failure (CHF), Chronic Kidney Disease Stage 3, Hypertension, Atrial Fibrillation, Obstructive Sleep Apnea (OSA), Infection due to Multi-resistant organism, and Morbid Obesity with BMI (Body Mass Index) ,d+[DATE]. Review of the clinical record was conducted on [DATE]-[DATE]. Documentation in the hospital records on Admission to the facility showed orders for a Carbohydrate Controlled Diet and Glucerna Shake. Both of these were indications that Resident #217 might have been a Diabetic. Review of the electronic clinical record revealed there was no documentation of a diagnosis of Diabetes listed in the record. There was no documentation of an order for the medication, Metformin. Review of the listed diagnoses did include Hypertension (high blood pressure) and Kidney failure. Review of the Nurses Notes revealed documentation of Shortness of breath, Blood pressure of ,d+[DATE], Pulse 126 irregular, new onset, Temperature 97.4, 02 (Oxygen saturation)- 95 %, Review of the eInteract form (communication form) dated [DATE] at 6:18 p.m. revealed documentation that Resident #217 was transferred to the hospital for Shortness of breath, wheezing and was on 5 liters of oxygen. Review of the Skin and Wound note Wounds - RLE with large intact and open blister wounds. Right lower leg surgical wound dehiscence. Sacrum and perineum with denudement and fungal dermatitis, MASD (moisture associated skin damage), .Lymphedema and Hyperkeratosis to BLE. See TA documentation for full wound assessment details. PRIMARY DIAGNOSIS ICD 10 - General Xerosis: L85. 3 - Wound, Lower Extremity Unspcfd Wnd RLE Init: S81.801A - ICD 10 - L22. - Diaper dermatitis - S80. 821A - Blister (nonthermal), right lower leg, initial encounter Review of the Progress Notes revealed a note written by the Nurse Practitioner on [DATE] at 16:22 (4:22 p.m.) which stated Resident # 217 was seen for complaints of increased edema and blisters. The resident was noted to have wheezing on examination by the Nurse Practitioner. The note included the following excerpt Noted to be having wheezing, SOB and increased work of breathing. Sat 87% on room air with abdominal breathing. The note also included the following Assessment and Plan: Acute Respiratory Failure with Hypoxia, Placed on 5 liters of Oxygen, nebulizers were given , placed on CPAP temporarily. if not improvement in dyspnea may need ER evaluation On [DATE] at 16:50 (4:50 p.m.),nurse documented Resident # 217 was alert and oriented x 3, had 3 + (3 plus) edema on bilateral lower legs, blisters, redness, warmth to the right lower leg, DTI to the sacrum, and redness and rash to the peri area. Wound nurse notified, Nurse Practitioner notified, son notified. Interview conducted on [DATE] with the Director of Nursing who stated she did not see a diagnosis of Diabetes for Resident #217 in the clinical record. The Director of Nursing stated the facility staff normally would review the hospital records upon admission to the facility. Any diagnoses would be carried over to the Admission Notes. An interview was conducted with the Responsible Party via telephone on [DATE] at 9:31 a.m. Resident #217's son stated the resident had been a known Type 2 Diabetic for over [AGE] years and had been taking Metformin. He stated the resident was aware of the diagnosis and that she told the staff that she was a Type 2 Diabetic. He stated medications were given by staff who did not explain what each pill was being taken for. Resident # 217's son stated that during the pandemic, we could not advocate for her. We could not see her. We had to trust what the facility was telling us. That started a lot of the problems. We could not see what was happening. We did not get answers from the staff when we called to express our concerns. Review of the Hospital Discharge Records dated [DATE] revealed no diagnosis of Diabetes in the list of diagnoses. Further review of the documents revealed documentation of an order for a Carbohydrate Controlled Diet and Glucerna. According to the American Diabetes Association, the Carbohydrate Controlled Diet Helps people with diabetes keep their carbohydrate consumption at a steady level, through every meal and snack. On [DATE] at 11:15 a.m., an interview was conducted with the Director of Nursing regarding Admission History and Physicals. The Director of Nursing stated the doctors come on Mondays and Fridays to review new admissions, review the history and physical, do the initial History and Physical on Admission usually on Mondays or Tuesdays. The Director of Nursing stated the Nurse Practitioner are in the facility Monday through Friday. We have two Nurse Practitioners who come to the facility. One just started recently. On [DATE] at 6:27 PM, a message was left on the telephone voicemail for the Medical Director . The Medical Director immediately returned the telephone call at 6:28 PM. An interview was conducted over the phone with the call on speaker phone with all 6 surveyors present. The Medical Director stated he was aware that the facility was being surveyed during the past week and that the surveyors were back to complete the survey. The Medical Director stated he had been out of town at a meeting in Richmond and was going out of town for the next 10 days. The Medical Director was asked about the process for obtaining history and physical information on new admissions to the facility. The Medical Director stated one of the three physicians who see residents in the facility. The Medical Director stated the facility accepts the patients. We (doctors) don't decide who gets admitted . The facility knows what they can do. The Administrative team makes the decision about who gets admitted . When asked about the process of determining chronic disease diagnoses, the Medical Director stated we look at the records from the hospital. The hospital has their history. It's their responsibility to obtain an accurate history. We have the patient for Physical Therapy. We have them for a short time. If there are signs and symptoms, we would check labs. Then the Medical Director questioned the surveyor Why don't you ask the Hospital why they didn't do it? They are supposed to do a medical history. We review that history. It is not standard of practice to check A1C on residents or check for Diabetes unless they have a history or have medicine for Diabetes. We review the hospital records, examine the patient and look at the medicines. I've worked in the hospital before. The hospital is supposed to check the medical history. They do lab work there routinely. We don't routinely do labs for rehab patients unless they have signs and symptoms. When asked if a Blood Glucose result of 145 was considered an indication of a need for further follow up, The Medical Director stated it depends on whether the resident was fasting or nor. An A1C (Hemoglobin A1C) is not indicated unless there are signs or symptoms of Diabetes. The Medical Director was asked if a resident 5 foot 3 inches tall weighing over 370 pounds was a person that might need close follow up to determine if there was Diabetes. The Medical Director again stated that the facility would check the hospital records to see if there was a previous diagnosis of Diabetes. The Medical Director was asked about Residents with Diabetes who were managed by Diet alone or what if the hospital did not obtain a complete medical history. The Medical Director again stated the hospital was supposed to obtain the medical history and the facility would review those documents to obtain the information. The Medical Director was asked if the facility staff ever contacted the Primary Care Physician to make sure an accurate history was obtained. The Medical Director stated no. When the Medical Director was informed that Resident #217 had a Blood Sugar of 844 that was obtained at the facility but not resulted out until after the transfer to the hospital., the Medical Director stated that could have been an acute thing. It could have just happened. She had no signs or