Every finding on record at Petersburg Healthcare Center

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to protect the resident's right to be free from abuse and neglect for four residents in a survey sample of 53 residents (Resident #61- R61, Resident #74-R74, Resident #76-R76, and Resident #77-R77). This non-compliance resulted in R61 sustaining a fracture, R74 having a bloody nose, R76 having scratches, all which required medical interventions, which constituted harm for those three of the four residents. This noncompliance resulted in the identification of immediate jeopardy (IJ) and substandard quality of care which began on 10/29/24 and required immediate facility intervention to protect residents from abuse and neglect. The facility had self-identified the deficient practice and achieved past non-compliance. Following the removal of IJ on 10/28/25 by implementation of a plan of correction, the scope and severity was lowered to a level three, isolated.The findings included:1. For R61 the facility neglected to provide the appropriate assistance during a mechanical lift transfer, which resulted in the resident being found with bruises and pain to her right leg and later diagosed with a tibia/fibula fracture, which constituted harm. R61 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to schizophrenia, chronic atrial fibrillation, generalized anxiety disorder, acute pulmonary edema, dysphasia, neuropathy, peripheral, vascular disease, recurrent depressive, mood disorder, and hypokalemia. The most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/11/25 coded Resident # 61 as having a Brief Interview for Mental Status (BIMS) score of 0 out of a possible 15 indicating severe cognitive impairment. R61 was coded as requiring assistance from staff with all aspects of ADL care. A review of the clinical record revealed that on 9/1/25 resident # 61 had increasing complaints of pain in her right leg and bruising to her right leg. The facility staff notified the nurse practitioner who ordered x-rays of both lower legs, and it was found that the resident had a right tibia/fibula fracture. The clinical record revealed that the doctor was notified who then sent the resident out to the emergency room for further evaluation and treatment. R61 returned to the facility on 9/4/25 with a splint in place A review of the incident investigation revealed that the facility interviewed staff as well as other residents and it was found that CNA #7 (certified nursing assistant) was observed by another resident transferring resident # 61 with a mechanical lift, alone without another staff member being present. CNA #7 was placed on suspension during the investigation however she resigned from her position prior to the conclusion of the investigation. A review of the clinical record revealed the following care plan entry Focus: [resident name redacted] has an ADL Self Care Performance deficit, requires assistance with ADL r/t [related to] cognitive deficit, intellectual disability, Functional Deficit, impaired mobility, neuropathy, schizophrenia Date Initiated: 09/04/2025 Revision on: 09/04/2025. The Goal: [resident name redacted] will maintain/improve current level of function through review date. Date Initiated: 06/23/2023 Revision on: 10/27/2025 Target Date: 03/01/2026. Interventions: Resident requires the use of mechanical lift with 2 person support Date Initiated: 06/23/2023 On the afternoon of 3/11/26 an interivew was conducted with CNA #4 who stated that all transfers requiring a mechanical lift must use two people. On the morning of 3/12/26 an interview was conducted with the DON [director of nursing] who stated that it is facility policy that anyone transferring with a mechanical lift must have two staff members. The DON further stated that the CNA #7 resigned but other staff as well as residents had reported she would transfer residents alone with the mechanical lift. On 3/12/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 2. For Resident #74 (R74), the facility staff failed to provide adequate supervision to protect the resident from physical assault by another resident resulting in a bloody nose thus constituting harm. On 3/12/26, during a clinical record review of R74's chart, it was noted that on 9/7/24, a nursing note entry read, Resident to resident altercation. This resident was struck by another resident in the nose and cheek. Nose did have some bleeding although has subsided. Tylenol (Acetaminophen) given. Instructed to apply ice. Also, on 9/7/24, a change in condition note was entered into R74's clinical record, it read in part, .nose injury from altercation no bleeding no edema from nose right cheek slightly edematous. The doctor ordered PRN [as needed] pain medication and ice if needed. According to the medication administration record for R74, the resident was given Acetaminophen on 9/7/24 for an associated pain score of 7. On 9/8/24, R74 was again given Acetaminophen for a pain score of 5. On 3/12/26-3/13/26, review of the documentation provided by the facility was reviewed. According to an incident synopsis and incident summary, the facility gave the following details regarding the incident. On the evening of 9/7/2024, [Resident #118's- R118 name redacted] and [Resident #74's name redacted] were observed by other residents, in a verbal altercation while outside in the facility courtyard playing cards. The verbal escalated, in which [R118's name redacted] was observed throwing cards at [R74's name redacted] and then stood up and struck him in his face resulting in a bloody nose. At this time, it was witnessed [Resident #75's name redacted] stood up to stop the altercation which ended in [R118 and R74's names redacted] on the ground. On 3/13/26 at 9:11 AM, an interview was conducted with Resident #74 and Resident #75, who were roommates. R74 was asked about the incident that occurred on 9/7/24. R74 reported he recalled the incident and said, I really wanted to beat his a$$. R74 recalled that no staff were present when the incident occurred. R74 denied feeling any different following the incident and reported it didn't affect him or his daily routine. R75, the roommate didn't add to the conversation and didn't acknowledge that he recalled the incident. 3. On 10/29/24 Resident #77 (R77) was a victim of verbal abuse by a certified nursing assistant (CNA #5), which was witnessed by another staff member (CNA #6). The resident suffered psychosocial harm as a result as documented by a mental health provider, licensed professional counselor. On 03/12/26, during a clinical record review of R77's chart a Licensed Professional Counselor (LPC) note entry dated 10/30/24 was noted. The note read in part, . The staff accused was heard by another staff and they were removed. [R77's name redacted] had more isolation this day, staying in her room for a longer period of time. Although she could not recall what happened due to her memory, she did have increased delusions and hallucinations. She had higher anxiety and was possibly experiencing acute stress. Staff is supporting and monitoring her mood. On 3/12/26, a review of the facility's documentation regarding the incident was reviewed. There was a typed paragraph/letter format of the facility investigation summary, an incident synopsis/alleging the initial allegation of abuse with minimal details, and only two staff witness statements. There was no evidence of any additional staff working having been interviewed, no resident interviews to include Resident #77 or the roommate. According to the statement from CNA #6, it indicated CNA #6 stated she heard CNA #5 state 'What the f*** is your problem? We need to get ready,' to Resident #77. According to the facility's investigation summary it noted that the allegation of abuse was unsubstantiated. On 03/12/2026 at approximately 11:40AM an interview was conducted with the Administrator. She was shown the investigation file, and the Administrator confirmed the investigation was incomplete. The administrator was shown the statement from CNA #6 who alleged to have witnessed the incident of verbal abuse and was asked based on the investigation only containing the two statements from the CNAs, how the allegation was unsubstantiated. The administrator confirmed based on the investigation information she was unable to determine why that conclusion had been made and indicated she did not agree with the prior administrator's conclusion. 4. For Resident #76 (R76), who was displaying behaviors, the facility staff left R76 unattended in the presence of another resident who assaulted R76, resulting in scratches that required physician orders for treatment. On 3/12/26-3/13/26, a review of R76's clinical record was conducted. This review revealed that according to R76's care plan he had a communication barrier and used an interpreter, because English was not the resident's dominate language. According to a progress note dated 10/22/25, it read, Resident had a physical altercation with a staff and another resident while seated in the wheelchair on the corridor located by his room Resident was observed going into the wound nurse's office and assaulting her and spitting on another resident. Staff was able to intervene to separate the residents; [R76's name redacted] was relocated to his room; head to toe complete, revealed minor scratches to back, abdomen, bil. [bilateral/both] arms/legs; skin otherwise intact, no complaints of pain or discomfort voiced via interpreter line.resident placed on 1:1 for safety, local law enforcement notified. According to the facility investigation documents it alleged that R76 went into the wound care nurse's office, hit her and pushed her. The nurse exited the office to call for assistance. During that time another resident, (Resident #16-R16) told R76 to sit down. R76 then spit on R16 causing [R16's name redacted] to physical assault him [R76] (sic). On 3/11/26, an interview was conducted with the wound care nurse. The wound care nurse (WCN) recalled the events involving R76. The WCN recalled that she had helped R76 in the hallway then went into her office. While at the filing cabinet with her back to the door, she was startled to turn around and see R76 walking toward her. She said he kept approaching her. When asked if the resident made physical contact, she couldn't recall. She said she was scared, maneuvered past him and left the office to get assistance. The WCN was asked if she was aware that R76's dominant language was not English which may have been a factor in the resident not responding to her asking him to leave. The WCN acknowledged that she should have ensured R76 was safe prior to leaving the resident in the presence of another resident. On 3/11/26 at 10:48 AM, an interview was conducted with R76 using the facility's interpreter line via telephone, as R76's primary language was Spanish. R76 reported no concerns. On 3/12/26 at 8:30 AM, an interview was conducted with the facility administrator. A conversation was held regarding the incident involving R76, the wound care nurse and then R76 being assaulted by R16. The administrator stated that her expectation is for staff to make sure a resident is safe before leaving them. When asked if the wound care nurse ensured R76 was safe, the administrator said, I cannot prove he [R76] was safe before she left, if it isn't documented it didn't happen. On 3/12/26 in the afternoon, an interview was conducted with Resident #16. R16 was asked about the incident and reported that he recalled the wound care nurse left the room. R16 asked R76 to sit down and then R76 spit on him. R16 went on to explain that where he came from spitting on someone is the most disrespectful thing you can do and it just set him off causing him to hit and curse the resident. 5. For R76 the facility staff failed to protect the resident from an incident of physical and verbal abuse by a staff member. A clinical record review of R76's chart revealed no documentation regarding the incident of abuse that occurred on 7/29/25. On 3/11/26 at 10:48 AM, an interview was conducted with R76 using the facility's interpreter line via telephone, as R76's primary language was Spanish. R76 reported no concerns. On 3/12/26, a review of the facility's investigation file was conducted. The file included an incident synopsis and investigation summary on 7/29/25, R76 was hit with a towel twice and cursed by certified nursing assistant #4 (CNA #4) which was witnessed by LPN (licensed practical nurse) #8. On 3/12/26 at 9:55 AM, an interview was conducted with LPN #8. LPN #8 recalled, So it was about five something in the morning, I was on wing 2, as I was charting, I heard some yelling on wing 2, I thought someone had fallen or needed help. [Resident #76's name redacted]'s door was open and [Certified nursing assistant #4's name redacted] was yelling. I asked her what was going on, she was washing him up, said he spit on her and she had to hit him. I told her to leave the room; he has the right to refuse care. She [CNA #4] refused to stop washing him. He did spit on her, I told her to go, as we were leaving, she turned around and whipped him with the towel. His nurse came in and another CNA came in and helped remove [CNA #4's name redacted] after that. LPN #8 was asked how R76 responded. LPN #8 said, He seemed afraid and was fighting. LPN #8 went on to report R76 was combative prior to the incident but said, you have to tell him what you are going to do, he doesn't really understand English. Within the facility's investigation documents was a statement from another staff member who reported that CNA #4, . she took the wet towel and slapped him across the face and called him a b$t$h. The facility administrator's investigation summary substantiated the incident of abuse and CNA #4 was terminated as a result. Other staff who wrote witness statements and witnessed the incident were no longer working at the facility and/or were unable to be reached during the survey. According to the facility's abuse policy titled, Abuse, Neglect and Exploitation Policy – Virginia, it read in part, .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. It is the intent of this facility to prevent the abuse, mistreatment, or neglect of residents or the misappropriation of their property, corporal punishment and/or involuntary seclusion and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect or misappropriation of their property. On 3/12/26 at 4:37 PM, the survey team met with the facility administrator, director of nursing and regional director of operations. They were notified that the survey team had identified Immediate Jeopardy (IJ) in the area of freedom from abuse, neglect and exploitation. The above findings were discussed and the IJ template was read and a copy provided to the administrator via email. On 3/12/26, following the identification of IJ, the facility's administrator and regional director of operations provided credible evidence that they had self-identified the non-compliance and implemented a plan of correction. They provided the survey team with a performance improvement plan that involved the previous administrator, who was the administrator at the time of several of the incidents. The administrator was then terminated on 1/2/25 for performance concerns that included their role as the abuse coordinator for the facility. The facility again on 10/22/25, self-identified concerns regarding abuse following the incident on 10/22/25 involving R76. The facility took measures to protect the residents by removing them from each other, assessed for injuries, and psychosocial outcomes. The facility then conducted interviews with all interviewable residents regarding abuse and conducted skin assessments of residents who were not interviewable. All staff were educated on abuse, neglect and misappropriation of property. The facility conducted an audit to ensure 100% of staff had received education. The facility implemented ambassador rounds to include interviews with residents daily to identify concerns regarding abuse and/or neglect. On 10/28/25, the quality assurance and performance improvement committee met to review the facility's actions and implemented monitoring that would continue for three months. The facility provided credible evidence of all actions taken and achieved past noncompliance as of 10/28/25, at which time the scope and severity was lowered to a level three, isolated. On 3/13/26, following review of the facility's submitted credible evidence the regional director of operations was made aware that past noncompliance had been confirmed by the survey team. No further information was provided.

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure residents receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 resident (#29) in a survey sample of 53 residents.For resident #29 (R29) the facility staff failed to ensure adequate hygiene and grooming assistance for a resident who is dependent on staff for ADL careR29 was admitted to the facility on [DATE] with diagnosis and that included but not limited to atrial fibrillation, alcohol, abuse, history of right hemispheric CVA with left upper extremity weakness, low back pain, and alcohol induced dementia. R29's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/1/25 coded R29 as having a brief interview of mental status score of three out of a possible 15 indicating severe cognitive impairment. R29 was coded as requiring moderate assist from staff for all aspects of ADL (activities of daily living) [bathing, dressing, personal hygiene, etc.] care.On 3/10/26 at 11:00 am R29 was observed in the hallway, his hair appeared extremely oily and unkempt. R29 was noted to have food in his beard and stains on his shirt. He had a strong odor of urine and body odor. On 3/11/26 at 3 PM, R29 was in the wheelchair and in the hallway, the food stains on his shirt, hair oily and uncombed, and his beard had food debris in it. R29 still was noted with a strong body odor and smells of urine.A review of the clinical record revealed that R29 was scheduled to have two showers per week. Resident # 29 did not receive 4 of his 12 showers for the month of February and had only received 2 bed baths in March, none of the entries were coded as refusals. On 3/11/26 an interview was held with CNA #3 who stated that R29 did not usually refuse showers and that R29 was unable to complete his own personal hygiene and bathing and shampooing his hair. On 3/11/26 at approximately 3:30 pm an interview was attempted with R29 was unsuccessful as R29 was unable to follow the conversation.A review of the clinical record revealed the following entry for ADL care: [Resident name redacted] has an ADL Self Care Performance deficit r/t metabolic encephalopathy, impaired cognition, alcohol induced dementia Date Initiated: 10/01/2025 Revision on: 12/18/2025Goal: [Resident name redacted] will improve current level of function Date Initiated: 10/01/2025Interventions: Shower /Bathe Self: Supervision/Touching Assist-Helper cues and/or touches/steadies resident Date Initiated: 01/12/2026On 3/12/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to have credible evidence of a thorough investigation of an allegation of abuse for one resident (Resident #77) in a survey sample of 53 residents. The findings included: On 03/12/26 at 01:35 PM, an attempt was made to interview Resident #77, but the resident was not available. On 03/12/26, a clinical record review of Resident #77's chart was performed. A Licensed Professional Counselor (LPC) note entry dated 10/30/24 read, The staff accused was heard by another staff and they were removed. [Resident #77] had more isolation this day, staying in her room for a longer period of time. Although she could not recall what happened due to her memory, she did have increased delusions and hallucinations. She had higher anxiety and was possibly experiencing acute stress. Staff is supporting and monitoring her mood. Within the investigation file was a typed paragraph/letter format of the facility investigation summary, an incident synopsis/alleging the initial allegation of abuse with minimal details, and only two staff witness statements. There was no evidence of any additional staff working having been interviewed, no resident interviews to include Resident #77 or the roommate. According to the statement from CNA #6, it indicated CNA #6 stated she heard CNA #5 state 'What the f*** is your problem? We need to get ready,' to Resident #77. According to the facility's investigation summary it noted that the allegation of abuse was unsubstantiated. On 03/12/2026 at approximately 11:40AM an interview was conducted with the Administrator. She was shown the investigation file, and the Administrator confirmed the investigation was incomplete. The administrator was shown the statement from CNA #6 who alleged to have witnessed the incident of verbal abuse and was asked based on the investigation only containing the two statements from the CNAs, how the allegation was unsubstantiated. The administrator confirmed based on the investigation information she was unable to determine why that conclusion had been made. On 03/12/26, the above findings were reviewed with the Administrator, RDO (Regional Director of Operations), DON (Director of Nursing), and RDCS (Regional Director of Clinical Services). No additional information was provided.