symptoms. The Medical Director was asked if he thought there was a potential for important diagnoses to be missed if the facility staff was relying on the discharging hospital to provide all of the history and physical information. The Medical Director stated the hospital was supposed to be obtain a complete history and physical and the facility would review that information when the resident was admitted to the facility. He then stated the nursing staff would ask information during the admission assessment but would use the hospital discharge summary. The physician at the facility would examine the resident and interview them about the medical history. On [DATE] at 10:45 a.m., another surveyor interviewed one of the physicians (Employee T) about another resident in the survey sample. Employee T was listed on the hospital discharge Summary (and in the clinical record) as the Primary Care Provider for Resident #217. This surveyor immediately asked the Regional Nurse Consultant to have Employee T to call this surveyor. The Regional Nurse Consultant stated Employee T had already left the facility but a message had been left for her to call the surveyor. The Regional Nurse Consultant stated she spoke with Employee T and that Employee T checked her records mentioned something about Diabetes and noted that Resident #217 had not been her patient anymore for 3 years but may have been seen by one of the partners in the group. Requests were made to have the physician (employee T) to call this surveyor. The Regional Nurse Consultant stated the physician wanted to make sure the family gave permission for her to talk with the surveyors due to HIPPA. This surveyor informed the Regional Nurse Consultant that the Resident's son was aware and told the surveyor to call the Primary Care Doctor to gather information. Employee T never returned the call to the surveyor. Several attempts to reach the physician (Employee T) were unsuccessful while on survey. On [DATE] at 11:45 a.m., an interview was conducted with the Regional Nurse Consultant who stated she reviewed the clinical record and could not find any documentation that Resident #217 had Diabetes. She stated she did find evidence of an order for a Diabetic Diet and Glucerna on the hospital discharge records in [DATE] that were used for admission to the facility. The Regional Consultant stated that when the labs were ordered and results came back, Resident #217 was already in the hospital. The Regional Consultant stated we probably should have been checking the blood sugar due to the Diet Order and the Glucerna which are both used for Diabetes. That was a clue She also stated the facility staff should do a thorough History and Physical to include interviewing the resident, family members and the Primary Care physicians. The family should be asked about past medical history too. Review of the Blood Sugar Review of the Blood Sugar readings revealed documentation of two elevated Comprehensive Metabolic Profile blood sugar results in [DATE]. There were no other Blood Glucose results noted that were drawn after the level of 145 in [DATE] in the clinical record. According to the lab report, normal range is less than 110. There was no noted follow up to check the Hemoglobin A1C after the documented elevated blood glucose level. [DATE]- CMP-blood glucose level 118 [DATE]-CMP-blood glucose level 145 [DATE]-CMP-blood glucose level 844 There was no documentation of a Hemoglobin A1C being ordered for Resident #217. The A1C evaluates the amount of glucose in the blood over the last two to three months. Resident #217 had several risk factors that would indicate a work up or evaluation for Diabetes including age, race, BMI greater than 60 and elevated blood glucose levels on routine lab work while in the facility. Resident #217 was alert and oriented. According to Resident #217's son, Resident #217 stated 'that;s a lie, I told them. There was no documentation that the facility staff asked questions about a previous history of Diabetes. The was no was documentation that anyone assessed the clinical picture of told about the diagnosis When Resident #217 was transferred to the hospital on [DATE], the Blood Sugar was 844. Resident #217 was immediately taken to the Intensive Care Unit and stayed for a few days. Upon discharge from the hospital, Resident #217 went to another facility because she refused to return to the facility. He stated Resident #217 had to have a partial amputation while in the hospital. The numbers were not right. So, they could not do the entire amputation. He stated Resident #217 had to be hospitalized again and had pneumonia, COVID and 'Kidney Failure. The resident expired in [DATE]. 40452 2. For Resident #23, the facility staff failed to provide a left upper extremity device on [DATE] as recommended by the therapy department. On [DATE] at 2:55 P.M., Resident #23 was observed in her bed. Resident #23 had a contracture of her left upper extremity and there was no positional device observed. At approximately 2:57 P.M., Certified Nursing Assistant Q (CNA Q) was interviewed. When asked about a positional device for Resident #23, CNA Q stated that Resident #23 has one but she hates it and she always throws it away.When asked where the device was located, CNA Q looked around the room and found it in the closet. CNA Q did not attempt to apply the device but put it back in the closet. On [DATE] at 3:02 P.M., the Director of Rehab was interviewed. When asked about the dates of service for therapy for Resident #23, the Director of Rehab referred to Resident #23's clinical record and stated the dates of service were [DATE] to [DATE]. When asked about therapy recommendations at the conclusion of her therapy care, the Director of Rehab stated that therapy recommended a positional device for her left upper extremity. When asked if Resident #23 tolerates the device, the Director of Rehab stated that She tolerated it really well, some days better than others. At 3:09 P.M., this surveyor and the Director of Rehab entered Resident #23's room to do an observation. The Director of Rehab retrieved the positional device from the closet and positioned it on Resident #23's left upper extremity. Resident #23 tolerated the application of the positional device. At 3:19 P.M., Resident #23 was observed awake in bed still wearing the device. On [DATE], the facility staff provided a copy of Resident #23's Occupational Therapy notes. On the Occupational Therapy Discharge Summary dated [DATE] under the header Patient Response an excerpt documented, Patient tolerating orthotics well. No large gains in ROM [range of motion] however decreased skin to skin contact and risk of skin breakdown and further contracture. Under the header, D/C Recs [discharge recommendations] an excerpt documented, placement of LUE [left upper extremity] orthotics (UE [upper extremity] device and palm protector . On [DATE], Resident #23's clinical record was reviewed. There were no physician's orders for a positional device for Resident #23's left upper extremity. The care plan was reviewed. There was no focus, goals, or interventions pertaining to Resident #23's left upper extremity contracture. On [DATE] at approximately 4:15 P.M., the Administrator and Director of Nursing were notified of findings. When asked about the expectation, the Director of Nursing indicated contracture management should be on the care plan. On [DATE] at 10:30 A.M., Resident #23 was observed resting in her bed with the positional device in place. On [DATE] at 10:45 A.M., the Director of Rehab was interviewed. When asked about the process for therapy recommendations upon discharge from services, the Director of Rehab stated that therapy staff will enter the orders into the electronic health record. When asked why Resident #23 did not have orders for the therapy-recommended orthotic, the Director of Rehab stated, It just got missed. Complaint related deficiency.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure that Residents receive care, consistent with professional standards of practice to prevent pressure ulcers from worsening or new ulcers developing for 2 Residents (Resident #111 and 86) in a survey sample of 60 Residents, resulting in harm for Resident #111. The findings included: 1. For Resident #111, the facility staff failed to identify, treat and prevent a pressure ulcer until it was found at an advanced stage, necrotic and required sharp debridement. This constituted harm. On 9/12/22, Resident #111 was observed in his room. Resident #111 indicated that he had new wounds that were not present on admission during the interview. On 4/21/22, a Braden scale assessment was conducted that revealed Resident #111 was at moderate risk for developing pressure related skin issues. A clinical record review revealed that Resident #111 had been admitted to the facility on [DATE]. Nursing notes on admission indicated Resident #111 had a necrotic wound on his left foot. There was no mention of any other skin breakdown or ulcers. The admission MDS (minimum data set) (an assessment tool) with an assessment reference date of 4/20/22, had section M, for skin conditions coded as Resident #111 having had no unhealed pressure ulcers/injuries. Weekly skin checks completed 4/18/22, 4/25/22, 5/2/22, and 5/16/22, made no reference of Resident #111 having had any pressure ulcers or skin issues identified. The skin check completed 5/9/22, indicated Resident #111 had a wound on his left toe(s). On 5/15/22, a Skin Grid Pressure assessment was completed that revealed Resident #111 had an area identified on that date on his left gluteal fold which measured 5 cm x 2 cm x 0 cm. A nursing note was entered into the record on 5/15/22, which read, Writer was called to observed resident skin at about 3 pm. Writer notice skin ulcer and writer notified supervisor and wound nurse who was in house. Skin ulcer to left gluteal and scrotum. MD notified .[sic] On 5/16/22 at 8:56 AM, Resident #111 was seen by a wound care specialist who assessed the wound as 2.91 cm x 2.70 cm x 0.1 cm, with 0.62 cm black tissue, 0.53 cm yellow tissue, and 40 % granulation, 30 % eschar/slough. The note went on to read, Full thickness, and wound debrided .Etiology Pressure ulcer- stage 3 . Orders for Medihoney, Calcium alginate were noted. Review of Resident #111's care plan revealed on admission he had the following focus area, [Resident #111's name redacted] has impaired skin integrity, and is at risk for altered skin integrity. The following interventions were noted to be entered on the care plan following his admission, Administer treatments as ordered by medical provider, complete skin at risk assessment upon admission / readmission, quarterly, and as needed, Complete Weekly Skin checks. The intervention to add a pressure reducing mattress to the bed, was not added to the care plan until after the wound had been identified on 5/16/22. There is no evidence of any preventative measures being implemented to prevent the development of pressure wounds when Resident #111 had been identified to be at risk. This wound at the time of discovery had necrotic tissue that required sharps debridement, this constituted harm for Resident #111. Guidance is provided for the staging of pressure ulcers by the National Pressure Ulcer Advisory Panel (NPUAP), and is as follows; THE NATIONAL PRESSURE INJURY ADVISORY PANEL (NPIAP) provides guidance on the staging of pressure ulcers in the document titled, NPIAP Pressure Injury Stages. This document read, Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue . It goes on to state: .Stage 3 Pressure Injury: Full-thickness skin loss: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Accessed online at: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf Review of the facility policy titled, Skin Care & Wound Management Overview was conducted. This policy read, Procedure: Prevention.3. Identify diagnosis or conditions to place the resident/patient at risk for pressure ulcer development .4. Develop a care plan with individualized interventions to address risk factors. 5. Communicate risk factors and interventions to the care giving team. 6. Evaluate for consistent implementation of interventions and effectiveness at clinical meeting. 7. Modify and document goals and interventions as indicated. 8. Communicate changes to the care giving team . On 9/21/22, during an end of day meeting with the facility Administrator, Director of Nursing and Corporate staff, they were made aware of the above concerns. No additional information was provided. 40026 2. For Resident # 86 the facility staff failed to put interventions into place for a Resident that is non-ambulatory and at nutritional risk. Resident # 86 was admitted on [DATE] with diagnoses that included ALS, dysphasia, failure to thrive, and a peg tube had been inserted. A review of the Admission Initial Evaluation revealed that Resident #86 had one Non-Pressure Area under her left and right breast MASD this was being treated with antifungal cream. A review of the care plan revealed that Resident #86 was care planned for impaired skin integrity, or at risk for altered skin integrity. 08/12/22 upon admission [Resident #86] has MASD under L and R breast Date Initiated: 08/13/2022 The following interventions were put into place: Administer treatments as ordered by medical provider. Date Initiated: 08/13/2022 Complete skin at risk assessment upon admission / readmission, quarterly, and as needed. Complete Weekly Skin checks. Date Initiated: 08/13/2022 Resident #86's most recent MDS (Minimum Data Set) with and ARD (Assessment Reference Date) of 8/13/22, coded Resident #86 as requiring #3 Extensive Assistance with 2 person physical assistance for bed mobility and transfers. She is coded as Extensive assistance or totally dependent for all other ADL tasks requiring 1 person physical assistance. 9/3/2022 10:08 PM- Skin/Wound Note - Date of service: 08/30/2022- Chief Complaint: Comprehensive skin and wound evaluation for Sacral DTI. Past Medical, Surgical, Social and Family History: reviewed per patient's chart ALS, adult failure to thrive. Dermatologic - Wound(s) present; Please see wound assessment below. Wounds - Sacral DTI See TA (Tissue Analytics) documentation for full wound assessment details. ICD 10 Comorbidities Wound Healing Risk Factors - Function Urinary incontinence: - Fecal incontinence 9/10/22 at 10:30 AM See Tissue Analytics Documentation for full wound description and recommended nursing plan of care. I am recommending an air mattress for pressure reduction. Plan of Care Assessment & Plan - Patient has a pressure injury; Pressure reduction and turning precautions discussed with staff at time of visit recommended, including heel protection and pressure reduction to bony prominences. Staff educated on all aspects of care. On 9/14/22 an interview with LPN who stated that she follows the wound care orders after the NP sees the Residents. When asked how heel boots or air mattresses get ordered she stated that the NP who cares for the wounds will order them. When asked if the Resident was on a turning schedule to off load the pressure from her buttocks she stated that she was turned when they gave incontinence care. Wound Care NP followed resident for this wound and on 8/30/22 wrote the following on the TA Documentation to the facility: Ensure compliance with turning protocol, Wedge/ foam cushion for offloading, Wheelchair Cushion, Specialty Bed, Dressings Collagen Ag,Secondary Dressing Bordered foam On 9/16/22 the NP wrote the following on the TA Documentation to the facility: Ensure compliance with turning protocol, Wedge/ foam cushion for offloading, Wheelchair Cushion, Specialty Bed, Dressings Skin prep,Secondary Dressing Bordered foam The care plan was not updated to include these items, and there was no physicians order for an air mattress. On 9/20/22 at the end of the meeting the DON and Administrator were made aware of the findings and no further information was provided.