Based on observations and staff interview and facility documentation review, the facility failed to properly post nurse staffing information at 2 of 2 units with an up-to-date and current nursing sheet for resident, staff, and public view.The findings included: The facility staff failed to post up-to-date nurse staffing to reflect the actual staff working for public view. On 2/26/2026, during a facility tour an observation of the daily nursing staffing sheets noted the staffing wase posted at the front desk and outside of the Staffing Managers office near nursing station on unit wing 1. On 2/26/2026 at 1:00 PM, an interview with the staffing manager (Other #2) was conducted. The staffing manager stated the daily nursing staff sheets were located in two locations. Observation of nursing staffing sheet for the day was located at the entrance near the front desk window and outside of Other #2 office on the wall in a see through case. On 2/26/2026 at approximately 1:15 PM, the staffing manager was asked, if there are changes to nursing staffing schedules what happens? The staffing manager stated that if staff calls out or are a no show for their shift they are marked off of an additional sheet located behind the counter at the nursing station, outside of the the staffing managers office. When the staffing manager was asked if the nursing staffing sheets located in the facility were updated with call outs or no shows, she stated that those sheets are not updated just the sheet behind the desk at the nursing station, which was not available for public view. On 2/26/2026 at approximately 1:20 PM, during an observation an updated nursing staff sheet was unable to be seen in plain sight at the nursing desk at unit wing 1. On 2/27/2026 at approximately 10:30 AM, the above findings were reviewed with the facility Administrator and Director of Nursing. No additional information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure the residents right to a dignified existance for 2 residents (resident #10 and resident #94) in a survey sample of 53 Residents.The findings included:1.For R10 the facility staff failed to ensure the resident was fully dressed before exiting her room, thus allowing her to exit the room and propel herself approximately 40 ft down the hall to the nurses station wearing nothing but an incontinence brief, in full view of other residents, staff and visitors.R10 was admitted to the facility on [DATE] with diagnoses that included but were not limited to bipolar disorder, major depressive disorder, schizophrenia, chronic kidney disease, heart failure, and history of falls. Resident #10's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/21/26 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 13 out of 15 indicating moderate cognitive impairment. R10 was coded as needing moderate to fully dependent on staff for all aspects of ADL and personal care apart from eating. R10 was able to self-propel her wheelchair for ambulation in the facility. The MDS section E0200 Behavioral Symptoms coded R10 as follows: Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) (E0200A) 1-3 days. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) (E0200B) 1-3 days Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) (E0200C) 1-3 days. E0900. Wandering - Presence & Frequency Has the resident wandered? (E0900) 1-3 days.On 3/10/26 at approximately 3 pm licensed practical nurses #6 and #7 (LPN's # 6 and 7), (the off-going day shift LPN and on-coming evening LPN) were observed making walking rounds and giving report on each resident as they briefly stopped at each door. LPN's 6 & 7 were observed briefly stopping at Resident #10's room)before moving on down the hall. Within one minute, Resident #10 was then observed by surveyors exiting her room dressed only in an incontinence brief and propelling self approximately 40 feet to the nurse's station in full view of staff visitors and other residents. Once at the nurse's station LPN #5 (Unit Manager) came from behind the nurse's station and said redirected the resident back to her room. On 3/10/26 at approximately 3:15 pm an interview was conducted with the Unit Manager and LPN's 6 and 7. The Unit Manager stated that resident #10 had not come out of her room without clothes on before. She stated this is the first time she had witnessed this behavior. LPN 6 and 7 both stated that R10 has not come out of her room without a top on.A review of the clinical record revealed the following care plan entry: FOCUS: [R10 name redacted] has a behavior problem related to bipolar, takes off brief and urinating on the floor in her room and in the hallway of the facility. Yelling, smoking cigarettes in her room, disrobes in her room and wheels out of her room in the hallway, reusing to wear briefs, refuses incontinence care Date Initiated: 09/12/2025 Revision on: 03/10/2026.GOAL: [R10 name redacted] will have fewer episodes of behaviors through review date. Date Initiated: 09/12/2025 Revision on: 02/24/2026 Target Date: 02/24/2026INTERVENTIONS: Administer medications as ordered. Observe and document s /sx of effectiveness and side effects. Educate resident / resident representative to medication effectiveness and side effects Date Initiated: 09/12/2025Approach, speak in calm manner. Date Initiated: 09/12/2025Behavioral health consults as needed; 1:1 supervision until evaluation is complete. Date Initiated: 03/10/2026 Revision on: 03/10/2026Communicate with resident / resident representative regarding behaviors, and treatment Date Initiated: 11/04/2025Consult with: Pastoral care, Psych services, and/or support groups Date Initiated: 11/04/2025.On 3/10/26 at 4:00 pm, attempts were made to interview R10, but were unsuccessful as the resident did not wish to speak to the surveyor and began yelling and using profanity.On 3/13/26 the Administrator was made aware of the findings, and no further information was provided. 2. For R94 the facility staff failed to ensure the resident was dressed appropriately to maintain dignity.R94 was admitted to the facility with diagnosis that included, but we're not limited to hypertension, hyper lipidemia, seizure, disorder, malnutrition, anxiety, disorder, depression, bipolar disorder, and schizophrenia.Resident #94 most recent brief interview for mental status (BIMS) score was a zero out of a possible 15 indicating severe cognitive impairment. Resident number 94 was coded as being able to eat independently resident was dependent on staff for toileting, hygiene, dependent on staff for bathing and showering dependent on staff for upper body and lower body dressing dependent on staff for taking off and putting on footwear dependent on staff for personal hygiene section GG of the MDS states that R94 Is dependent on staff for turning repositioning lying to sitting on the bed, not attempted due to medical condition or safety. Sit to stand, not attempted due to medical condition or safety transfer bed to chair, not attempted due to medical condition or safety. R94 was dependent on staff for all aspects of ADL care. Once transferred to the wheelchair was able to propel herself by moving her feet.On 3/11/26 at approximately 3:30 pm, R94 was found in her room with curtain closed around bed, all linens off of the bed on the floor, visible from the hall, Resident had a dirty stained t shirt pulled up over her head completely covering her face and head, he breasts were exposed. The Resident did not respond when spoken to. Surveyor stepped out into the hallway and alerted RN #1 who was walking by. RN #1 was asked if this was an acceptable condition for this resident, RN #1 replied No but she is Geri- psych and resistant to care and she pulls the sheets off her bed. This statement was made in the resident's room in front of the resident.On 3/11/26 at 4:15 pm an interview was conducted with CNA 3 who stated that they should not refer to residents by their diagnosis.On 3/12/26 at 12:00 pm an interview was conducted with LPN 6 who stated that residents should be addressed as Mr. or Miss and their last name. She said residents should never be referred to as a diagnosis or condition. On 3/12/26 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policy for 1 resident (Resident #113), and 1 employee (Employee #6) in a survey sample of 53 Residents, and the facility as a whole. The findings included; For Resident #113, the facility staff failed to notify the state agency timely after a serious injury and further failed to file an accurate 5-day follow-up report to the state agency of the results of their internal investigation. Resident #113 was most recently admitted to the facility on [DATE]. Diagnoses included: Parkinson's disease, bipolar disorder, anemia, and depression. At the time of survey, the Resident had expired due to the incident and so could not be interviewed. The closest Minimum Data Set (MDS) assessment to the survey time period associated with the event that injured Resident #113, was an unplanned discharge assessment with an assessment reference date (ARD) of 1-20-25. Prior to the incident Resident #113 was coded with a Brief Interview of Mental Status score of 13 indicating mild cognitive impairment. The Resident was independent for most activities of daily living and was her own decision maker and responsible party. Nursing and physician progress notes were reviewed and revealed a note on 1-20-25 at 1:00 A.M., that described finding the Resident with bruising and bleeding noted to head and face. [NAME] and throat appear discolored-purple, eyes darkened, lower lip purple, mouth bloodied, groggy and delayed verbal responses, due to the severity of the injuries to head will be transferred to the ER (emergency room) for evaluation. On 2-26-26 during the survey all facility investigation records were requested from the Administrator and the Regional Director of Operations (RDO). Among them were statements collected from staff including the Licensed Practical Nurse (LPN) who responded to the Resident after a CNA (Certified Nursing Assistant), found the Resident on the floor and reported it. In those records the LPN documented on 1-20-25 head felt lumpy, .when asked what happened Resident's words were gibberish. Resident to ER for further evaluation. On 1-20-25 an evaluation document was completed at 1:26 A.m. by a staff nurse in the facility. That evaluation described the Resident as found laying on her front side (face down) on the floor with legs stretched out straight and arms on her side. The staff member also included that a floor mat was present. Floor mats are placed beside beds in the resident's rooms for those with histories of falls to provide a cushioned area should the residents fall to mitigate injuries. Those mats are cushioned and run the entire length of the sides of the bed. An initial facility reported incident (FRI) was received in the Virginia Department of Health, Office of Licensure and Certification (VDH/OLC) on 1-20-25 at 10:07 A.M. (9 hours after the event) documenting that the Resident had an unwitnessed fall, injuries none, and that the hospital called the facility to inform them that the Resident arrived with suspicious bruises. The description went on to state that Law enforcement then followed up at the facility. A second Addendum report was received at VDH/OLC on 1-20-25 at 1:34 P.M (12.5 hours after the event). The addendum documented injuries, none, injury of unknown origin, and added that the receiving hospital had communicated to the nursing facility that they were making an allegation of sexual and physical abuse, No staff named at this time. The facility is fully cooperating with law enforcement and has launched their own investigation. The Resident was initially sent to the closest hospital on 1-20-25 at 2:00 A.M. (an hour after the incident). The first hospital then transferred the Resident to a second hospital according to facility documents and an APS (Adult Protective Services) report, after assessment and stabilization. The transfer was due to severe injuries requiring neurosurgery and care beyond their scope. The Resident arrived at the second hospital on 1-20-25 at 4:30 A.M., and was unconscious, unresponsive, and was already intubated at the time of arrival. The documentation goes on to say that discussions with the nursing facility alleged that the extensive injuries were from the Resident falling out of a seated position in a wheelchair and the Resident was found on the floor by a Certified Nursing Assistant (CNA). The hospital and APS description of injuries included old and new bruising on the body covering most of their arms, their legs, and over much of their body, the front of their neck, face, the top of their head, the back of their head, the back of their neck, their back, their abdomen, swelling and bleeding of the brain, and vaginal tearing and bleeding. At the second hospital, after assessment the Resident was stated to have significant bruising and injuries, and is not likely to survive their injuries, (location name) police department has been contacted. The Resident was transferred to the Intensive Care Unit (ICU) and expired on 1-24-25. On 1-20-25 at 9:32 A.M. a local Police Department Detective arrived at the facility to begin a forensic investigation and was in possession of a search warrant and secured the scene with other officers. Virginia Social Services/Adult Protective Services (APS) became involved as the hospital contacted them and reported the event for further investigation of physical and sexual abuse. On 2-25-26 the Administrator was interviewed and revealed that the only male working the night of the incident with Resident #113 was CNA (#3). As the investigation continued, it was learned that Resident #113 had reported an allegation of abuse on 12-30-24 involving her roommate (who was non-verbal) and CNA (#3). The full facility investigation completed for that incident was reviewed and deemed unfounded by the facility. CNA (#3) returned to work on 12-31-24. Time clock punch records for staff were requested and reviewed. The documents revealed that on 1-19-25 CNA (#3) was on duty overnight, and in the area, of Resident #113, and assigned to the next-door neighbor of Resident #113. Those same records indicated that he did not work after that. Interview with the RDO reveled that CNA (#3) was terminated on 8-19-25, late however did not return to work after the incident on 1-20-25. The Human Resources Director at the time had not removed his name from the roster in error which was a clerical error. Time clock records revealed this to be accurate. On 1-20-25 10:07 AM., the first report (FRI) of the incident, which was identified as an injury of unknown origin, and injuries none, was sent to the VDH/OLC, Late, (9 hours after the incident) and with incorrect information as found on floor post unwitnessed fall. The Facility staff were aware of the incident and serious injury within 2 hours of the incident as the facility sent the Resident to the hospital with serious injury and had communication with the hospital. Federal regulation requires a 2-hour report time, after the serious injury is known. A second Addendum report was received at VDH/OLC on 1-20-25 at 1:34 P.M (12.5 hours after the event). The addendum documented injuries, none, injury of unknown origin, and added that the receiving hospital had communicated to the nursing facility that they were making an allegation of sexual and physical abuse, No staff named at this time. The facility is fully cooperating with law enforcement and has launched their own investigation. This second report was also 7.5 hours late as the Abuse allegations were known at approximately 6:00 A.M. on 1-20-25 when the police detective made them aware of the criminal investigation upon their arrival. The facility Abuse policy was received as requested and revealed the following. The facility policy described under the heading Screening . a state criminal background check will be performed. During the course of the survey, it was identified by a second surveyor that screening of a state criminal background check had never been completed for Employee (#6). The policy goes on to instruct that under the heading Reporting.injuries of unknown source will be reported immediately, but not later than 2 hours after the allegation is made, if the events of the allegation involves abuse or results in serious bodily injury. Accurate and timely reporting of this incident to the state agency (VDH/OLC) did not happen. On 1-24-25 the 5-day follow-up Fri Investigation Final Report was completed by the Interim Administrator at the time of the incident who no longer worked for the facility. The timeline in the document described their conclusions (which by this time were known by the facility to be inaccurate). The document stated the following. The cause of the injury is unable to be substantiated., (and it is still being classified by them as) Allegation of abuse/mistreatment, injury of unknown origin, .and unwitnessed fall. The report continued documenting On the morning of 1-20-25, staff found (Resident #113 name) in (sic) the floor after an unwitnessed fall. Resident had bruising on her face and neck from the fall and had signs of head trauma from the fall. (these fall assumptions had not been proven, and the severe extent of the injuries were not disclosed) .911 was called and Resident transported to (name of hospital). At approximately 6:00 A.M., law enforcement arrived at the facility to inform they were investigating suspicious bruising. The report goes on to say, Law enforcement returned at 12 noon on 1-20-25 with a subpoena for medical records and to retrieve items from the patient's room. The subpoena indicated there was vaginal tearing and bleeding. Facility amended their initial report to include allegation of abuse/mistreatment. The 5-day follow-up document goes on to describe the facility investigation and facility response to the allegation. Finally, the document stated that the facility investigation thus far does not indicate that any abuse/mistreatment occurred. However, due to the fact that this is an ongoing police investigation, facility is unable to substantiate or unsubstantiate the allegations until the police conclude their investigation. Facility will continue to cooperate with law enforcement and will update this FRI if the police department is able to substantiate abuse occurred, or provides additional information related to this case. No update to this FRI was ever made by the facility. The police subpoena was reviewed and indicated it was issued at 9:30 A.M. and the facility was served at that time. Further the facility staff failed to make an initial report to the state agency timely, within 2 hours according to federal regulation for the known serious injury and failed to provide an accurate follow up report that was misleading when the details of the incident were known to them. On 1-20-25 A Quality Assessment and Process Improvement (QAPI) meeting was held with department directors, the RDO, the Administrator, and the DON. The meeting-initiated responses of the facility to the investigation, statements from staff, training on abuse, and statements from all residents who were queried as to abuse observations of others or self. The documents revealed signatures of those attending and those involved in the ongoing investigations and corrections. The RDO also supplied a chronology of events timeline which described the actions of those involved in the facility after the event regarding the incident. On 2-25-26 the Employee record for CNA (#3) was reviewed and revealed one sworn statement document provided by CNA (#3) that described in 1992 the CNA had been found guilty of misdemeanor larceny and the attestation was signed by him on 11-11-24. No other convictions nor pending criminal charges were revealed by the staff member. A review of state court records revealed that CNA (#3) had also been charged on 6-11-24 of a obtaining money by false pretenses felony and was found guilty on 10-27-25 after plea bargain to False statement on a criminal background history, misdemeanor with a sentence for 12 months in jail, however, all jail time was suspended after the conviction of that charge. That criminal act was evidenced to have happened again as the sworn statement provided to the facility dated 11-11-24 and signed by the prospective employee (5 months after pending criminal charges) revealed he made a materially false sworn statement again. Charges were pending for the 6-11-24 arrest and not revealed on the sworn statement document by CNA (#3), when he was hired at the facility on 11-25-24, as was described and mandated on the document . A criminal background check was completed by the facility on 11-11-24, and received by them revealing the 1992 larceny conviction, however, the pending charges of obtaining money by false pretenses was not yet a conviction, and so did not show up on that criminal records check and were not revealed by CNA (#3) as required. In summation, the facility staff failed to implement their abuse policies in regard to timely reporting and accurate reporting of an abuse allegation. They further failed to screen a new employee (Employee #6) for a criminal background check found during the survey which was unrelated to this incident. On 2-26-26 at 4:00 p.m., the facility Administrator, RDO, and DON were made aware of findings, at the end of day debriefing meeting. The facility stated they had no further information to provide. This allegation is Substantiated with a related Federal deficiency at F-607. 2. The findings included: [DATE] 25 random employee records were reviewed for compliance with the facilities per-employment screening and background check. Of the 25 records, Employee #6 did not have a sworn statement on file nor was the facility able to find an electronic copy of the sworn statement. Upon further investigation employee #6 did not have a Virginia State Police background check on file nor was an electronic copy able to be found. [DATE] at 8:20 AM interview with Other staff #1, Regional Human Resources representative from the corporate office was interviewed. Other #1 was informed that Employee #6 had no sworn statement nor background check performed by the Virginia State Police (VSP) documented to be on file. The facility was unable to locate the file on paper nor electronic copy of records. [DATE] at 1:38 PM a teleconference interview was conducted with Other #3 VSP background check personnel. Other #3 stated that there was no background check performed on Employee #6. The employee records showed that Employee #6 was hire on [DATE] and had access to all residents until termination on [DATE]. The facility P&P #: NS 1019-01-VA page 9 of 23 states Following the personal interview and upon recommendation of the interviewer, a background check will be performed. Additional information received appeared to be old court and criminal information on Employee #6 b ut not a VSP background check. [DATE] at 1030 AM these finding were reviewed with the facility Administration and DON.