Based on observation, Resident family interview, staff interview, clinical record review and facility documentation review, the facility staff failed to prevent the development of a contracture resulting in limited range of motion, which constituted harm, for one Resident (Resident #14) in a survey sample of 60 Residents. The findings included: For Resident #14 who was admitted without any contractures of her hand and arm, the facility staff failed to implement therapeutic interventions to prevent the development of contractures. As a result, Resident #14 developed contractures of her fingers, wrist and elbow, and therapeutic interventions were not initiated for over three months following the identification, this constitutes harm for Resident #14. On 09/12/22 at 02:49 PM, Resident #14 was visited in her room and a family member was at the bedside. A Resident and family interview were conducted. Resident #14's family member said he is very concerned about the Resident's left hand, she is no longer able to use it and when touched on the hand she has pain. The family member went on to say that they have talked to various staff, including but not limited to nursing and the social worker to request therapy services for several months and still nothing has been done. During the above interview, Surveyor B observed Resident #14's left hand and noted that her fingers appeared to be contracted in a closed position, her wrist appeared to have some limited movement as well. When asked if she (Resident #14) could open her hand she was not able to do so independently. Resident #14's finger nails appeared very long and were making contact with her palm which was in a closed fist position. There was no brace, wash cloth or any other device observed in her hand. A clinical record review was conducted and the following findings were noted: Resident #14 was admitted to the facility on [DATE]. Review of the admission assessment and notes revealed that upon admission Resident #14 had contractures of her lower extremities. There was no indication of her having any limitations in range of motion or contractures of her upper extremities. The most recent MDS's [minimum data set/an assessment tool] conducted 3/6/22 and 6/24/22, were reviewed. Both were coded in section G0400. Functional Limitation in Range of Motion, question G0400 A: Upper extremity (shoulder, elbow, wrist, hand): no impairment On 3/8/22, the doctor saw Resident #14 with regards to concern about rings on three fingers. The doctor assessed Resident #14's hand and made no indication that Resident #14 had any limited range of motion or contractures in her hands/arm. On 3/15/22, the doctor again saw Resident #14 with regards to rings on her left hand fingers. The doctor note read, .osteoarthritis of PIP [proximal interphalangeal joints/located in fingers] and Bouchards nodules [hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints] . The note made no indication of Resident #14 having any contractures of her wrist, elbow, or hand/fingers, and no mention of limited range of motion. On 5/17/22, the doctor saw Resident #14 and noted in the progress notes, .Son visiting patient today noted she pulls left hand away when touched in pain .Hand: no erythema or warmth and limited both active and passive extension left ____finger(s); pulls hand away when examined, has ring on2-4 fingers cannot remove as PIP joints enlarged from osteoarthritis; distal circulation intact with no erythema, no warmth no swelling . On 5/31/22, the doctor assessed Resident #14 and noted the following, .pip joints enlarged limiting ability to remove rings from left fingers 2-4- distally neurovascular intact but pulls hand away when goes to examine it - ? pain at rest or only when handled, contractures of fingers present also - has been on tramadol for pain and would continue low dose and monitor response - had discussed with son no urgency to remove rings but would have to go to ER or urgent care for removal . The MDS [minimum data set/an assessment tool] conducted 6/24/22, which was coded as a quarterly assessment was reviewed. This assessment was coded in section G0400. Functional Limitation in Range of Motion, question G0400 A: Upper extremity (shoulder, elbow, wrist, hand): no impairment On 7/1/22, an x-ray of Resident #14's left hand was performed. This x-ray was unremarkable. On 7/5/22, the doctor noted the following upon assessment of Resident #14, .Hand: no erythema or warmth and limited both active and passive extension left finger(s); has ring on 2-4 fingers cannot remove as PIP joints enlarged from osteoarthritis; distal circulation intact with no erythema, no warmth no swelling but unable to rotate rings . A physician order dated 7/13/22, that read, OT [occupational therapy] evaluation for splint for left hand contracture of fingers. A progress note written by the provider the same day read, .Assessment / Plan 1. Contracture of multiple joints- particularly left hand with apparent pain with movement and when try to examine it but seems comfortable when left alone 2. degenerative joint disease of hand - Left -has rings on 2-4 fingers not able to be removed due to osteoarthritis of pip, neurovascular intact distally no sign acute synovitis -discussed with son this evening will have OT see for possible splint to minimize movement may help with pain for care and handling of patient . A physician progress note dated 8/23/22, that read, .Follow-up: Contracture of multiple joints .Musculoskeletal System: Hand: no erythema or warmth and limited both active and passive extension left finger(s); able to move arm to examine and hand but does draw away when attempt to open fingers, rings on fingers but distal neurovascular intact. Musculoskeletal System contracture of extremities .Assessment / Plan: 1. Contracture of joint of left hand - no erythema, no warmth does pull away when attempts to move fingers - have asked OT to see patient for contracture cushion . On 8/23/22, a nursing to therapy notification was entered into Resident #14's record that read, .weakness upper/lower extremities and contractures upper/lower extremities. Resident #14's care plan did not identify or address the hand/wrist and elbow contractures and therefore no interventions were put in place to prevent the development of and prevent further decline. On 9/15/22 at 9:15 AM, an interview was conducted with Employee N/the rehab director. Employee N accessed the therapy records and was asked to identify if and when Resident #14 had received therapy services. Employee N stated that she had not previously been on therapy caseload but when they screened her two weeks ago due to an upcoming MDS [minimum data set assessment] and a therapy referral being entered on 9/1/22, they determined she needed services and were planning to start therapy today or tomorrow. Employee N reviewed the physician orders and stated he was not aware of the physician order entered on 7/13/22, he said, This is the first time I'm seeing the order from July. Employee N stated, If the doctor writes and enters an order I don't get a notification. Nursing has to go in and enter a therapy referral for us to get a trigger. Employee N confirmed that Resident #14 had been screened for therapy services 5/24/22, and was at baseline with no contractures identified at that time. When asked to explain the purpose of contracture management, Employee N said, To make sure we are maintaining what has been achieved, to make sure we prevent it from getting worse, to prevent skin break down and to maintain functional activity for the Resident, comfort and prolonging the worsening. On 9/15/22, an interview was conducted with the facility social worker/Employee E. Employee E confirmed that she recalled Resident #14's family talking with her about and requesting therapy services and she had notified the rehab director. Employee E provided the survey team with a copy of an email that she sent on 8/15/22, that read, [Resident #14's name redacted] have you assess her for the hand the son was asking . On 9/15/22, the facility Administration was asked to provide a timeline with regards to Resident #14's contracture development. The facility provided copies of admission assessments which revealed the contractures were not present upon her admission to the facility and were developed/acquired in-house. On 9/15/22 at 7:20 PM, the therapy director provided the survey team with a copy of the Occupational Therapy (OT) evaluation that was completed for Resident #14 on 9/15/22. It read, .Reason for Referral: Patient is a 88 y/o [year old] female referred to skilled OT evaluation for assessment and management of LUE [left upper extremity] flexor contractures at elbow, wrist and hand due to hx [history] of R [right] intracranial hemorrhage LUE [left upper extremity] ROM [range of motion]= Impaired (L wrist rests in 80 degrees flexion with ~30 degrees of passive extension from fixed position available. L D3 [left digit 3/finger] and 4 most severe with 90 degree contractures from MCP [Metacarpophalangeal joint/commonly known as knuckles] to DIP [Distal Interphalangeal Joint/bones at the tip of the fingers]. L thumb proximal phalange in fixed adducted position with hyperextension of IP joint, unable to form functional grasp. L D2 and D5 [left digit 2 and 5/ index and pinky fingers] are least affected with resting MCP flexion at 90 degrees and ability to extend 45 degrees from this position, distal segments flaccid and passively WFL [Within Functional Limits]. L elbow passively WFL, shoulder flexion PROM [passive range of motion] 0-120 degrees and AROM [active range of motion] 0-35 degrees; patient rests in elbow flexion (~70 degrees) and internal rotation . The lack of intervention by facility staff permitted the contractures to develop and then worsen for Resident #14. This constitutes harm for Resident #14. On 9/15/22, the facility policy regarding contracture prevention and management of contractures was requested but not received prior to the conclusion of the survey. On 9/21/22, during an end of day meeting, the facility Administrator, Director of Nursing and Corporate staff were made aware of the above findings. No additional information was received.

Based on observations, Resident/family interview, staff interview, clinical record review, facility documentation review and in the course of a complaint investigation, the facility staff failed to provide specialized rehabilitative services to prevent the functional decline for two Residents (Resident #14 and #68), resulting in harm for Resident #14, in a survey sample of 60 Residents. The findings included: 1. For Resident #14, who developed a hand/wrist contracture while a Resident of the facility, the facility staff failed to provide specialized rehabilitative services as ordered by the physician, to prevent the worsening of the contracture for a period of two months resulting in harm. On 09/12/22 at 02:49 PM, Resident #14 was visited in her room and a family member was at the bedside. A Resident and family interview were conducted. Resident #14's family member said he is very concerned about the Resident's left hand, she is no longer able to use it and when you touch it she has pain. The family member went on to say that they have talked to various staff, including but not limited to nursing and the social worker to request therapy services for several months and still nothing has been done. During the above interview, Surveyor B observed Resident #14's left hand and noted that her fingers appeared to be contracted in a closed position, her wrist appeared to have some limited movement as well. When asked if she (Resident #14) could open her hand she was not able to do so independently. Resident #14's finger nails appeared very long and were making contact with her palm which was in a closed fist position. There was no brace, wash cloth or any other device observed in her hand. Review of the clinical record for Resident #14 revealed the following: a. A physician order dated 7/13/22, that read, OT [occupational therapy] evaluation for splint for left hand contracture of fingers. A progress note written by the provider the same day read, .Assessment / Plan 1. Contracture of multiple joints- particularly left hand with apparent pain with movement and when try to examine it but seems comfortable when left alone 2. degenerative joint disease of hand - Left -has rings on 2-4 fingers not able to be removed due to osteoarthritis of pip, neurovascular intact distally no sign acute synovitis -discussed with son this evening will have OT see for possible splint to minimize movement may help with pain for care and handling of patient . b. A physician progress note dated 8/23/22, that read, .Follow-up: Contracture of multiple joints .Musculoskeletal System: Hand: no erythema or warmth and limited both active and passive extension left finger(s); able to move arm to examine and hand but does draw away when attempt to open fingers, rings on fingers but distal neurovascular intact. Musculoskeletal System contracture of extremities .Assessment / Plan: 1. Contracture of joint of left hand - no erythema, no warmth does pull away when attempts to move fingers - have asked OT to see patient for contracture cushion . c. There was no evidence within the clinical record that therapy services had been initiated as ordered. d. The MDS [minimum data set - an assessment tool] conducted 3/6/22, which was coded as an annual assessment was reviewed. This assessment was coded in section G0400. Functional Limitation in Range of Motion, question G0400 A: Upper extremity (shoulder, elbow, wrist, hand): no impairment. e. The MDS [minimum data set/an assessment tool] conducted 6/24/22, which was coded as a quarterly assessment was reviewed. This assessment was coded in section G0400. Functional Limitation in Range of Motion, question G0400 A: Upper extremity (shoulder, elbow, wrist, hand): no impairment. f. Resident #14's care plan doesn't identify or address the hand contracture and therefore no interventions are in place to prevent further decline. On 9/15/22 at 9:15 AM, an interview was conducted with Employee N - the rehab director. Employee N accessed the therapy records and was asked to identify if and when Resident #14 had received therapy services. Employee N stated that she had not previously been on the therapy caseload but when they screened her two weeks ago due to an upcoming MDS [minimum data set assessment] and a therapy referral being entered on 9/1/22, they determined she needed services and were planning to start therapy today or tomorrow. Employee N reviewed the physician orders and stated he was not aware of the physician order entered