Based on interview, clinical recrord review, and facility documentation the facility staff failed to ensure residentsrecei ve treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 1 Resident (#10) in survey sample of 53 Residents.For Resident #10 (R10) the facility staff failed to ensure the resident received her medication in accordance with professional standards of practice and physician orders. R10 was admitted to the facility on [DATE] with diagnoses that included but were not limited to bipolar disorder, major depressive disorder, schizophrenia, chronic kidney disease, heart failure, and history of falls. R10's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/21/26 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 13 out of 15 indicating moderate cognitive impairment. R10 was coded as needing moderate to fully dependent on staff for all aspects of ADL and personal care apart from eating. R10 was able to self-propel her wheelchair for ambulation in the facility. The MDS section E0200 Behavioral Symptoms coded R10 as follows: Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) (E0200A) 1-3 days. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) (E0200B) 1-3 days Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) (E0200C) 1-3 days. E0900. Wandering - Presence & Frequency Has the resident wandered? (E0900) 1-3 days.On 3/11/26 a review of the clinical record revealed that R10 had gone out to the hospital on [DATE] and returned on 12/29/25. R10 had orders for Invega Sustena (an anti-psychotic) administered one a month for management of the symptoms of Schizophrenia. Prior to the hospital stay the order read:Invega Sustena Intramuscular Suspension Prefilled Syringe 156 MG/ML (Paliperidone Palmitate) Inject 1 ml intramuscularly one time a day every 30 day(s) for schizophrenia. R10 was due for the injection on 12/19/25, due to her hospital stay this was not given on time. R10 returned to the facility on [DATE] with orders for the Invega Sustena that read:Invega Sustena Intramuscular Suspension Prefilled Syringe 117 MG/ 0.75 ML (Paliperidone Palmitate) Inject 0.75 ml intramuscularly one time a day every 30 day(s) for schizophrenia.A review of the MAR (Medication Administration Record) revealed that the resident was not given Invega Sustena during the month of December 2025 and was given the incorrect dosage of 156 MG/ML on 1/21/26. The dose was also incorrectly ordered on the MAR for the month of February, and the resident also did not receive the medication in the month of February. On the morning of 3/11/26 an interview with the DON was conducted and she stated that it is the expectation of our nurses that they follow the physicians orders, and use [NAME] as the professional standard. The DON stated that the nurses are supposed to go by the rights of medication administration. (Nursing Centrer.com, 2026)Rights of Medication Administration1. Right patient2. Right medication3. Right dose4. Right route.5. Right time6. Right documentation7. Right reason8. Right response On 3/12/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

3. For Resident #76 (R76), the facility staff failed to remove the one-on-one supervision on the care plan, when it was discontinued. On 3/10/26, R76 was observed in his room lying in bed with no one else present in the room. R76 did not respond when spoken to. On 3/11/26 at 10:48 AM, an interview was conducted with R76 using the facility's interpreter line via telephone, as R76's primary language was Spanish. R76 reported no concerns. On 3/11/26, during a clinical record review, it was noted that R76's care plan had an intervention dated 10/22/25 that read, 1:1 supervision related to resident to resident altercation. On 3/11/26 at 2:03 PM, an interview was conducted with registered nurse #2 (RN #2), who was the care plan coordinator. RN #2 explained that care plans are updated during daily clinical meetings, when there is a change in condition, or when they have order changes. RN #2 went on to state that the care plan is important so the plan of care is followed, everyone knows what is going on and the goals. When asked to explain the importance of the care plan being up to date, RN #2 said, So as their condition changes everyone knows what is going on with the resident. The information is a tool so that certified nursing assistants (CNAs) know how to care for the resident. During the above interview with RN #2 she was asked about R76 being on one-to-one observation. RN #2 confirmed the resident was not on one-to-one and she would review the care plan. On 3/11/26 at 3:46 PM, RN #2 returned to the surveyor and reported that R76's one-to-one had been for less than 24 hours and said, It should have been resolved before now. According to the facility policy titled, Plan of Care Overview Revision 7.0 printed on 3/11/26, it read in part, . 2. Nurses are expected to participate in the resident plan of care for reviewing and revising the care plan of resident they provide care for as the resident's condition warrants. III. Care Plan documents. b. Care plan documents are resident specific/resident focused and reflect resident/representative opportunities for participation and preferences. On 3/11/26, during an end of day meeting, the above findings were reviewed with the facility administrator and director of nursing. No additional information was provided.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for two residents (Resident #117-R117 and Resident #64-R64), in a survey sample of 53 residents. The findings included: 1. For R117 who had an incident which resulted in the police being called, the facility staff failed to document details of the incident within the clinical record. On 3/11/26, during a review of facility documentation it was noted in a facility incident synopsis that on 10/21/22 there was an allegation of abuse involving R117. According to the incident summary signed by the director of nursing (DON) and dated 10/26/22, it noted that on 10/21/22, R117 was attempting to retrieve linen from linen closet. [LPN #9's name redacted] approached [R117's name redacted] and asked him to wait for assistance due to cross contamination . [R117's name redacted] approached [LPN #9's name redacted] and proceeded to push her and hit her with towels. Staff were able to intervene and assist [R117] back to his room, where he calmed down . [LPN #9's name redacted] called law enforcement to report resident for assaulting her . Review of R117's progress notes, revealed no progress note entries dated 10/21/22 or the following day. On 3/11/26, an interview was conducted with the facility administrator who said that she would expect when incidents occur, they are clearly documented within the resident's clinical record. According to an undated facility policy titled, Clinical Documentation Standards it read in part, Maintaining the integrity, quality, and safety of medical records can help to provide an effective communication between practitioner that may serve to enhance resident outcomes . Nurses will follow the basic standard of practice for documentation including but not limited to providing a timely and accurate amount of resident information in the medical record . On 3/11/26 during an end of day meeting the above findings were reviewed with the facility administrator and director of nursing. No additional information was received. 2. For Resident #64 (R64) the facility staff failed to maintain an accurate clinical record to include the details of R64's debit card being taken and used by other residents. On 3/10/26, a review was conducted of R64's clinical record and facility investigation documents. This review revealed that R64's clinical record had no recorded details of the incident of misappropriation and financial exploitation that R64 was victim of. On 3/10/26, according to the facility's investigation synopsis, on 12/30/25 R64 reported to the social services director that she wanted to change rooms and reported that her roommate had stolen her debit card information several months prior. R64 reported that several months prior, while asleep when she awakened R64 observed her roommate placing her debit card back into her purse. According to the facility investigation summary and investigation synopsis, R64 dismissed the incident at the time. When R64 was asked by facility staff why she was bringing up the incident at that time, R64 reported since that incident she has consistently lacked funds in her bank account. During the facility's investigation of R64's allegation, the roommate confirmed she had provided R64's debit card information to another resident. According to R64's clinical record there was no documentation within the record about the incident, facility investigation, or actions taken during and following the investigation. On 3/12/26 at 2 PM, an interview was conducted with R64. R64 recalled the incident and confirmed the details as documented in the facility investigation summary and investigation synopsis. On 3/12/26, during and end of day meeting, the facility Administrator, Director of Nursing, and Regional Director of Clinical Services were made aware of the above findings. The Administrator agreed that she would expect documentation within a resident's clinical record of such incidents. No additional information was provided prior to conclusion of the survey.

Based on observation, staff interview, and facility document record review, the facility failed to ensure that medications were stored correctly for one of two medication carts inspected.The findings include:On 2/25/26 at 2:04 PM, an inspection was conducted on two facility medication carts, cart #1 and cart #2. During this inspection, an opened vial of Lispro (an insulin medication) 100mL (milliliters) was noted in the top drawer of medication cart #1 inside a transparent plastic bag. A sticker was affixed to the bag stating, Discard by: 2/24/26. Further inspection of this medication revealed an opened date transcribed on the vial of 12/25/25. A review of facility policy demonstrated that the facility is to discard immediately any outdated medications. A review of the facility med cart sheet showed that Lispro has a discard date of 4 weeks after opening.An interview was conducted on 2/25/26 at 2:04 PM with LPN (Licensed Practical Nurse) #2. LPN #2 stated that Lispro should be good for 30 days after it is opened and they will discard this medication.No further information was provided prior to exit.