on 7/13/22, he said, This is the first time I'm seeing the order from July. Employee N stated, If the doctor writes and enters an order I don't get a notification. Nursing has to go in and enter a therapy referral for us to get a trigger. Employee N confirmed that Resident #14 had been screened for therapy services 5/24/22, and was at baseline with no contractures identified at that time. On 9/15/22, an interview was conducted with the facility social worker/Employee E. Employee E confirmed that she recalled Resident #14's family talking with her about and requesting therapy services and she had notified the rehab director. Employee E provided the survey team with a copy of an email that she sent on 8/15/22, that read, [Resident #14's name redacted] have you assesd her for the hand - the son was asking . On 9/15/22, the facility Administration was asked to provide a timeline with regards to Resident #14's contracture development. The facility provided copies of admission assessments which revealed the contractures were not present upon her admission to the facility and were developed/acquired in-house. On 9/15/22 at 7:20 PM, the therapy director provided the survey team with a copy of the Occupational Therapy (OT) evaluation that was completed for Resident #14 on 9/15/22. It read, .Reason for Referral: Patient is a 88 y/o [year old] female referred to skilled OT evaluation for assessment and management of LUE [left upper extremity] flexor contractures at elbow, wrist and hand due to hx [history] of R [right] intracranial hemorrhage LUE [left upper extremity] ROM [range of motion]= Impaired (L wrist rests in 80 degrees flexion with ~30 degrees of passive extension from fixed position available. L D3 [left digit 3/finger] and 4 most severe with 90 degree contractures from MCP [Metacarpophalangeal joint/commonly known as knuckles] to DIP [Distal Interphalangeal Joint/bones at the tip of the fingers]. L thumb proximal phalange in fixed adducted position with hyperextension of IP joint, unable to form functional grasp. L D2 and D5 [left digit 2 and 5/ index and pinky fingers] are least affected with resting MCP flexion at 90 degrees and ability to extend 45 degrees from this position, distal segments flaccid and passively WFL [Within Functional Limits]. L elbow passively WFL, shoulder flexion PROM [passive range of motion] 0-120 degrees and AROM [active range of motion] 0-35 degrees; patient rests in elbow flexion (~70 degrees) and internal rotation . Resident #14 was admitted to the facility without contractures, and developed contractures at the facility. This constitutes harm for Resident #14. 40452 2. For Resident #68, the facility staff failed to provide physical therapy services as ordered by the physician. On 09/12/2022 at approximately 12:35 P.M., Resident #68 was interviewed. When asked about having any concerns about care at the facility, Resident #68 stated that he has not received physical therapy. On 09/13/2022, Resident #68's clinical record was reviewed. A physician's order dated 08/10/2021 documented, Physical therapy evaluate and treat for generalized weakness, bilateral lower extremity weakness. On 09/13/2022 at 10:45 A.M., the Director of Rehab was interviewed. When asked about dates of service for Resident #68, the Director of Rehab referred to Resident #68's electronic health record and stated that Resident #68 was admitted to the facility in 2019 and received therapy services in 2020. This surveyor observed the therapy electronic record that the only dates of service listed were 07/14/2020 through 09/16/2020. The Director of Rehab verified Resident #68 had not received therapy services since 2020. When asked about the process for receiving orders for therapy services, the Director of Rehab stated that if the physician writes an order for therapy, the therapy department does not get alerted to the order for therapy. The Director of Rehab explained that nursing would see the order and put a Nursing referral to therapy and Therapy Notification into the system which is located under the Assessment tab in the electronic health record. The Director of Rehab then stated that once that is done, it shows up on the dashboard. The Director of Rehab stated that he checks his dashboard daily.

Based on observation, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to mitigate a fall hazard resulting in harm for 1 resident (Resident #1) from a sample of 4 Residents. The findings included: Resident #1 fell twice on [DATE]. The second fall required an emergency room visit, and hospital admission after sustaining a head injury. The Resident first fell at approximately 3:00 p.m. on [DATE], sustaining no injury, and was then placed back in bed unattended and fell again at approximately 4:30 p.m. sustaining a head injury with bleeding and swelling requiring an emergency room visit and hospital admission for subdural hematoma to the brain. The Resident also suffered an intraparenchymal hemorrhage, however, the Radiology report from the hospital revealed that the physician did not feel this was caused by the fall. The Resident expired on [DATE] while hospitalized . Resident #1 was admitted to the facility on [DATE] at approximately 6:51 p.m. according to a nursing admission assessment. The Resident's 3 day MDS (minimum Data Set) assessment dated [DATE] revealed that the Resident required extensive assistance, or was totally dependent for all activities of daily living with 2 staff member assistance. The Resident was always incontinent of bowel and bladder. The Resident was severely cognitively impaired and not able to complete a Brief Interview for mental status (BIMS) assessment. The MDS documented incorrectly at section J, that the Resident had no previous falls prior to entry, and had only one fall since entry to the facility, prior to discharge. The assessment was signed as complete and accurate on [DATE]. Hospital records received by the facility upon admission were reviewed. Those revealed that the Resident had fallen at home prior to admission to the hospital, and that the Resident was a fall risk and agitated while at the hospital requiring a companion sitter. While in the hospital an antianxiety medication was ordered prior to transfer and admission to the Nursing facility. The 48 hour baseline care plan was reviewed and revealed that it was effective as of 6:51 p.m. on [DATE], the day of admission, and was signed as completed by the interdisciplinary team on [DATE]. The care plan documented that the Resident was confused, had a history of [REDACTED]. As cognitive/psychosocial behavior concerns the document listed Resident trying to get out of bed. On the last page an undated handwritten note was added by the facility which documented Focus Problem safety/fall precaution staff to assist with mobility., and (Name of Resident) has had an actual fall. Goal: monitor patient for any change. Intervention: (Resident name) was sent to the hospital for more evaluation. No fall precaution interventions were ever care planned during the facility stay for this Resident. Physical (PT) therapy, Occupational (OT) therapy, and Speech (ST) therapy notes were reviewed and revealed the following: Physical therapy notes revealed that on [DATE] at 7:09 p.m., after the PT eval was completed the PT positioned the Resident back in bed and left the Resident's