Based on staff interview, clinical record review and facility documentation, the facility staff failed to ensure residents were free from significant medication errors for 1 Resident (# 10) in a survey sample of 53 residents.For Resident #10 (R10) the facility staff failed to administer Invega Sustena (a psychotropic medication) during the month of December 2025, gave the incorrect dosage in January of 2025 and did not give it in February of 2025.R10 was admitted to the facility on [DATE] with diagnoses that included but were not limited to bipolar disorder, major depressive disorder, schizophrenia, chronic kidney disease, heart failure, and history of falls. Resident #10's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/21/26 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 13 out of 15 indicating moderate cognitive impairment. Resident #10 was coded as needing moderate to fully dependent on staff for all aspects of ADL and personal care apart from eating. R10 was able to self-propel her wheelchair for ambulation in the facility. The MDS section E0200 Behavioral Symptoms coded R10 as follows: Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) (E0200A) 1-3 days. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) (E0200B) 1-3 days. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) (E0200C) 1-3 days. E0900. Wandering - Presence & Frequency Has the resident wandered? (E0900) 1-3 days.On 3/11/26 a review of the clinical record revealed that R10 had gone out to the hospital on [DATE] and returned on 12/29/25. R10 had orders for Invega Sustena (an anti-psychotic) administered one a month for management of the symptoms of Schizophrenia. Prior to the hospital stay the order read:Invega Sustena Intramuscular Suspension Prefilled Syringe 156 MG/ML (Paliperidone Palmitate) Inject 1 ml intramuscularly one time a day every 30 day(s) for schizophrenia. Resident #10 was due for the injection on 12/19/25, due to her hospital stay this was not given on time. R10 returned to the facility on [DATE] with orders for the Invega Sustena that read:Invega Sustena Intramuscular Suspension Prefilled Syringe 117 MG/ 0.75 ML (Paliperidone Palmitate) Inject 0.75 ml intramuscularly onetime a day every 30 day(s) for schizophrenia. A review of the MAR (Medication Administration Record) revealed that the resident was not given Invega Sustena during the month of December 2025, and was given the incorrect dosage of 156 MG/ML on 1/21/26. The dose was also incorrectly ordered on the MAR for the month of February, and the resident also did not receive the medication in the month of February.On the morning of 3/11/26 an interview with LPN 6 was conducted and she stated that when the facility receives an admission or readmission the nurse on the floor gets the discharge summary and goes over the med list and notifies the provider or the on call to get the medications verified. LPN 6 also stated that if a resident who recieves monthly injections of Invega Sustena skips a month or is not given the correct dosage it can have an effect on their behaviors. It can cause an escalation or increase in behavioral symptoms.On 3/11/26 at approximately 1:00 pm an interview was conducted with the DON who stated that it is the expectation of the nurses that they verify the orders on admission or readmission to the facility. She stated the nurse is supposed to reconcile the meds with the physician or on call provider using the discharge summary from the hospital. A review of the discharge summary revealed the change in dosage of Invega Sustena to 117 mg / 0.75 ml upon admission. The DON further stated that if medication is not given for any reason the provider must be notified. When asked about the significance of not receiving anti-psychotic on a routine schedule as ordered by the physician, she stated the behaviors could change and the symptoms exacerbate.On 3/13/26 the Administrator was made aware of the findings, and no further information was provided.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to respond to a pharmacy recommendation for one of fifty three residents in the survey sample. Resident # 54. The findings included:The physician did not respond to a pharmacy recommendation regarding scheduled vital signs for Resident #54 (R54). Diagnoses for R54 included cerebrovascular disease, hypertension, and edema related to fluid retention. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 2/6/26. R54 was assessed with long and short-term memory problems and severely cognitively impaired. Medication Regimen Review (MRR) for R54 indicated that the pharmacist had made a recommendation on 12/26/25. On 2/26/26 at 10:11 a.m. the director of nursing (DON) presented the recommendation. The recommendation listed three medications: Metoprolol (given for hypertension, Amlodipine (given for hypertension), and furosemide (given for fluid retention). The recommendation was asking to consider adding an order for scheduled vitals. The recommendation form titled Note to Attending Physician/Provider had an area on the form for the physician/provider to complete a response to the recommendation. This part of the form was not filled out by the provider and was left blank. The DON verbalized the physician did not respond to the recommendation and no orders were implemented. On 2/26/2026 at 3:54 p.m. the above information was presented to the DON and administrator. The facilities policy titled Medication Regimen Review read in part The resident's medical practitioner must document in the medical record that the identified irregularity has been reviewed, and what, if any action has been taken to address it. No other information was presented prior to exiting the facility on 2/27/26.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure proper foot care was provided to one resident (Resident # 94) in a survey sample of 53 residents.The findings included:For Resident # 94, the facility staff failed to ensure proper nail care was provided.Resident # 94 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to: hypertension, legal blindness, schizoaffecrive disorder, bipolar type, seizures and bipolar disorder current episode manic without psychotic features and generalized anxiety disorder.The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 1/12/2026. Resident # 94's BIMS (Brief Interview for Mental Status) Score was a 00 out of 15, indicating severe cognitive impairment. Resident # 94 required assistance with Activities of Daily Living.Review of the clinical record was conducted 2/24/2026 to 2/27/2026.During the initial tour of the facility on 2/24/2026 at 11:30 a.m., Resident # 94 was observed lying in bed. Both feet were uncovered. Observation of the toenails on both feet revealed thick and long toenails. The toenail on the great toe on the right foot was dark in color, approximately an inch and half in length, pointed and curved to the right over the second toe. The left great toenail was approximately a half inch to one half inch long, thick and dark in color.On 2/25/2026 during rounds at 9 a.m., 11 a.m., and 1:30 p.m., Resident # 94 was observed lying in bed with feet uncovered. The toenails remained the same.On 2/26/2026 at approximately 2:30 p.m., an interview was conducted with Certified Nursing Assistant # 2 who stated the expectation was for the nursing assistants to cut the toenails of residents unless they were Diabetics. She stated the nurses should be notified if the residents refuse to allow the staff to provide nail care.Review of the Podiatry records revealed that Resident # 94 was not listed as one of the residents to be seen by the podiatrist from November 2025 to February 2026. Review of the clinical record revealed no documentation that the resident was treated by the Podiatrist nor any documentation regarding toenails being cut by the staff during those months. On 2/26/2026 at 2:50 p.m., an interview was conducted with Licensed Practical Nurse # 3 who stated proper nail care should be provided to residents. Licensed Practical Nurse # 3 stated Resident # 94 needed footcare. On 2/26/2026 at 9:30 a.m., an interview was conducted with the Director of Nursing who stated the facility staff should provide nail care to the residents. The Director of Nursing stated that Resident # 94 often refused care. The Director of Nursing observed the toenails of Resident # 94 and stated that the right great toe nail was very long and needed to be trimmed.On 2/26/2026 during the end of day meeting, the Administrator and Director of Nursing were made aware of the findings. No further information was provided.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to report incidents of abuse in accordance with regulatory requirements for three residents (Resident #52, Resident #74 and Resident #76) in a survey sample of 53 residents.The findings included:1. For Resident #52 (R52), who struck another resident with a rock, resulting in a cut to the other resident's forehead, the facility staff failed to report the incident to regulatory authorities as required. According to facility documentation and an incident summary, on 8/31/24, R52 allegedly striking [other resident's name redacted] on his forehead with a small rock. [Other resident's name redacted] was attempting to place a flower in [R52's name redacted] hair and [R52's name redacted] became irritate. The residents were separated for the courtyard. police notified [sic]. The facility failed to have credible evidence that the incident of abuse was reported to adult protective services or the state survey agency within 24 hours of the incident. The facility only had credible evidence of the investigation findings having been reported to adult protective services on 9/6/24. 2. For Resident #74 (R74), who was assaulted by another resident, the facility staff failed to have credible evidence that the incident was reported in a timely manner. On 3/12/26, during a clinical record review of R74's chart, it was noted that on 9/7/24, a change in condition note was entered. According to that note, it read in part, .nose injury from altercation no bleeding no edema from nose right cheek slightly edematous. The doctor ordered PRN [as needed] pain medication and ice if needed. On 9/7/24, a nursing note entry read, Resident to resident altercation. This resident was struck by another resident in the nose and cheek. Nose did have some bleeding although has subsided. Tylenol given. Instructed to apply ice. According to the medication administration record for R74, the resident was given Acetaminophen on 9/7/24 for an associated pain score of 7. On 9/8/24, R74 was again given Acetaminophen for a pain score of 5. On 3/12/26-3/13/26, review of the documentation provided by the facility was reviewed. According to an incident synopsis and incident summary, the facility gave the following details regarding the incident. On the evening of 9/7/2024, [Resident #118's- R118 name redacted] and [Resident #74's name redacted] were observed by other residents, in a verbal altercation while outside in the facility courtyard playing cards. The verbal escalated, in which [R118's name redacted] was observed throwing cards at [R74's name redacted] and then stood up and truck him in his face resulting in a bloody nose. At this time, it was witnessed [Resident #75's name redacted] stood up to stop the altercation which ended in [R118 and R74's names redacted] on the ground. On 3/13/26 at 9:11 AM, an interview was conducted with Resident #74 and Resident #75, who were roommates. R74 was asked about the incident that occurred on 9/7/24. R74 reported he recalled the incident and said, I really wanted to beat his a$$. R74 recalled that no staff were present when the incident occurred. R75, the roommate didn't add to the conversation and didn't acknowledge that he recalled the incident. There was no evidence of the incident being reported to adult protective services or the state survey agency until the investigations summary was sent via fax on 9/13/24. 3. For Resident #76 (R76), who was assaulted by another resident, the facility staff failed to report the incident of abuse to the regulatory agencies. On 3/12/26-3/13/26, a review of R76's clinical record was conducted. This review revealed that according to R76's care plan he had a communication barrier and used an interpreter. According to a progress note dated 10/22/25, it read, Resident had a physical altercation with a staff and another resident while seated in the wheelchair on the corridor located by his room Resident was observed going into the wound nurse's office and assaulting her and spitting on another resident. Staff was able to intervene to separate the residents; [R76's name redacted] was relocated to his room; head to toe complete, revealed minor scratches to back, abdomen, bil. [bilateral/both] arms/legs; skin otherwise intact, no complaints of pain or discomfort voiced via interpreter line.resident placed on 1:1 for safety, local law enforcement notified. According to the facility investigation documents it alleged that R76 went into the wound care nurse's office, hit her and pushed her. The nurse exited the office to call for assistance. During that time another resident, (Resident #16-R16) told R76 to sit down. R76 then spit on R16 causing [R16's name redacted] to physical assault him [R76] (sic). The facility failed to have any credible evidence that this incident was reported to the state survey agency or that the investigation summary was reported to any of the regulatory agencies. On 3/12/26 at 11:13 AM, an interview was conducted with the facility administrator. The administrator was asked to explain the process when the facility receives an allegation of abuse, or an incident of abuse occurs. The administrator said, when get allegation of abuse, do initial FRI [facility reported incident], get witness statements from staff, after that we notify the appropriate parties, who are the ombudsman, APS [adult protective services], law enforcement, DON [director of nursing], MD [medical doctor], RDO [regional director of operations] and myself [administrator] and any other party that is necessary. Regarding the timing of reporting, the administrator said, anything with abuse we do reporting within 2 hours and anything other than that, I have a 24-hour time frame to get it reported. On 3/13/26 at 8:56 AM, an interview was conducted with the facility's director of nursing (DON). When asked to explain the reporting process for allegations of abuse, the DON said, We do an initial report to the OLC [state survey agency], ombudsman and APS (adult protective services) . Once we gather all of the information we talk about it and put everything together and form a conclusion and it gets sent to the OLC, ombudsman, and APS. The DON was asked, why reporting is important, the DON said, so they can be aware of what id going on in the facility between residents, to see if there is anything we need to put in place or prompt their investigation. When asked about timing of reporting, the DON said, initially within 2 hours and the final within 5 days. The facility's policy titled, Abuse, Neglect and Exploitation Policy-Virginia which was undated, was reviewed. The policy on age [AGE] read in part, . V. Reporting of Incidents and Facility Response: 1. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury a. If the events that cause the allegations do not result in serious bodily injury, reporting to the administrator (Executive Director) and to other reporting regulatory bodies must occur within twenty-four (24) hours. 2. Alleged violations are reported immediately to the Executive Director of the facility. a. The ED/designee will report appropriate incidents to the Adult Protective Services and the Division of Licensing and Regulation as required by state law. 3. The results of the facility's investigation must be reported to the survey agency, the ED/Designee and other officials in accordance with state law, within five working days of the incident. No additional information was provided prior to the conclusion of the survey.

Based on observations, resident and staff interviews, and medical record and facility policy reviews the facility failed to provide Resident (R51) with essential discharge planning. This failure impacted R51's psychosocial wellbeing, causing him anxiety at times and desperation to return to his community. This is harm. The facility failed to meet this requirement by failing to: 1. Ensure R51's discharge goals were clearly understood through the use of an interpreter. 2. Develop a discharge plan for R51 to return to his community. 3. Regularly evaluate R51 for his desire to return to his community and assist with resources to make his transition successful. Findings include: Observation on [DATE] at 11:00 AM, revealed R51 at the Receptionist's window. R51 was ambulatory, without the need of a walker or wheelchair to assist in mobility, and he was agitated. R51 is Korean and speaks only a few words of English. He stated .forty dollars-forty dollars! and he waved a small black notebook at the Receptionist and the Business Office Manager (BOM). The BOM addressed R51's concern and they were attempting to communicate using a translation application on his phone. Review of an undated Face Sheet (a document with demographic and limited diagnostic information) found in the Electronic Medical Record (EMR) under the profile tab, revealed R51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R51's Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] revealed R51 is ambulatory per self with no assistive device required. He is assessed as independent requiring only oversight or cueing for his Activities of Daily Living (ADLs). The assessment indicated R51 had a Brief Interview for Mental Status (BIMS) score of 7 (of a possible 15 points). Previous MDS assessments were reviewed going back to R51's admission in 2017, and most of the MDS assessments were scoreless in this category due to the language barrier per the SW notes at the time. Review of the Quarterly MDS with an ARD of [DATE] did not complete the BIMS Assessment. Review of the Quarterly MDS with an ARD of [DATE] coded the resident as an 11 meaning moderately impaired. Review of the Quarterly MDS with an ARD of [DATE] indicated the BIMS assessment should be complete but no score was noted. Observations throughout the survey revealed R51 was rarely in his room. He walked the facility halls several times a day. He is very social with both staff and residents. In an interview on [DATE] at 10:15 AM Licensed Practical Nurse (LPN)B said .[R51] has had a room to himself since COVID - when we had to make a lot of room changes.he tends to be territorial and that works better for him. The LPN confirmed he is out of the room most days to burn off energy. During this same interview, LPNB and CNAA were asked about communicating with R51. They confirmed the device he wears around his neck is his cell phone and he has a translation application that he uses for Korean to English and vice versa. When asked if they felt this was effective, they both said yes, and added that R51 is very animated and used his body language when communicating his needs. This was observed to be true throughout the survey. LPNB also stated we can call his wife and gestured air quotation marks. Review of the residents EMR and hard chart at the nurse's station revealed a named resident representative (RR) and/or emergency contact identified as friend. The RR and her children were also listed under contacts. There was no documented evidence that R51 had been deemed unable to represent himself and make his own decisions since his admission. R51 has a language barrier and is frequently agitated (per the medical record review), because the language barrier hasn't been resolved by engaging a reliable interpreter. The EMR and hard chart were silent to documents that would deem the friend as an appropriate representative for healthcare and/or financial decisions. Nor was there documentation that one of the children was a deemed resident representative, but both had been notified by the facility of medical and financial concerns for R51. In an interview with the Social Worker (SW) on [DATE] at 2:20PM, the SW was asked about communicating with R51. The SW stated, .he has a device and if that doesn't work we can call his wife. When asked about documentation of the named girlfriend being deemed a representative to make decisions for, interpret for, and to be notified of changes for R51 both medical and financial, the SW said that she had only been at the facility for about a year but she would see what she could find related to social services and discharge planning provided to/for R51 since his admission. Review of the Social Services notes since admission revealed the following: [DATE] - Met with resident's girlfriend who had questions about filling out an application for [R51] new social security card . SW advised girlfriend. [DATE] - Care Plan meeting held. Resident declined and no contact from family .Resident continue to be Full Code and long term. [DATE] - Care Plan meeting held. Resident did not attend, no contact from family. Resident is long term and CPR. [DATE] - Care Plan meeting held. Resident did not attend, no contact from family. Resident is long term and CPR. [DATE] - [R51] is a 69yo [year old] long term care resident due to convulsions and muscle weakness. He is alert and oriented and can make needs known but does have difficulty with English as a second language. Only ask about returning to community on annual assessments . [DATE] - Resident visited SS (Social Services) with his cell phone to translate. Resident wanted money and green card and wants to go home. SW advised resident a call was placed to RP. [DATE] - SW communicated with resident today on his app on telephone. Resident stated he was frustrated and wanted to know why he cant go home.SW communicated this is his home now and staff will take care of laundry. SW reminded resident that [named girlfriend] does not return calls from SW. [DATE] - Resident at SW office agitated. SW uncertain what resident was saying because resident was yelling in addition to language barrier.he stated he came four times.SW attempts to get stepson on phone. [DATE] - Conference call with SSA, and resident regarding resident income. During an interview on [DATE] at 3:30 PM, the SW was asked if the facility had ever made an attempt to engage an interpreter, without a potential conflict of interest, so that R51 could be clearly understood regarding his treatment and resident rights for appropriate care and discharge planning. The SW stated .there is a phone number we can call for an interpreter and I know they (BOM and R51) had a meeting using that interpreter line in the business office about his green card. When asked if she had ever engaged the interpreter line in her role as SW to ensure R51's needs were being met, the SW said, No. When asked about the effectiveness of communicating through the translating device, due to its dependence on R51's understanding of what he is trying to ask/say, and the immense opportunity for misinterpretation the SW said .we do the best we can to understand him. Review of the Nurse Practitioner and Nursing Progress notes in the EMR found in the Progress Notes tab revealed the following: [DATE] - Nurse Practitioner Note .language barrier makes difficult to communicate called wife to explain and interpret patient complaints. [DATE] - Note text: visited resident in his room.Resident speaks Korean and some English but is usually understood. Resident nodded head up and down when I asked if he was ok. I asked if he had any problems and he smiled and said good, good. [DATE] - Activity Note Text: Resident received a copy of Resident Rights and Ombudsman information. Surveyor asked Activities Director on [DATE] at 7:40 AM if it was provided in Korean and it was not. When asked if R51 attends activities regularly the AD said sometimes. [DATE] - Social Services [SS] Note Text: On [DATE] resident became very upset and loud by the SS door because he thought the number of medications he was receiving was wrong. SW Unit Manager and Nurse finally explained his medications and was able to calm him down. [DATE] - Social Services Note: [R51] is alert and oriented with a BIMS score of ,d+[DATE]. He has difficulty making his needs known because English is his second language .only ask about returning to community on annual assessment. [DATE]- Social Services Note: resident visited SS today with his cell phone to translate. Resident wanted money, green card and wants to go home. SW informed resident that a call was placed to RP and left a message. [DATE] - Social Service Note: SW communicated with resident today on his app on telephone. Resident stated he was frustrated and wanted to know why he cant go home.SW communicated this is his home now and staff will take care of laundry. SW reminded resident that [named girlfriend] does not return calls from SW. [DATE] - Nurse Practitioner Note:.Neuro: alert and oriented x4 [times four]. Follows commands, no neural deficits noted. Psych: appropriate mood, affect and judgment . [DATE] - physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Neuro: alert and oriented x4 [times four]. Follows commands, no neural deficits noted. Psych: appropriate mood, affect and judgment. In an interview with the Director of Nursing (DON) and the Administrator on [DATE] at 4:05 PM, the DON and Administrator were made aware of the concerns related to R51's language barrier as it related to resident rights and medically necessary social services. Neither were aware that the emergency contacts were not appropriate to act as R51's representative. They were advised that the facility must ensure he is clearly understood, and can speak for himself, by whatever means necessary. The DON agreed that he is high functioning and his level of care should be reassessed when the resident could be fully involved in the conversation. She confirmed no clear baseline had been established due to the language barrier. Both the Administrator and DON stated that situation would be clarified and taken care of immediately. On [DATE] at 8:00 AM R51 was interviewed in his room using his interpretive app on his cell phone. The effectiveness of this app is questionable because it relies on R51 having a clear understanding of what he wants to ask or say. He did make clear that he is desperately trying to return to his Korean community. He was adamant through body language and the device that the listed RR was not an appropriate decision maker for him. He stated this was a lover but the relationship had ended and she hasn't return his calls for over a year. The resident had been journaling his situation and had multiple notebooks filled with notes since his admission. R51 offered them to read but they are written in Korean and this too, would require an interpreter. With patience R51 was able to communicate that he had a Pastor that would come to the facility to interpret for us. He trusted the Pastor and called him on his cell phone. The Pastor agreed to meet with the surveyor and R51 at 9:00 AM on [DATE]. With the interpreter/Pastor present in the facility on [DATE] at 9:10 AM, along with R51 and two surveyors, R51 was able to explain his situation as he understood it. R51 said that two years ago he had a stroke and woke up here. Through the interpreter R51 said that he had needed rehab and was in a wheelchair for a short time. He has recovered remarkably, by all accounts, and wishes to return to his community. R51 confirmed the emergency contact/resident representative that the facility had been contacting was a former girlfriend/lover, but that relationship had ended. When asked how long since the relationship had ended, R51 said since before COVID through the interpreter/Pastor, and he adamantly crossed his arms in the air and said, no more. R51 was clear that the woman named should not be making decisions or receiving information about his situation. He stated he feels trapped and frustrated, and feels he is capable of caring for himself and is aware he should have the right to try. Review of the facility's policy tilted Policy and Standard Procedures - Subject: Discharge Planning - Category: Social Services - Effective: [DATE] revealed, A process [discharge planning] that generally begins on admission and includes each resident's discharge goals and needs, developing and implementing interventions to address discharge goals/needs and continuously reevaluating throughout the residents stay to ensure a successful discharge.1.) The discharge plan must be consistent with discharge rights set forth in 483.15(b).2.) Ensure the discharge needs of each resident are identified and result in a discharge plan .work with the clinical team to ensure discharge needs are addressed.3.) Include regular reevaluation of residents to identify modifications needed.7.) Address the resident's goal and treatment preferences.8.) Document that a resident has been asked about their interest in returning to their community.a.) If the resident indicates interest in returning to the community the facility must document referrals to local agencies or appropriate agencies .10.) Document and include in the resident's record the evaluation and discharge plan.a.).ll relevant information must be incorporated into the discharge plan to facilitate its implementation and avoid unnecessary delays in the resident's discharge.

Based on staff interview and facility documentation review, the facility staff failed to develop and implement a water management plan for Legionella with regards to a risk assessment to identify where Legionella and other waterborne bacteria could grow, which has the ability to affect all Residents residing at the facility. The findings included: On 4/14/22, during review of the facility water management program the facility submitted an incomplete and inaccurate facility risk assessment, used to identify where Legionella and other waterborne bacteria could grow and spread in the facility water system. This was reviewed with the facility Administrator and Director of Maintenance, who confirmed the form was not accurate and incomplete. During the review of the water management program, when asked about the water testing as noted as being conducted as per the facility assessment for Legionella, the maintenance director stated that the kitchen has the test strips and tests this. The maintenance director was asked to confirm that the kitchen staff are testing for Legionella and he stated, Yes, they have the test strips that change color. On 4/14/22 at 4:00 PM, the facility Administrator stated that the Divisional Director of Facilities management was walking them through the form [Legionella risk assessment]. The facility Legionella policy was reviewed. It read, .Surveillance for Legionella includes monitoring for appropriate levels of disinfectants in the public water system as well as the facility water system .4. Monitoring Environment. a. Maintenance performs routine water monitoring services documented in electronic surveillance systems . Administrator was made aware of the lack of an appropriate and accurate water management program on 4/14/22, during the end of day meeting. On 4/15/22 at 7:52 AM, the facility Administrator provided a revised Legionella Assessment form and stated, The form sent yesterday was completed incorrectly. Therefore, The maintenance director and area director completed a new form yesterday. No further information was provided.

Based on observations and resident and staff interviews the facility failed to promote dignity with dining by failing to provide residents with proper silverware by serving the residents in the facility with disposable, plastic spoons daily. Finding Included: 1. The facility failed to promote dignity with dining by failing to provide residents with proper silverware by serving the residents in the facility with disposable, plastic spoons daily During the initial pool portion of the survey process on the afternoon of 04/12/22 and through the morning of 04/13/22 several alert and oriented residents were interviewed/screened. Some of the residents were observed with their meal trays during the interviews and it was noted that they had regular forks and knives but could only get plastic spoons with their meals. Some of the residents complained the plastic wares could be difficult for residents with impaired grip and/or hand function/coordination issues. When asked, the residents stated they had made the facility aware that they preferred regular silverware. During a group meeting on 04/14/22 at 2:00 PM, the residents also stated that they had run out of spoons in the facility, and they had been getting plastic spoons on their trays since plastic wares were initiated for COVID containment. Those restriction had been lifted but the facility remained out of standard spoons for residents to use. In an interview with the Dietary Manager (DM) on 04/14/22 at 12:30 PM, the DM stated he thought majority of the facility spoons had been accidentally thrown away when the residents were using disposable wares (plastic containers and silverware) during the COVID-19 restrictions. The DM stated he had been out of dinnerware spoons for a few months because they had been on back order. He was asked to produce the work order or invoice for the spoons, but could not find it. On 04/15/22 the DM advised the surveyor that he had spoons for residents to use. The facility paid for him to get some locally while waiting for his order to be filled. The Administrator confirmed he had approved the expense for new silverware for the resident's use and the DM had purchased spoons on 04/14/22 at 5:00 PM during the end of day meeting with the team.

Based on dining observations, resident and staff interviews, and review of the Food and Drug Administration's Food Code 2017, the facility failed to provide foods that were palatable and maintained at appetizing temperatures for 3 of 40 sampled residents (R44, R86 and R88). Findings include: During the initial pool portion of the survey process on the afternoon of 04/12/22 and through the morning of 04/13/22 many alert and oriented residents were interviewed/screened. Some of the residents were observed with their meal trays during the interviews and were asked about the food quality in the facility. Residents (R)44, R86 and R88 said their food was frequently cold by the time it reached them. During an interview on 04/13/22 at 8:30 AM, R86 stated it makes bad food worse. On 04/14/22 at 12:00 PM, food temperatures were checked on the serving line and found to be at appropriate temperatures when the food was plated and left the kitchen on the tray cart. A test tray was requested and followed for a temperature check by the Dietary Manager (DM) and surveyor. The test tray was the last tray, on the last cart served on the 200 top hall. The temperatures were checked at 12:37 PM on 04/14/22. The hot foods tested at or above 140 degrees as required. However, the cold items were not maintained at optimal temperatures to remain appetizing. The unopened yogurt on the test tray was 51 degrees, and the container was 'sweating'. The yogurt was not under the food cover, but was uncovered and unopened on the tray and failed to hold it's temperature. Interview with the DM at time of the temperature taking confirmed the yogurt was not less than 41 degrees as recommended. A group meeting was held on 04/14/22 at 2:00 PM with six alert and oriented residents willing to participate in resident council. During this meeting the residents stated their food is often cold when they receive it in their rooms. They said no certain meal was worse than others and that it happens frequently. On 04/14/22 at 2:30 PM the DM was made aware of the resident's comments about cold food during the screening process and during the resident group meeting. The DM stated he would work on fixing that. The DM stated he would look for a facility policy regarding food temperatures when asked, but he said he wasn't sure there was a facility policy because they follow FDA recommendations. No policy was received prior to exiting the survey. Review of the Food and Drug Administrations Food Code 2017: 7 Recommendations of the United States Public Health Service Food and Drug Administration, reviewed and current as of 03/2022, revealed .Foodborne illness in the United States is a major cause of personal distress, preventable illness and death.Epidemiological outbreak data repeatedly identify five major risk factors related to employee behaviors and preparation practices in food service settings as contributing to foodborne illness: o Improper holding temperatures, o Inadequate cooking, such as undercooking raw shell eggs, o Contaminated equipment, o Food from unsafe sources, and o Poor personal hygiene.The Food Code addresses controls for risk factors and further establishes 5 key public health interventions to protect consumer health. Specifically, these interventions are: demonstration of knowledge, employee health controls, controlling contamination, and time and temperature parameters for controlling pathogens.3-202.11 Temperature. (A) Except as specified in (B) of this section, refrigerated temperature control for food safety will be maintained at a temperature of 5oC (41oF) or below when served/received. (D) Temperature control for food safety of cooked foods that is cooked to a temperature and for a time specified under §§ 3-401.11 - 3-401.13 and received hot shall be at a temperature of 57oC (135oF) or above.

Based on observation, resident interview, staff interview, clinical record review, facility document review and in the course of a complaint investigation, the facility staff failed to facilitate resident self-determination for one resident (Resident #93) in a survey sample size of 40 residents. The findings included; 1a) For Resident #93, the facility failed to allow the Resident use of condom catheters. Resident #93's most recent MDS (minimum data set) assessment was dated 4-5-22. The document coded the Resident as always incontinent of bowel and bladder, fully intact with cognition, and was totally dependant on Staff for all activities of daily living to include toileting and hygiene. The Resident used a motorized wheel chair which he was able to maneuver himself without assistance as observed by the surveyor. On 4-13-22 At approximately 9:00 AM Resident 93 was observed and interviewed in his room. Resident #93 was dressed only in a shirt and an incontinence brief. The incontinence brief was soaked heavily with urine and the Resident stated look in that cabinet, it is full of condom catheters that I need to use, and have used for years. I want to use them, that would keep me dry and clean, I don't like stinking, and they won't let me use them. The surveyor inspected the cabinet and found it stacked with boxes of hundreds of condom catheters. The Resident stated they won't let me use them because they don't want me to be able to go out of the facility, and with the condom catheters I would not get wet, so I could have more freedom. The Resident's care plan was reviewed and revealed the Resident as incontinent of bowel and bladder, with interventions of the following only; Barrier cream after incontinence care. Assist with ADL's hygiene and toileting. On 4-13-22 the DON was asked why the Resident had not been allowed his preference for condom catheters, and she stated they were afraid it would break down the Resident's skin. On 4-13-22 at the end of day debrief, the DON notified the surveyor that they had received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On that day the condom catheters were placed on the Resident's care plan. On 4-14-22 during the end of day meeting the Administrator and DON were made aware of the concerns and no further information was provided. Complaint Deficiency. 1b). Resident #93 was not permitted to go out of the facility by himself. Resident #93's most recent MDS (minimum data set) assessment was dated 4-5-22. The document coded the Resident as always incontinent of bowel and bladder, fully intact with cognition, and was totally dependant on Staff for all activities of daily living to include toileting and hygiene. The Resident used a motorized wheel chair which he was able to maneuver himself without assistance as observed by the surveyor. On 4-13-22 At approximately 9:00 AM Resident 93 was observed and interviewed in his room. Resident #93 was dressed only in a shirt and an incontinence brief. The resident stated, they won't let me use them because they don't want me to be able to go out of the facility, and with the condom catheters I would not get wet, so I could have more freedom On 4-13-22 the DON was asked why the Resident was not allowed to go out with family and friends, she stated the doctor feels it is not safe. On 4-14-22, there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4-14-22 during the end of day meeting the Administrator and DON were made aware of the concerns and no further information was provided.