room. The PT went back to the Resident's room and found the Resident positioned with feet on the floor and head on the side of the bed. The PT then documented Positioned patient back with head of bed and bilateral extremities elevated and lowered the bed (the bed had been in high position). Notified CNA (Certified Nursing Assistant) to be on watch due to risks for falls. On [DATE] at 12:51 p.m., the PT notes documented Patient received sitting in hallway in geri chair (recliner) .CNA staff made aware of patient positioning and nursing cart was placed behind patient geri chair to prevent the chair from sliding backwards. On [DATE] at 2:01 p.m. the PT notes documented Patient found different geri chair with working brakes and patient ended session seated in geri chair in hallway for increased supervision. On [DATE] at 2:05 p.m. the OT notes documented Discussed with nursing staff patient's past medical history as well as safety concern due to severe dementia and restlessness. Co-treat with PT due to safety concerns because of decreased ability to follow commands with patient being hard of hearing and having severe cognitive impairments at baseline to decrease risk for falls. Nursing progress notes were reviewed for the Residents 3 day stay in the facility and revealed the following; On [DATE] at 3:27 p.m., the nursing note document read Resident was found on the floor lying on (gender) right side. Head to toe assessment done and Resident denies pain. No injuries noted. Resident was put back in bed and redirected. On [DATE] at 7:48 p.m. the nursing note document read resident sustained [REDACTED]. Dr (name) was notified and Resident sent out to (name of hospital). RR (son of Resident name) notified. On [DATE] at 7:57 p.m., the nursing note document read Physician notified at 5:00 p.m., Responsible party notified at 6:00 p.m. The first Fall Risk assessment document in the clinical record was completed for this Resident on [DATE] at 8:09 p.m. after the 2 falls had occurred. The form documented Resident #1 as Diminished safety awareness, fall in the past 30 days, Resident is a fall risk. The first Fall Follow Up document in the clinical record was completed on [DATE] at 8:11 p.m. after the 2 falls had occurred. As for interventions to prevent another fall redirect was given as the only answer. The facility doctor who was treating Resident #1 documented a History and Physical form dated [DATE] at 5:30 p.m., which read: Patient alert but confused does not answer questions or follow commands. Patient is not capable of making any decisions regarding (gender) care. Indicating that the Resident was severely demented and unable to follow direction or redirection. A Hospital Transfer Cover Sheet was reviewed and indicated the reason for the transfer to the hospital was for Fall evaluation, sustained a hematoma the size of an egg on the right temporal area bleeding. EMS notes were reviewed and revealed that on [DATE] an ambulance was called for Resident #1 at 4:30 p.m., which arrived on scene at the facility at 4:38 p.m. The Resident was discharged into the care of Emergency Medical Services (EMS), who documented a 3 foot ground level fall as the reason for the transport to the hospital with injury. EMS delivered the Resident to the hospital at 4:58 p.m. Resident #1's two falls are listed below: 1. A Nursing hand written and signed witness statement documented the following; On [DATE] at 7:00 a.m., report was given to me by the outgoing nurse on (name of Resident #1) a (gender) new admit who is a fall risk due to confusion and agitation. Resident was witnessed in a Geri chair (recliner) for proper monitoring and safety. Resident had no sleep during the night. After taking report, Resident was seen restless and wanted to get out of Geri chair. (Resident name) later verbalized he wanted to sleep. The CNA (certified Nursing Assistant) and myself put (gender) in bed and therapy came for (gender) later. After Resident came back (from therapy) (gender) was witnessed finishing lunch. Later around 3:00 p.m. Resident seen on the floor. After head to toe assessment Resident was not noted with no injuries. 2. A Nursing hand written and signed witness statement documented the following; Later at 3:50 p.m., Resident was found on the floor again with a hematoma and a cut to the right upper forehead. Bed was in the lowest position and 911 was called immediately and Resident was taken to the emergency room . Son and MD (doctor) notified. The facility Fall Protocol and policy were requested and supplied. Review of the facility documents revealed the following: Policy It is the policy of this facility to promote resident centered care by providing a fall risk observation on admission, quarterly and following any fall that occurs. Procedure: 1. Complete the fall risk observation found in the electronic medical records. 2. Institute appropriate precautions that are individualized to the resident needs. In summation of findings, the Resident was known to be confused, agitated, unable to be redirected, and a known fall risk with a known history of falls with injury. No interventions were planned or specified to prevent falls, or mitigate serious injury. The first fall occurred while the Resident was unsupervised in bed on [DATE]. Staff did not intervene after the first fall and placed the Resident back in bed unattended. Resident #1 fell a second time on [DATE] causing serious injury and requiring hospitalization . On [DATE] at the end of day meeting, Resident #1's falls were reviewed with the Administrator and Director of Nursing (DON). They were asked to provide investigations and statement by staff of the falls and precipitating and mitigating information. On [DATE] at 12:00 p.m., during the end of day meeting the Administrator and DON were again made aware of the lack of supervision for Resident #1, and asked for any further information as the second fall resulted in harm for the Resident. On [DATE] at 2:00 p.m. during the exit interview, the Administrator and Director of Nursing stated they had nothing else to provide. All information regarding the falls was accepted and reviewed. No further information was provided. COMPLAINT DEFICIENCY

Based on observation, interviews, facility documentation and clinical record review the facility staff failed to provide care to promote healing prevent infection and prevent new pressure ulcers from forming for 2 Resident (#161 and #[AGE]) in a survey sample of 43 Residents. The findings included: 1. For Resident #161 the facility staff failed to identify a pressure ulcer to the coccyx before it was found at an advanced stage with necrotic tissue. In addition, the resident went the hospital and the coccyx wound was diagnosed with [REDACTED]. Resident #161, a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #161's most recent MDS ( minimum data set) coded the Resident as having a (Brief Interview of Mental Status) BI[CONDITION] score of 15 indicating no cognitive impairment. Resident #161 was also coded as needing extensive assistance of 2 person physical assistance for bed mobility, toilet use, dressing and personal hygiene. She was coded as total dependence with 2 person physical assistance for transfer, and extensive assistance with 1 person physical assistance for mobility on and off unit via wheel chair. On 11/7/19 during clinical record