Based on staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to notify the responsible representative of a change in condition for one Resident (Resident #103) in a sample size of 40 Residents. For Resident #103, the facility staff failed to: a) Notify the Physician and the Responsible Representative in a timely fashion for significant weight loss on 09/03/2020. b) Notify the Responsible Representative for Resident #103's right eye infection on 09/17/2020. The findings included: On 04/12/2022 and 04/13/2022, Resident #103's clinical record was reviewed. According to the Weight Flowsheet, Resident #103 weighed 138 pounds on 08/01/2020 and weighed 125 pounds on 09/03/2022 which was a 9.42% weight loss in one month. The progress notes for August and September 2020 were reviewed. A nurse's note dated 09/03/2020 at 9:52 A.M. documented, Note Text: Ate 25% or less x 1 day. Alternate meals and snacks offered and accepted. Nursing staff will continue to monitor. There was no evidence the Physician or the Responsible Representative was notified of Resident #103's significant weight loss. A progress note dated 09/17/2020 at 8:26 P.M., documented, Note Text: NP [Nurse Practitioner] notified of thick yellow drainage from right eye. New order given for [MEDICATION(S)] [antibiotic] 0.3% eye drop solution to right eye TID x 5 days [three times a day for 5 days]. There was no evidence the Responsible Representative was notified of eye infection or the new treatment order. On 04/15/2022 at 2:00 P.M., the Director of Nursing (DON) was notified of findings. The DON confirmed she would expect the Physician and Responsible Representative to be notified for changes in condition. The facility staff provided a copy of their policy entitled, Notification for Changes in Condition. Under the header, Policy, an excerpt documented, Changes may include but are not limited to accidents, incidents, transfers, changes in overall health status, significant medical changes . In Section II(a), it was documented, When a change in condition is noted, the nursing staff will contact the resident representative. In Section III(b)(c), it was documented, The attending practitioner must be immediately notified of significant changes in condition, and the medical record must reflect the notification, response, and interventions implemented to address the resident's condition. The nurse will record in the progress notes, the name of the person called, the time of each attempt to contact, and the telephone number attempted. On 04/15/2022 at approximately 4:30 P.M., the administrator indicated there was no further information or documentation to submit.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to provide the assistance of 2 staff persons for a transfer, instead using one person transfer for 2 residents (Resident # 2 and # 4) resulting in harm for one Resident (Resident # 4) who sustained a fall and fracture of the leg. And the facility staff failed to apply a bed alarm for one resident (Resident # 16) all in a survey sample of 23 residents. 1. For Resident #2, the facility staff failed to provide the assistance of two staff persons for a transfer from the wheelchair to bed. 2. For Resident #4, the facility staff failed to provide the assistance of 2 staff persons for a transfer from the bed to the wheelchair, resulting in a fall and fracture of the leg. 3. For Resident #6, the facility staff failed to apply a fall alarm per physician's orders [REDACTED]. The findings included: 1. For Resident #2, the facility staff failed to perform a two person transfer for Resident #2, instead using a one person transfer from the wheelchair to bed. Resident #2, a [AGE] year-old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #2's most recent MDS (minimum data set) with an ARD (assessment reference date) of 8/3/2017 was coded as a Quarterly assessment. She was coded as having short and long term memory deficits, severe cognitive impairments. She was also coded as needing extensive to total assistance of one person to perform all of her activities of daily living with the exception of transfers. For transfers, she was coded as needing total assistance of two staff members. She was coded as always incontinent of bowel and bladder. On 9/19/2017, Resident # 2's clinical record was reviewed. Review of the Nurse's Notes revealed entries: 8/9/2017 17:15 (5:15 p.m.) Called to room by CNA (Certified Nursing Assistant) ____. Stated Res.(Resident) right hand was swollen and Res. was guarding and protecting her right hand. Upon assessment res. noted alert and verbally responsive, right hand at wrist area warm to touch, bruising to hand and forearm edema to hand. Res. pulls away when assessment performed, right hand elevated on pillow res. medicated for pain. Physician notified orders received continue to observe. Documentation revealed that on 8/9/2017 at 5:30 p.m., the clinician ordered an X-ray of Resident # 2's right hand. The X-ray was obtained 8/10/2017 at 2:15 a.m. and Resident #2 was determined to have a spiral fracture of the distal third of the ulna. The facility began an investigation into the injury of unknown origin, her fractured ulna. The investigation was unable to determine the cause of the injury and unable to substantiate abuse. Review of the investigation revealed a statement from the CNA (certified nursing assistant) (CNA F) that cared for Resident #2 during the 7-3 shift of 8/9/2017 provided ADL (Activities of Daily Living) care throughout the day who stated she did not notice any injuries during her shift. Review of the Witness statement from CNA F (typed by Director of Nursing and signed by the witness on 8/11/2017) included statements: I work with _________ on Wednesday, August 8/9/17 on the 7-3 shift. I gave her a bath in bed in the morning. I didn't notice anything. I got her up and put her in the chair for breakfast. She rolled around in her wheeled chair. About 2:20 I put her back in the bed. I put her side rails up and pull her blanket over her. When interviewed, the DON stated the CNAs have a Kardex for each Resident that provides guidance for their needs. The facility staff was asked to provide a copy of the Kardex. Review of the MDS assessment in effect during August, 2017 revealed Resident # 2 required a two-person total assist for transfers and one person extensive assist for bed mobility. On 9/19/2017 at 4:02 p.m., the CNA F was interviewed by the surveyor in the presence of the Director of Nursing and three other surveyors in the facility conference room. CNA F stated she remembered taking care of Resident # 2 on 8/9/2017 during the day shift. CNA F stated she put Resident # 2 to bed at the end of the shift by herself. CNA F stated Resident # 2 did not have any problems or swelling noted on her right arm when she last saw her. CNA F stated she was trained to transfer Resident # 2 using one person because of her size. CNA F stated Resident # 2 was small and could be transferred by one person. CNA F stated she did not know the MDS coded Resident # 2 has needing 2 staff persons to transfer. CNA F stated she did not know what was written on the CNA Kardex. CNA F again stated she had taken care of Resident# 2 and was trained to transfer the resident by herself. On 9/19/2017 at 4:10 p.m., CNA B was observed in the hallway near Unit 1. An interview was conducted with CNA who stated she worked on Unit 1 and was familiar with Resident # 2. CNA B stated it required 2 people to transfer Resident # 2. The CNA Kardex for Resident # 2 was not in the book designated for Unit 1. The facility staff stated they did not know where the CNA Kardex for Resident # 2 was located. On 9/19/2017 at 4:15 p.m., an interview was conducted with the Unit Manager on Unit 1 (LPN A) who stated Resident # 2 required 2 people to transfer. The investigation indicated the CNA had transferred Resident #2 from her wheelchair back to bed by herself. On 9/19/2017 at 5 p.m., the administrator and DON were informed of the failure of the staff to perform a two person transfer for Resident #2, instead using a one person transfer. During the end of day debriefing on 9/19/2017, the facility Administrator was informed that CNA F was interviewed earlier that day and told the surveyors and Director of Nursing that she transferred Resident # 2 by herself as she had been shown during her orientation by another CNA. On 9/20/2017 at 4 p.m., an interview was conducted with the Director of Nursing who stated CNA F told her that she used a Stand and Pivot technique to transfer Resident # 2 by herself. The DON was asked if she was aware that the MDS dated [DATE] coded Resident # 2 as requiring total assist of two staff persons for transfers. The DON stated she did see that on the MDS. On 9/21/2017 at approximately 1:00 p.m., three copies of the CNA Kardex were presented. Two copies were labeled with a print date of 9/18/2017. One form had handwritten on the right of the form Transfer 2 assist. Another copy of the CNA Kardex was presented to the surveyor with a print date of 9/21/2017. The categories generated by the computer were Safety, toileting, personal hygiene/oral care, mobility, monitoring, bathing, dressing, resident care and transferring. Under transferring was written by computer Requires 2 assist for transfers. This copy had the web address of the computer system written at the bottom of the page and dated 9/21/2017. There was no explanation for why the CNA Kardex had been unavailable during the first days of survey. Facility staff stated they could not find it. The DON presented a handwritten note on 9/21/2017 at 9 a.m. that was dated 9/20/2017 and stated during her interview with CNA F, she stated that she stand Pivot with one person assist for Resident # 2 and the note was signed by the DON. During the end of day debriefing on 9/21/2017, the facility administrator and DON were informed of the failure of the staff to perform a two person transfer for Resident #2, instead using a one person transfer. No further information was provided. 2. For Resident #4, the facility staff failed to provide the assistance of 2 staff persons for a transfer from the bed to the wheelchair, resulting in a fall and fracture of the left leg, which is harm. Resident #4 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #4's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 6/7/17, coded Resident #4 as having a Brief Interview of Mental Status Score of 7 - indicating severely impaired cognition. For transfers, she was coded as requiring the extensive physical assistance of two persons. In the area of functional limitation in range of motion, she was coded as having lower extremity impairment on both sides. Her mobility device was a manual wheelchair. On 9/19/17 a review was conducted of facility documentation, revealing Resident #4's Care Plan, which read, Initiated 3/9/10. Revised 7/18/17. I am at risk for and have had an actual fall related to: Cognitive impairment with decreased safety awareness. I am easily distracted and have poor insight/judgement. I am incontinent and I am dependent for ADLs (Activities of Daily Living). Assist resident with all transfers. The Care Plan had not been revised to include the requirement of the extensive physical assistance of two persons for transfers. On 9/19/17 a 8:30 A.M., an observation was conducted of Resident #4, who was in her bed. When asked about how her leg was feeling, Resident #4 smiled and appeared to be confused. Suddenly, her roommate who was identified and put into the sample as Resident #1, made an unsolicited statement. She said, One of the aides named Carolyn (CNA A) came in here by herself and dropped her on the floor while putting her in her wheelchair. She slipped out of her hands and fell on the floor. She broke her leg and went to the hospital. She came back here with a leg brace on, and had it on for a month and a half. Resident #1's Brief Interview of Mental Status Score was 14, indicating no cognitive impairment. She was also coded as having adequate vision and hearing. Resident #4's clinical record contained the following x-ray report, 6/28/17 10:23 A.M. Findings: Four views of the left knee. Proximal tibia displaced metaphyseal and impacted plateau fractures, are partially obscured by severe tricompartmental osteoarthritis with large osteophytes and loss of joint space. Effusion. On 9/19/17 a review of facility documentation was conducted, revealing a Facility Reported Incident on 6/29/17. It read, Injury of Unknown Origin. Resident assessment revealed left tibia plateau fracture. Documents reveal resident had a fall on 6/25/17. Investigation pending. On 7/3/17, the facility follow-up read, Upon investigation, June 25, 2017, (CNA A - Certified Nursing Assistant) transferred (Resident #4) from the bed to the wheelchair. According to the report, only one staff member conducted the transfer instead of two. CNA A's signed statement (dated 6/25/17) read, I set her down in the chair. I walked away. I heard a noise. I turned around I saw resident body in front of wheelchair Resident butt was on the floor in between the leg rest. The leg rest was extended. Resident left leg was under her butt. This incident occurred during the day shift a 7:50 A.M. The clinical record contained the following Nursing Progress Note, 6/25/17/ 10:51 P.M. Resident resting in bed, respirations unlabored, lung fields clear, no coughing or congestion noted. No dizzy spells noted. Bed in lowest position, call bell in reach. Staff monitoring Q 2 hours. For the next three days, until 6/28/17 there was no further post-fall monitoring (7 continuous shifts). On 6/28/17 the Nursing Progress Note read, Vital signs 99.2-90-22-138/86-96%. Resident noted with edema to left knee and lower leg bruising present to lower leg. Resident C/O (complains of) pain when touched, will not allow CNA to dress her. Resident medicated for pain Tylenol Tabs 2 PO (by mouth) for left leg pain. DR (doctor) made aware STAT x-ray of left FIB TIB and left knee (left lower leg). Resident #4 was admitted to the hospital at 7:00 A.M. and returned to the facility at 6:45 P.M. New orders for pain medication, use of knee immobilizer, and no weight bearing to left leg were given by the resident's MD at the facility. The nursing Progress note read, SRMC (hospital) called report. No surgery indicated at this time because its to extensive. Keep knee immobilizer in place. On 9/19/17 at 4:05 P.M., an interview was conducted with CNA A in the conference room. The Director of Nursing, who had conducted the investigation, was present. When asked why she transferred Resident #4 without the assistance of another staff member, CNA A stated, The way I was trained the person demonstrated that the resident needed only 1 person for transfers. When CNA A was informed that Resident #1 witnessed the fall, she admitted that Resident #1 was in the room, but said that the curtain was pulled. There was no documentation that the curtain had been pulled. When the Director of Nursing was asked why Resident #1 wasn't interviewed regarding the fall, she stated, Because I didn't know that she was in the room and I didn't ask. On 9/19/17 at 5:00 P.M. the facility Administrator (Administration A) was notified of the findings. On 9/20/17 the Administrator submitted following Petersburg Plan of Correction; Findings: Facility failed to properly investigate two injuries of unknown origins. The facility failed to interview all potential witnesses. Resident: (#4) fell on [DATE], and on 6/28/17 diagnosed wit a left knee fracture. Resident: (#2) diagnosed with [REDACTED]. 100% of residents with hi risk for injuries related to falls were reviewed to ensure proper transfers were being performed. The Plan of Correction also stated that all facility residents were assessed for proper transfer techniques and initiated on 9/19/17. Nursing staff were in-serviced. In addition, CNA A had been suspended pending investigation, and had subsequently resigned. The Plan also stated that all department heads were in-serviced on the proper way to complete an investigation. The following day, on 9/20/17, another resident who was identified and placed in the sample as Resident #16, was also transferred with 1 staff instead of 2, utilizing a hoyer lift. Resident #16 was an [AGE] year old who as admitted to the facility on [DATE]. Resident #16's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 7/3/17, coded Resident #16 as having a Brief interview of Mental Status Score of 13, indicating that he was independent in decision making ability. He was also coded as requiring the extensive physical assistance of two staff persons for transfers, having functional limitation of both legs, and requiring a wheelchair for mobility. The Administrator and Director of Nursing were present when the surveyor confirmed the improper transfer with Resident #16, who was cognitively intact. Resident #16 stated that CNA D used a hoyer lift to transfer him by herself from his bed to his wheelchair. The Administrator later reported that CNA D had received disciplinary action for performing an improper transfer after being inserviced the previous day. 3. For Resident #6, a Resident with a fall history, and a fall risk, the facility staff failed to apply a physician ordered fall alarm from 9:00 a.m. to 1:00 p.m. on 9-19-17. Resident #6 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 6-22-17. The MDS coded Resident #6 with severely impaired cognition, and requiring extensive assistance from staff for all activities of daily living. On 9-19-17, beginning at 9:00 a.m. observations of the Resident were completed up until 1:00 p.m. Resident #6 was observed laying in a low bed with a scoop mattress, pads on the floor of both sides of the bed, a padded foot board on the bed, and wedges on top of and under the mattress for Resident positioning. The Resident was awake, alert, non-verbal, and kicking her legs over the side of the bed almost continuously. On one occasion the Resident was halfway out of the bed, with her legs completely out of the bed, and the Resident's buttocks were on the edge of the bed. A staff member followed the surveyor into the room and repositioned the Resident. On 9-19-17 Resident #6's clinical record was reviewed. The review revealed physician's orders [REDACTED].>12-5-16 personal bed alarm every shift. No bed alarm was applied to the Resident for 4 hours on 9-19-17 until after the 1:00 p.m. observation. Surveyors returned to the facility at 2:00 p.m., and a bed alarm was in place on the Resident at that time. The Resident's care plan was reviewed and included the bed alarm in the interventions for Fall Risk . The facility policy titled Treatment Administration was reviewed, and revealed the following: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. The purpose of this policy is to provide guidance for the process for providing monitoring that all treatments are received and administered in a timely manner. The facility Director of Nursing (DON) stated Lippincott as the facility reference for nursing standards. Both medication and treatment administration policies from the facility followed the standard. On 9-19-17, 9-20-17, and 9-21-17 at the end of day debriefs, the Administrator and Director of Nursing were informed of the failure of staff to apply the fall alarm to Resident #6 for 4 hours on 9-19-17. This omission presented a hazard, and accident precursor for Resident #6. The facility provided no further information.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure two (Residents #7 and Resident #14) of 23 residents in the survey sample, were free from significant medication errors. Resident #7's medication error resulted in harm. 1. For Resident #7, the facility staff administered the wrong insulin causing the Resident to be hospitalized for [REDACTED]. 2. Resident #14 received two different doses of the medication [MEDICATION NAME] (ordered for the treatment of [REDACTED]. When the physician was notified on 9/21/17 that the original order for [MEDICATION NAME] 125 mg (milligrams) had not discontinued at the time 250 mg was ordered, the physician discontinued the 125 mg order. The findings included: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7's most recent MDS (minimum data set) with an ARD (assessment reference date) of 7-3-17 was coded as a significant change assessment. Resident #7 was coded as having memory loss, and severe cognitve loss. Resident #7 was coded as requiring extensive assistance to total dependence on one to two staff members for all ADL's (activities of daily living), and always incontinent of bowel with a Foley urinary catheter for bladder elimination. On 9-19-17 a thorough review of the resident's clinical record was conducted. Nursing progress notes were reviewed and revealed the following; On 6-20-17 at 12:55 p.m. the Resident was cold/clammy/diaphoretic with a blood sugar of 31. The note goes on to state that the Resident received a subcutaneous injection of [MEDICATION NAME] in her left upper arm by Registered Nurse (RN) B. On 6-20-17 at 3:03 p.m. a nursing note by Licensed Practical Nurse (LPN) F described that the Resident had a blood sugar reading of 34 at 2:00 p.m., as the doctor ordered the blood sugar recheck in 1 hour after the [MEDICATION NAME] given at approximately 1:00 p.m. (12:55). At 3:00 p.m. LPN F documented that the Resident's blood sugar was 158, and at 3:30 it was documented by her as 138 milligrams/deciliter (mg/dL). On 6-20-17 at 5:25 p.m., the Resident was sent to the hospital via 911 to the emergency room (ER) for evaluation of [DIAGNOSES REDACTED], by the 3p-11p shift nurse, and facility staff documented in the nursing notes that the Resident's blood sugar was 116 at the time of transfer. This does not agree with the hospital records of transfer. Review of hospital emergency room records revealed that EMS (emergency medical services) ambulance reported to the hospital that they administered oral [MEDICATION NAME] to the Resident, and after administration, the Resident's blood sugar was now 78, at 5:39 p.m., (15 minutes after the facility note), and at the time of transfer. Further review of the hospital record revealed that at 7:16 p.m., on 6-20-17, the Resident's blood sugar had again dropped to 46, and by 11:00 p.m. it had gone up to 79, after intravenous (IV) [MEDICATION NAME] 10% 1000 ml (milliliters) was given and [MEDICATION NAME] 5% 1000 ml to include sodium chloride and potassium chloride was given. The Resident was admitted to the hospital and remained for 7 days, until 6-26-17, when she was returned in the evening, to the facility. Interviews were conducted on 9-19-17, and 9-20-17 with the Administrator and Director of Nursing (DON) with regard to this situation. They stated that the Resident had received 18 units of regular rapid acting (Humalog) insulin at 9:00 a.m., on 6-20-17, instead of the ([MEDICATION NAME] N) [MEDICATION NAME] long acting insulin, which was ordered to be given at that time. Prior to the administration of the wrong insulin, the Resident's blood sugar at 6:00 a.m., was 82. Review of physician's orders [REDACTED]. 1. [MEDICATION NAME] (N) long acting insulin, inject 18 units subcutaneously every 12 hours for diabetes at 9:00 a.m., and 9:00 p.m. 2. Humalog ([MEDICATION NAME]) rapid acting insulin, inject as per sliding scale every 6 hours; at 12 midnight, 6:00 a.m., 12:00 noon, and 6:00 p.m. if blood sugar is 351 to 400 give 20 units subcutaneously, if 401 to 450 give 25 units, if 451 to 500 give 30 units, if 501 to 502 give 35 units and call doctor. If blood sugar less than 60 or greater than 501 call doctor. The Administrator and DON went on to state that the nurse (LPN F) who had given the wrong insulin had not realized the error until another nurse (RN B), stumbled upon it. RN B went into Resident #7's room at lunch time, saw the Resident, and asked what medication (LPN F) had given to the Resident. The medication nurse (LPN F) went to the medication cart, and showed (RN B) the vial of regular insulin. RN B validated the series of events as correct in a written statement. The nurse who made the error was terminated, and unavailable for interview. At the time of the incident, the administrator was not the same individual acting as administrator at the time of survey, and so the current Administrator could only answer as to the information left by the former Administrator. The Resident's care plan was reviewed, and revealed interventions for administering medications as ordered, labs as ordered, and with changes in condition/manifestation of clinical signs or symptoms, and to observe for low blood sugar symptoms of sweating, flushing, change in mental status, lethargy, etc. The nursing staff notes revealed that no assessments occurred from 9:00 a.m., until 12:55 p.m. when the Resident was in severe distress and the 12:00 p.m. blood sugar reading taken by RN B revealed a critical level of 31. The facility medication management policy was reviewed, and revealed that all current standards and requirements were in place for medication administration within the documents. An excerpt of that policy follows: The facility policy entitled Medication Administration with a review date of 4-20-17 included: .II. Safety Precautions: a. Observed the five rights for administration i. the right resident ii. the right time iii. the right medicine iv. the right dose v. the right method of administration . .III. Basic Safety in Administration a. Medication i. Read labels multiple times comparing to MAR 1. Review original physician order [REDACTED].> a. Do not provide if discrepancies continue . Guidance is given for Professional standards, such as the American Nurses Association's Nursing : Scope and Standards of Nursing Practice (2004), which apply to the activity of medication administration and treatment 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. Same source, p. 707, A medication order is required for every medication or treatment you administer to a client .Regardless of how you receive an order, compare the prescriber's written orders with the Medication Administration Record [REDACTED]. Verify medication information whenever new MARs are written or distributed or when clients transfer from one nursing unit or health care setting to another. Once you determine that information on the client's MAR indicated [REDACTED]. The previous Administrator sent a Facility Reported Incident (FRI) to the state agency on Wednesday 6-21-17, and a follow up report on Tuesday 6-27-17 in regard to the serious medication error. Both were late. The Resident was admitted to the hospital on Tuesday 6-20-17 for [DIAGNOSES REDACTED], and the initial report should have occurred (within 2 hours of hospitalization ) the same day. The follow up 5 day report should have occurred no later than 6-26-17, the 5th business day. The investigation showed no realization that the same orders which produced the error were reinstituted when the Resident returned from the hospital. The [MEDICATION NAME] N (long acting) insulin was decreased, and administration time was changed to avoid confusion in the orders on 7-1-17, 5 days after the Resident returned, and the Regular humalog sliding scale insulin was continued as before. No re-education of staff was included in the investigation packet reviewed by surveyors, and was not provided by administration as evidence of re-training. Other instances of issues were found during this survey with regard to administration of insulin within the facility, and those are documented in other deficiencies, contained within this survey statement of deficiencies (SOD) report. In conclusion, the investigation, reporting, and education, for this incident were not completed as required by federal mandate. The current Administrator and DON were made aware of the harm level deficient practice for this Resident with regard to insulin administration at the end of day debriefs on 9-20-17, and 9-21-17. No further information was presented by the facility. 2. Resident #14 received two different doses of the medication [MEDICATION NAME] (ordered for the treatment of [REDACTED]. When the physician was notified on 9/21/17 that the original order for [MEDICATION NAME] 125 mg (milligrams) had not discontinued at the time 250 mg was ordered, the physician discontinued the 125 mg order. Resident #14 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 6/28/17. The MDS coded Resident #14 with moderately impaired cognition; required extensive assistance from staff for transfers, dressing, toileting, and hygiene. On 9/20/17 at 1 p.m. Resident #14 was observed sitting in a wheelchair in her room. She was alert and conversational. Resident #14 stated lunch was great and stated her sister will be coming in for church services that day. Resident #14 did not display and negative behaviors or symptoms of depression. On 9/20/17 at 2:30 p.m. Resident #14's clinical record was reviewed. The review revealed physician's orders [REDACTED].>1/9/17 [MEDICATION NAME] Sprinkles Capsule Delayed Release 125 mg Give 1 capsule by mouth two times a day related to Major [MEDICAL CONDITION] and 2/22/17 [MEDICATION NAME] Delayed Release 250 mg Give 1 tablet by mouth two times a day related to Major [MEDICAL CONDITION]. Both the 125 mg and 250 mg orders were listed and signed as administered on the Medication Administration Record [REDACTED]. On 9/20/17 at 4 p.m. the Administrator and Director of Nursing were informed of the [MEDICATION NAME] orders. The pharmacy review sheet and physician notes were requested. On 9/21/17 at 9:30 a.m. the [MEDICATION NAME] orders on the MAR indicated [REDACTED]. LPN-B showed surveyor the opened and empty medication package which revealed Resident #14 received both the 125 mg and 250 mg of [MEDICATION NAME]. It was discussed with LPN-B and RN-B that when the medication was increased to 250 mg that the 150 mg was not discontinued. Clarification whether the physician wanted both orders or not was requested. On 9/21/17 at 11:00 a.m., RN-B stated she called the doctor and he discontinued the 125 mg of [MEDICATION NAME]. When asked what should have been done, RN-B stated nursing and pharmacy should have clarified it. Facility policy titled Medication Administration with a reviewed date of 4/20/17 included: .II. Safety Precautions: a. Observed the five rights for administration i. the right resident ii. the right time iii. the right medicine iv. the right dose v. the right method of administration . .III. Basic Safety in Administration a. Medication i. Read labels multiple times comparing to MAR 1. Review original physician order [REDACTED].> a. Do not provide if discrepancies continue . Physician notes that were reviewed did not have documented evidence that Resident #14 was to receive both 125 mg and 250 mg of [MEDICATION NAME]. A [MEDICATION NAME] Acid level (a blood test to monitor the levels of [MEDICATION NAME] circulating in the blood) laboratory result dated 7/11/17 was observed in the record which was within normal range. Physician orders [REDACTED]. Review of the pharmacy Medication Regimen Review Summary and Pharmacy Review progress notes from 2/23/17 through 9/12/17 did not have any medication irregularities documented. On 9/21/17 at 1:05 p.m. the Administrator and Director of Nursing were informed of the failure to clarify the [MEDICATION NAME] orders which resulted in unnecessary medication administration and significant medication error. No further information was provided by the facility staff.