review it was discovered Resident #161 developed pressure ulcers. The progress notes read: 10/24/18 - New skin issue and 10/24/18 6:51 AM - Redness and open areas noted on bilateral buttocks and left inner thigh area However, the progress notes also show the discovery of another wound. The note reads; 11/1/18 3:05 AM new skin issue Resident has open area on the coccyx area approximately 4 cm (centimeters) circular area with necrotic tissue present 2.5 cm depth and has foul odor present with moderate amount of dark foul smelling drainage. Area cleaned with wound cleansed and covered with dry dressing. Resident is followed by wound team. Resident has dressing intact to the bilateral buttocks open areas no drainage noted to these areas. This note shows that the coccyx area was a new area not previously known and it shows that the area was found with necrotic tissue. The wound care physician notes read: 11/7/18- At the request of the referring provider (MD name redacted} a thorough wound care assessment and evaluation was performed today. She has a stage 4 pressure wound to coccyx of at least 1 day duration. There is moderate serous exudate. Stage 4 Pressure Wound Coccyx Etiology - Pressure MDS 3.0 Stage - 4 Wound Size - 4 x 2 x 3.5 cm Thick adherent devitalized necrotic tissue - 20% Granulation Tissue - [AGE]% Surgical Excisional Debridement Procedure The wound was cleansed with normal saline and anesthesia was achieved using topical [MEDICATION NAME]. Then with clean surgical technique, 15 blade was used to surgically excise 1.6 cm of devitalized tissue and necrotic muscle and surrounding facial fibers were removed. In addition, Resident #161 went to the local hospital on [DATE] and was discharged on [DATE] excerpts from the hospital record are as follows. Discharge Diagnosis: [REDACTED].([MEDICAL CONDITION]) Sacral Ulcer Hospital Course: [AGE] year old female with history of [MEDICAL CONDITION], chronic lower extremity ulcers / wounds who was brought in from nursing facility with altered mental status and new sacral ulcers. The change in mental status was due to metabolic [MEDICAL CONDITION] in the setting of infected sacral ulcer. Patient underwent debridement and irrigation with sacral wound VAC placement on 11/15/19. Wound culture positive [MEDICAL CONDITION], [CONDITION] and [CONDITION]. Patient seen by ID (Infectious Disease). Discharge recommendation is [MEDICATION NAME] and [MEDICATION NAME] for 4 weeks followed by [MED] for 4 weeks. She will continue to have wound VAC changed 3 times per week. On [DATE] an interview was held with the DON who stated that ideally wounds should be found before a stage IV. She stated that wounds are usually found during bathing by the CNA or on skin assessment by the nurse. On [DATE] during the end of day meeting the Administrator was made aware of the findings and no further information was provided. 2. For Resident #[AGE], the facility staff failed to prevent the development of a pressure wound on the left ankle, and identify the wound prior to it becoming unstageable. In addition, the facility failed to prevent and identify a pressure ulcer on his left Lateral Tibia prior to it becoming Stage 3. Resident #[AGE] was a [AGE] year old who was admitted to the facility on [DATE]. Resident #[AGE]'s [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Significant Change Assessment with an Assessment Reference Date of 10/11/19 was reviewed. Resident #[AGE] had a Brief Interview of Mental Status Score of 12, indicating mildly impaired cognition. He was coded as requiring the extensive physical assistance of at least two people for bed mobility, and transfers. Resident #[AGE]'s range of motion was impaired in both of his upper and lower extremities. He was coded as having unstageable pressure ulcers. His previous MDS, which was a Quarterly Assessment, with an Assessment Reference Date of 8/26/19 was reviewed. He was not coded for any pressure ulcers. On 11/5/19 a review was conducted of Resident #[AGE]'s clinical record. According to a nursing progress note dated [DATE], a weekly skin assessment was completed. No findings were documented in the note, or on a skin assessment form. According to a wound care note, on [DATE], an unstageable pressure ulcer was initially identified by a wound care physician. An excerpt from the note read, Location: Left Lateral Malleolus. Etiology: Pressure injury/ulcer - Unstageable Pressure Injury. Dressing used: [MED]. Wound Description: Odor-None, Exudate - Scant Serous, Periwound - Stable, Wound Edge - Normal, Pain- 0/10. Tissue: 50% Granulation, 50% Necrotic. Length 0.5 x Width 1.0, Depth 0.1. Wound Progress - First Visit. For the week prior to 10/2/19, there was no documentation of a skin assessment, including the nursing progress notes. An excerpt from another wound care note read, 10/2/19. Location: Left Lateral Heel. Etiology: Pressure injury/ulcer - Unstageable Pressure Injury. Dressing used: [MEDICATION NAME] and Paint with [MEDICATION NAME] daily and float heels. Wound Description: Odor-None, Exudate - None, Wound Edge - Eschar, Tissue- 100% Eschar - Length 0.5 x Width 1.7, Depth Undetermined. Wound progress - Undetermined: First Visit. In addition, Resident #[AGE]'s care plan was reviewed. It did not document anything regarding his pressure ulcers, including their existence or treatment. On 11/6/19 at 11:20 A.M., an observation was conducted of Resident #[AGE]'s pressure ulcers by Surveyor D (Registered Nurse). The pressure ulcer on his left outer ankle measured 2 cm x 2 cm x .1 cm. It was unstageable, with a black center, and contained slough. It had rolled edges, and moderate drainage. In addition, Resident's left outer leg pressure ulcer had a reddened area, necrotic center with slough. It was unstageable. It measured 3 cm x 2.8. cm no depth, moderate serous, sanguineous (bloody) drainage. On 11/06/19 at 2:09 P.M., an Interview was conducted with the Director of Nursing (DON Employee B). She was asked about her expectation of when pressure ulcers are identified. She stated that they do weekly skin assessments. They have different disease processes. It may be found at unstageable. She stated, our job was to prevent any pressure wounds, to find them at stage 1, and resolve them quickly. The DON further stated that sometimes they floated the residents' heels. Resident #[AGE]'s diet orders were reviewed. Since 4/18/19, his order was as follows: Regular Diet, Regular Texture, Thin consistency, No pork, Prefers fish. The dietary orders related to wound healing were initiated on 7/9/19. [MED] 30 ml 2 x daily for wound healing. (Resident #[AGE] was admitted with a sacral wound that healed and reopened) On 11/6/19 a review of facility documentation was conducted, revealing a Skin Care & Wound Management Policy dated 5/30/19. An excerpt read, The facility staff strives to prevent resident/patient skin impairment and to promote the healing of existing wounds. Each resident is evaluated upon admission and weekly thereafter for changes in clinical condition, prior to transfer to the hospital and upon return from the hospital. On 11/6/19 an interview was conducted with the facility Administrator (Employee A) in the conference room. He stated that on October 1, 2019 the facility changed wound care providers. He further stated that the facility had a wound care nurse until mid-October.