Based on observation, staff interview, facility documentation and clinical record review, and in the course of a complaint investigation, the facility failed for two residents (Resident #202 and Resident #209) to implement fall prevention interventions, resulting in harm for Resident #202. 1. For Resident #202, the facility failed to implement a therapy screen and a toileting plan, as well as non skid footwear, resulting in a fall with fracture while toileting without assistance in regular socks. 2. Resident #209 did not have recommended post fall interventions of keeping the bed in low position and adding two half side rails. The findings included: 1. For Resident #202, the facility failed to implement a therapy screen and a toileting plan, as well as non skid footwear, resulting in a fall with fracture while toileting without assistance in regular socks. Resident #202 was admitted to the facility on [DATE], and was readmitted on [DATE] after a fall with fracture. Resident #202's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a quarterly assessment done prior to the fall with fracture, with an Assessment Reference Date of 8/4/16, coded Resident #202 as having a Brief Interview of Mental Status (BIMS) Score of 5 out of a possible 15, indicating severe cognitive impairment. The resident was coded as not having walked on or off the unit and was using the wheelchair for locomotion off and on the unit with standby assistance of one staff member. The resident was coded as being not steady moving between sitting and standing and surface to surface transfers with the resident requiring staff to steady during transfers. There were no observation of the resident during the days of survey as the resident was at a physician's appointment on 11/15 16 and was admitted to the hospital from the physician's office that evening. Review of the clinical record revealed the resident sustained [REDACTED]. The resident required surgery to correct the fracture. Fall risk assessments were conducted on 1/15/16 (admission), on 8/12/16, and on 11/2/16. The scores, respectively, were 8 (above 10 deemed resident at risk), 9, and 9. Review of the care plan prior to the fall with fracture, dated 1/29/16 (no new fall interventions added since 1/29/16). The resident was care planned for At risk for falls related to history of falls, dementia, bipolar, dependent for transfers and mobility. Interventions included: · Assess for pain · Bed in low position · Call light or personal items available and in easy reach or provide reacher · Contour mattress · Observe for side effects of medications · Therapy referral Review of the facility's fall investigations and post fall analysis revealed the following: · 2/3/16 at 3:00 AM: found supine on floor between wall and hallway door. The resident was wearing regular socks and it was recommended to wear non skid socks. · 8/3/16 at 11:42 PM, found sitting on floor in front of toilet in his bathroom. A therapy screen was done and the resident was on a restorative program for active range of motion and ambulation. · On 9/29/16 at 2:21 PM, the resident was found sitting on the floor in the shower room, trying to get to the bathroom. A therapy screen was recommended as well as offer the resident toileting every two hours. · On 11/16/16 at 10:00 AM, the DON (director of nursing) stated the unit manager was supposed to order a therapy referral and to initiate toileting every two hours. It was not done (the referral to therapy and every two hour toileting). · On 10/26/16 at 2:00 AM, the resident was found sitting on the bathroom floor in front of the toilet. Resident stated he had to use the bathroom. The resident was wearing regular socks. The recommendations were to use a bed and chair alarm, and gripper (non skid) socks. The resident was quickly sent to the hospital and a right hip fracture was diagnosed with [REDACTED]. On 11/16/16 at 10:30 AM, an interview with CNA (certified nursing assistant) A was conducted. CNA (A) stated, All ADL's (activities of daily living-dressing, toileting) are total (requiring all care to be done by staff). She stated the resident did not walk and required two staff members to get him out of bed. On 11/16 16 at approximately 12:00 PM, the Administrator and DON were notified of a harm level deficiency for this resident. A four point POC (plan of correction) was submitted by the DON. The initial inservice was done on 11/1/6. 100% audits were not completed (twenty one days following the fracture)and an AOC (allegation of compliance) date of 11/25/15 was included. However, another resident (Resident #209) was found not to have had fall interventions of adding 1/2 side rails to the bed and keeping the bed in low position during the days of survey. 2. Resident #209 did not have recommended post fall interventions of keeping the bed in low position and adding two half side rails. Resident #209 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, which was an annual assessment , with an Assessment Reference Date of 9/15/16, coded Resident #209 as having a Brief Interview of Mental Status (BIMS) Score of 9 out of a possible 15, indicating moderate cognitive impairment. The resident was coded as not having walked on or off the unit or having been transferred out of bed during the lookback period. On 11/15/16 at 2:45 PM, Resident #209 was observed in the bed. There were no alarms, side rails, mats and the bed was in a high position. The call bell was in reach. On 11/15/16 at 4:20 PM, the resident was again observed in the bed. The bed was not in a low position. CNA (certified nursing assistant) B was questioned about the bed height. CNA (B) lowered the bed to the lowest position (8 and a half inches from the floor, measured) and was approximately twice the height of the original position. There were no side rails on the bed. On 11/16/16 at 8:55 AM, Resident #209 was observed in bed. The bed was in a low position. On 11/16/16 at 10:30 AM, CNA (A) was interviewed concerning the resident's ADL's (activities of daily living such as toileting and bed mobility. CNA (A) stated, He is total care- needs to be set up for feeding. She stated the Resident did not walk. On 11/16/16 at 11:20 AM, CNA (A) was asked to come into the resident's room. When asked if the resident had any side rails on the bed, CNA (A) stated, No, ma'am. Resident #209 had a fall screen (risk form for determining fall risk) on 7/16/16, which scored the resident with a 15. Above 10 or above deemed the resident to be at risk. The resident's care plan dated 6/28/16 revealed the resident to be At risk for falls related to use of psychotropics, unsteady gait, seizure disorder and history of falls. Interventions included the following: · Activity as resident allows · Administer medications for orthostatic hypotension, Vital signs as ordered per MD order/nursing protocol · Assess that wheelchair is of appropriate size, assess need for footrests, assess for need to have wheelchair locked/unlocked for safety. · Bed in low position · Contour mattress · Encourage resident to call for assistance · Encourage resident to wear shoes when ambulating. · Encourage resident in activity prior to dinner · Keep environment well lit and free of clutter · Monitor for positioning in bed frequently. Remind resident to assure he is positioned correctly at the bedside before attempting to sit down on bed · Personal items available and in easy reach. Encourage me to use call bell for assistance prn (as needed) · Pharmacy to review medications monthly · Psych consult: Therapy working with resident · Rearrange furniture in room for easy access to personal belongings · Remind resident to change position slowly to prevent falls · Staff to round on resident to ensure safety measures are in place as resident allows · Therapy referral as needed/prn There were no new interventions added to the care plan since 1/16/15. Review of the resident's current signed physician orders [REDACTED]. Clinical record review revealed the resident sustained [REDACTED]. The resident was found on the floor beside his bed next to the air conditioner. The resident suffered no injuries. The post fall analysis/plan dated 9/27/16 included the following recommendation to keep bed on low position. An Occupational therapy screen was completed on 9/28/16 and included the following: Patient with recent fall out of bed while reaching for objects from bed; Patient does not have bed rails. Patient needing bed rails for safety and falls prevention to prevent further injury. As of 10/16/16, no side rails were in place. On 11/16/16 at 10:00 AM, the DON (director of nursing) stated the unit manager was supposed to order therapy referrals . It was not done On 11/16/16 at approximately 12:30 PM, the Administrator and DON were notified of above findings. Complaint deficiency

Based on observation, staff interview, facility documentation and clinical record review, and in the course of a complaint investigation, the facility failed for two residents (Resident #202 and Resident #209) to implement fall prevention interventions, resulting in harm for Resident #202. 1. For Resident #202, the facility failed to implement a therapy screen and a toileting plan, as well as non skid footwear, resulting in a fall with fracture while toileting without assistance in regular socks. 2. Resident #209 did not have recommended post fall interventions of keeping the bed in low position and adding two half side rails. The findings included: 1. For Resident #202, the facility failed to implement a therapy screen and a toileting plan, as well as non skid footwear, resulting in a fall with fracture while toileting without assistance in regular socks. Resident #202 was admitted to the facility on [DATE], and was readmitted on [DATE] after a fall with fracture. Resident #202's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a quarterly assessment done prior to the fall with fracture, with an Assessment Reference Date of 8/4/16, coded Resident #202 as having a Brief Interview of Mental Status (BIMS) Score of 5 out of a possible 15, indicating severe cognitive impairment. The resident was coded as not having walked on or off the unit and was using the wheelchair for locomotion off and on the unit with standby assistance of one staff member. The resident was coded as being not steady moving between sitting and standing and surface to surface transfers with the resident requiring staff to steady during transfers. There were no observations of the resident during the days of survey as the resident was at a physician's appointment on 11/15 16 and was admitted to the hospital from the physician's office that evening. Review of the clinical record revealed the resident sustained [REDACTED]. The resident required surgery to correct the fracture. Fall risk assessments were conducted on 1/15/16 (admission), on 8/12/16, and 11/2/16. The scores, respectively, were 8 (above 10 deemed resident at risk), 9, and 9. Review of the care plan prior to the fall with fracture, dated 1/29/16 had no new fall interventions added since 1/29/16. The resident was care planned for At risk for falls related to history of falls, dementia, bipolar, dependent for transfers and mobility. Interventions included: · Assess for pain · Bed in low position · Call light or personal items available and in easy reach or provide reacher · Contour mattress · Observe for side effects of medications · Therapy referral Review of the facility's fall investigations and post fall analysis revealed the following: · 2/3/16 at 3:00 AM: found supine on floor between wall and hallway door. The resident was wearing regular socks and it was recommended to wear non skid socks. · 8/3/16 at 11:42 PM, found sitting on floor in front of toilet in his bathroom. A therapy screen was done and the resident was on a restorative program for active range of motion and ambulation. · On 9/29/16 at 2:21 PM, the resident was found sitting on the floor in the shower room, trying to get to the bathroom. A therapy screen was recommended as well as offer the resident toileting every two hours. · On 10/26/16 at 2:00 AM, the resident was found sitting on the bathroom floor in front of the toilet. Resident stated he had to use the bathroom. The resident was wearing regular socks. The recommendations were to use a bed and chair alarm, and gripper (non skid) socks. The resident was quickly sent to the hospital and a right hip fracture was diagnosed with [REDACTED]. On 11/16/16 at 10:00 AM, the DON (director of nursing) stated the unit manager was supposed to order a therapy referral and to initiate toileting every two hours. It was not done (the referral to therapy and every two hour toileting). On 11/16/16 at 10:30 AM, an interview with CNA (certified nursing assistant) A was conducted. CNA (A) stated, All ADL's (activities of daily living-dressing, toileting) are total (requiring all care to be done by staff). She stated the resident did not walk and required two staff members to get him out of bed. On 11/16/16 at approximately 12:00 PM, the Administrator and DON were notified of a harm level deficiency for this resident. A four point POC (plan of correction) was submitted by the DON. The initial inservice was done on 11/1/16. 100% audits were not completed (twenty one days following the fracture) and an AOC (allegation of compliance) date of 11/25/15 was included. However, another resident (Resident #209) was found not to have had fall interventions of adding 1/2 side rails to the bed and keeping the bed in low position during the days of survey. 2. Resident #209 did not have recommended post fall interventions of keeping the bed in low position and adding two half side rails. Resident #209 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, which was an annual assessment , with an Assessment Reference Date of 9/15/16, coded Resident #209 as having a Brief Interview of Mental Status (BIMS) Score of 9 out of a possible 15, indicating moderate cognitive impairment. The resident was coded as not having walked on or off the unit or having been transferred out of bed during the lookback period. On 11/15/16 at 2:45 PM, Resident #209 was observed in the bed. There were no alarms, side rails, mats and the bed was in a high position. The call bell was in reach. On 11/15/16 at 4:20 PM, the resident was again observed in the bed. The bed was not in a low position. CNA (certified nursing assistant) B was questioned about the bed height. CNA (B) lowered the bed to the lowest position (8 and a half inches from the floor, measured) and was approximately twice the height of the original position. There were no side rails on the bed. On 11/16/16 at 8:55 AM, Resident #209 was observed in bed. The bed was in a low position. On 11/16/16 at 10:30 AM, CNA (A) was interviewed concerning the resident's ADL's (activities of daily living such as toileting and bed mobility. CNA (A) stated, He is total care- needs to be set up for feeding. She stated the Resident did not walk. On 11/16/16 at 11:20 AM, CNA (A) was asked to come into the resident's room. When asked if the resident had any side rails on the bed, CNA (A) stated, No, ma'am. Resident #209 had a fall screen (risk form for determining fall risk) on 7/16/16, which scored the resident with a 15. Above 10 or above deemed the resident to be at risk. The resident's care plan dated 6/28/16 revealed the resident to be At risk for falls related to use of psychotropics, unsteady gait, seizure disorder and history of falls. Interventions included the following: · Activity as resident allows · Administer medications for orthostatic hypotension, Vital signs as ordered per MD order/nursing protocol · Assess that wheelchair is of appropriate size, assess need for footrests, assess for need to have wheelchair locked/unlocked for safety. · Bed in low position · Contour mattress · Encourage resident to call for assistance · Encourage resident to wear shoes when ambulating. · Encourage resident in activity prior to dinner · Keep environment well lit and free of clutter · Monitor for positioning in bed frequently. Remind resident to assure he is positioned correctly at the bedside before attempting to sit down on bed · Personal items available and in easy reach. Encourage me to use call bell for assistance prn (as needed) · Pharmacy to review medications monthly · Psych consult: Therapy working with resident · Rearrange furniture in room for easy access to personal belongings · Remind resident to change position slowly to prevent falls · Staff to round on resident to ensure safety measures are in place as resident allows · Therapy referral as needed/prn There were no new interventions added to the care plan since 1/16/15. Review of the resident's current signed physician orders [REDACTED]. Clinical record review revealed the resident sustained [REDACTED]. The resident was found on the floor beside his bed next to the air conditioner. The resident suffered no injuries. The post fall analysis/plan dated 9/27/16 included the following recommendation to keep bed on low position. An Occupational therapy screen was completed on 9/28/16 and included the following: Patient with recent fall out of bed while reaching for objects from bed; Patient does not have bed rails. Patient needing bed rails for safety and falls prevention to prevent further injury. As of 10/16/16, no side rails were in place. On 11/16/16 at 10:00 AM, the DON (director of nursing) stated the unit manager was supposed to order therapy referrals . It was not done On 11/16/16 at approximately 12:30 PM, the Administrator and DON were notified of above findings. Complaint deficiency

Based on observation, resident interview, staff interview, facility documentation review, and clinical record review the facility staff failed for 1 resident (Resident #1) of 22 residents in the survey sample to ensure a pressure wound on the right heel was identified prior to unstageable resulting in harm and failed to ensure treatment interventions (calcium alginate for the control of wound drainage, heels up cushion and air mattress) were in place. The findings included: Resident #1, a [AGE] year old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #1's most recent Minimum Data Set assessment was a 30 day assessment with an assessment reference date of 7/20/16. Resident #1 had a Brief Interview of Mental Status score of 14 indicating no cognitive impairment. For bed mobility, Resident #1 was coded 3/3 (extensive assistance, 2+ persons physical assist). For bathing, Resident #1 was coded as 4/2 (total dependence, 1 person physical assist). Resident #1 was coded to be at risk for pressure wound development. She was not coded to have any wounds at the time of assessment. On 8/30/16, Resident #1 was identified to be on contact precautions for [MEDICAL CONDITION] infection in the right heel wound. Due to issues observed with the implementation of contact precautions, Resident #1 was added to the survey sample. Her documented wounds were reviewed in the clinical record. On 6/22/16, a Clinical Health Status assessment was performed upon Resident #1's admittance to the facility. Section B asked the question Is there a foot ulcer now? N was checked for both the right and left feet. It was documented that a callous was present on the right heel. The section titled Risk Category indicated that Resident #1 had No loss of protective sensation. A Braden Scale for Predicting Pressure Sore Risk was included in the assessment. Resident #1's risk was calculated as 18 indicating she was At Risk for developing a pressure sore. On 8/30/16 at 4:05 p.m., Resident #1's feet were observed elevated using a heels up cushion. The special mattress was unplugged at the pump attached to the foot of the bed. The plug laid on the floor. Resident #1 stated that her feet hurt. Certified Nursing Assistant B (CNA B) was asked to enter the room and assess the mattress. CNA B stated that the mattress was not plugged in or turned on. While the heels up cushion was in place on 8/30/16, Resident #1's heels were observed flat on the bed on two occasions during the wound observation, on 8/31/16 at 1:28 p.m. and 3:04 p.m. See observation notes below. According to the manufacturer's instructions provided by the facility staff, a heels up cushion is designed to provide more elevation to patients suffering with severe heel pressure ulcers. The diagram included in the instructions shows the cushion positioned between the Achilles area and the knee. When positioned correctly, the heels do not contact the mattress. Resident #1's skin assessment and wound tracking information was reviewed. A Weekly Skin Review form was completed on 8/9/16. The skin condition was documented as skin intact. The Weekly Skin Review dated 8/17/16 indicated Resident #1 had a new open area. The form read Resident presents with pressure wound to left upper sacrum- stage 2, Bilateral pressure pressures (sic)- both unstageable; [MEDICAL CONDITION] to bilateral feet. The 8/17/16 note was signed by the Director of Nursing (DON) on 8/31/16. A Wound Evaluation Flow Sheet Multiple Weeks was started on 8/17/16. It was signed by Registered Nurse C (RN C). The section titled Wound Evaluation Week 1 read Site: right heel, Type: pressure, Length: 4.2, Width: 4.0, Depth: blank, Stage; unstageable. Section 3 read, When was the wound identified?: 8/17/16. Section 4 read wound type: Pressure Ulcer (in-house acquired). The wound was documented to have a small amount of thin, serosanguineous exudate. The wound bed was documented to be yellow with 95% slough and 10% necrotic tissue and have undefined wound margins. The Current Wound Status/ Additional Comments section read New wound. Open wound with yellow/tan bed. Wound consult/wound culture ordered. Rp (responsible party) aware. The Wound Evaluation Flow Sheet Multiple Weeks included definitions for the staging of wounds. Unstageable was defined as Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. On 8/30/16, wound tracking in the electronic clinical record was reviewed. According to documentation, wound tracking was completed on 8/17/16, 8/23/16, and 8/30/16. The facility staffs were asked on three occasions to provide copies of the tracking for the above dates. During the afternoon of 8/31/16, wound tracking was provided. The wound information in the copies provided for the dates of 8/23/16 and 8/30/16 had been changed from the original documentation reviewed in the electronic clinical record. On 8/31/16 at 4:15 p.m., the DON stated that she had changed the information in the wound tracking. The alteration of the clinical record is addressed in the F281 citation. The wound was documented in the nursing notes. The note read 8/17/16, 12:44 Skin assessment performed. Dry skin to lower extremities and ulcers noted to bilateral lower extremities. Treatments in place, may have wound consult. RP (responsible party) and resident aware of alteration in skin integrity. On 8/17/16, the nurse practitioner documented the following note New wound on R (right) heel, facility orders for [MEDICATION NAME] + wound physician consult made. A wound consult was completed on 8/22/16. The Wound Care Specialist Initial Evaluation note read At the request of (doctor name), this [AGE] year old female was seen and evaluated today. She presents with an unstageable (due to necrosis) of the right heel of at least 1 day duration. The right heel wound measurements documented read 4 x 4 x Not Measurable cm (centimeter). The wound was described to have moderate serous exudate, 75% necrotic tissue and 25% granulation tissue. Dressing read Santyl- once daily, Foam- once daily, calcium alginate- once daily. Recommendations read float heels in bed, off-load wound, reposition per facility protocol. On 8/29/16, the wound care specialist evaluated Resident #1. The wound was documented to measure 3.5 x 3.5 x not measurable. The wound was described to have moderate sero-sanguinous exudate, 70% necrotic tissue and 30% granulation tissue. The wound was debrided to remove necrotic tissue. The wound progress was documented as improved. Dressing read Santyl- once daily, Foam- once daily, Calcium Alginate- once daily. Wound treatment orders and the August 2016 Treatment Administration Record (TAR) were reviewed. They read as follows: - 8/17/16: Cleanse right heel ulcer with normal saline/wound cleanser, apply medi honey and foam dressing daily and as needed every day shift. TAR: This treatment was not signed as completed on 8/18/16. According to the TAR documentation, the treatment was first completed on 8/19/16. -8/23/16: Santyl Ointment, Apply to right heel topically every day shift for Wound Care Cleanse wound to Right heel with 4x4 gauze and n/s (normal saline), pat dry and apply santyl ointment and cover with Foam Dressing QD (every day). TAR: According to the TAR, this order was first completed on 8/24/16. Note: this order originated from the wound care specialist visit on 8/22/16. The order was implemented 2 days after it was originally ordered and does not include calcium alginate as specified in the wound care specialist orders on 8/22/16 and 8/29/16. During a wound care observation on 9/1/16, calcium alginate was not applied to the wound as ordered. See below for detailed wound care observation notes. The Care Plan was reviewed. Included was a plan for skin integrity dated 7/1/16. The plan included a focus dated 8/17/16 that addressed the unstageable pressure ulcer to the right heel. Interventions dated 7/1/16 included weekly skin inspections, diabetic foot monitoring, pressure relieving mattress, treatments as ordered. Interventions dated 8/17/16 included consults as indicated, encourage float heels while in bed (heel pad). Also included was a care plan dated 7/1/16 for physical functioning deficit related to: self care impairment. Interventions included bed mobility assistance as needed, dressing assistance as needed, inspect skin with care. Report reddened areas, rashes, bruising, or open areas to charge nurse, locomotion assistance as needed, monitor and report changes in ROM (range of motion) ability. Resident #1's bathing record was reviewed. She received bathing care prior to the identification of the right heel wound as follows: 8/15/16 (11:30 p.m.- 7:30 a.m.)- partial bed bath 8/15/16 (7:30 a.m.- 3:30 p.m.)- shower 8/16/16 (7:30 a.m.- 3:30 p.m.)- full bed bath No skin issues were reported following these bathing occasions. During the wound care observation on 8/31/16 at 1:28 p.m., Resident #1 was asked how she thought her heel wound developed. She stated she was unsure how the wound developed. On 8/31/16 at 3:45 p.m., Certified Nursing Assistant H (CNA H) was asked what she was supposed to do if she noticed any changes in skin while caring for a resident. She stated that she was supposed to report any new skin issues to the nurse as soon as possible. She said she would notify the nurse if she saw a wound, skin tag, bruise, cuts or dry skin. On 8/31/16 at 4:15 p.m., the issues with Resident #1's wounds were reviewed with the facility staff. At this time, the Administrator, DON and corporate staff were notified that the survey team was considering a harm level deficiency. The DON was asked to explain the process for skin assessment and wound tracking. The DON stated that nurses were supposed to complete skin assessments every week. If a wound was identified, a SBAR (Situation, background, assessment and recommendation) and incident report should be completed. All wounds were discussed in the daily morning meetings. The DON or Unit Manager would stage the wound by the next day after a wound was found. A wound flow sheet would be created, to include staging and measurements. The DON stated that she had worked at the facility for three weeks. During that time, she had identified that the facility had an issue with skin and wound management. She stated that skin assessments, wound assessments and treatments were not completed in a timely manner. As a result, the facility completed a 100% skin audit on 8/17/16. During this audit, Resident #1's wounds were found. Resident #1 was the only resident found with wounds. The facility put a plan in place to fix the issues related to skin care. According to the plan, all staff were to be educated by 8/29/16. The skin education materials and sign in sheets were reviewed with the DON around 5:30 p.m. on 8/31/16. The sign in sheet did not include many signatures. The DON was asked if training had been completed. She stated no. On 9/1/16 at 8:50 a.m., the DON stated that Resident #1's wounds should have been found sooner. On 9/1/16 at about 8:50 a.m., the DON was asked to describe each type of bath. She stated that a partial bed bath would be used while providing pericare. She stated that the whole body should be cleaned and observed during a full bed bath and a shower. The following definition of an unstageable pressure injury was accessed on 9/6/16 at 2:15 p.m. from the National Pressure Ulcer Advisory Panel website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. The facility policy titled Skin Integrity Guideline was reviewed. The policy read Living Center develops a routine schedule to review patients/ residents with wounds or at risk on a weekly basis and will document findings. DNS (Director of Nursing Services) or designee will be responsible to implement and monitor the skin integrity program. Wound status is monitored on a weekly basis. The section titled Documentation of Weekly Skin Evaluation/ Observations: read Licensed nurse will be responsible for performing a skin evaluation/ observation weekly, utilizing the Weekly Skin Review UDA (User Defined Assessment). Care plan is to be implemented, evaluated and revised based on the needs of the resident. The facility policy did not define unstageable or provide a treatment protocol for an unstageable wound. In summary, the facility staff did not identify the right heel wound until it was unstageable. Calcium arginate was not applied as ordered by the wound care specialist. The special mattress was observed off and unplugged. The heels were not floated on the heels up cushion per the care plan and manufacturer's instructions. The facility was notified that the survey team had concerns about Resident #1's wound and the implementation of the interventions. No further information was provided prior to the survey exit. An observation of Resident #1's wounds and wound care was initiated 8/31/16 beginning at 1:28 p.m. LPN (licensed practical nurse) B donned a pair of gloves and entered Resident #1's bedroom. She cleaned the over bed table with bleach wipes and placed her dressing supplies on the table. Resident #1's legs were observed on a heels up device, positioned under her knees and upper lower legs. Resident #1's heels were observed flat on her bed. After changing her gloves and donning new gloves LPN B assisted Resident #1 to her left side. LPN B removed Resident #1's socks and her wounds on both heels were observed. There was no dressing on either heel wound. The right heel area was located on the outer lower aspect of the heel. The wound base was pink and granulating, with no noted drainage, redness, or odor. A small amount of slough was observed in the wound base. Slough is an accumulation of necrotic or dead tissue in the wound bed. LPN B attempted to clean the wound with normal saline moistened gauze and Resident #1 complained of pain. LPN B assessed her for pain and decided she (LPN B) needed to contact the physician to obtain something to treat Resident #1's pain. Resident #1's left heel wound was observed at the same time during the attempted wound care observation. Her heel area looked to be a deep tissue injury as evidenced by a deep reddened area over the end of her left heel. No opened area was noted nor was any drainage, odor, or [MEDICAL CONDITION] noted. The discoloration was diffuse in nature. Guidance for definition of a deep tissue by www.npuap.com: Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discolorationIntact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. After receiving pain medication, the wound care observation was resumed 8/31/16 at 3:04 p.m. Resident #1 stated she was in no pain and agreeable for wound care to continue. Upon entering Resident #1's bedroom, her legs were observed on a heels up device, positioned under her knees and upper lower legs. Resident #1's heels were observed flat on her bed. After cleaning the over bed table again with bleach wipes, LPN B prepared her wound care supplies and placed them on the over bed table. LPN B cleansed Resident #1's right heel with normal saline saturated gauze. LPN B applied Santyl ointment to the wound base and applied a foam dressing. LPN B did not apply calcium alginate. LPN B did not date nor initial the foam dressing. Guidance was provided at Potter-Perry Fundamentals of Nursing 7th Edition, p. 1317, 19. Write date and time dressing applied on tape in ink (not marker). According to www.santyl.com: [MEDICATION NAME] Santyl Ointment is the only FDA approved enzymatic debrider. It selectively removes necrotic tissue (dead tissue) without harming granulation tissue. LPN B then cleaned Resident #1's left heel with normal saline saturated gauze. The area was dried and skin prep was applied to the entire heel area. Licensed Practical Nurse C (LPN C) supported Resident #1 ' s feet while LPN B performed the treatments. After the heel treatments were completed, LPN C allowed the heels to again lay flat on the mattress. LPN B asked LPN C to adjust the heels up cushion so that the heels were up and off the mattress. According to www.smith-nephew.com: SKIN-PREP is a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films. Resident #1 was positioned on her left side by LPN B. Her sacral dressing was removed and the area was noted to be healed. No open area was noted. No redness, odor, or discharge was present. LPN B stated she would contact the clinician to inform her of the area being healed.

Based on observation, resident interview, staff interview, facility documentation review and clinical record review, the facility staff failed for 5 residents (Resident #2, #25, #4, #24 and #1) of 26 residents in the survey sample to implement an effective pressure ulcer program resulting in harm for Residents #2, #25, #4 and #24. Substandard quality of care was identified. 1. For Resident #2, the facility staff failed to identify a pressure ulcer prior to the area becoming a Stage III pressure ulcer. 2. For Resident #25, the facility staff failed to identify a pressure ulcer on the sacrum found as a stage 2 until it was found by surveyors on 9-10-15, and failed to identify a pressure ulcer on the left heel until it was found at Eschar and unstageable resulting in harm. The staff further failed to complete preventive weekly skin checks, every shift skin checks, and did not provide physician ordered and available treatment interventions, and did not revise the care plan after an unstageable pressure ulcer developed. 3. For Resident #4, the facility staff failed to identify and treat a pressure sore prior to it becoming a Stage 3, resulting in harm. 4. For Resident #24, the facility staff failed to prevent, assess, identify and treat an avoidable pressure ulcer to the sacral area. The wound was first identified by facility staff as unable to stage. 5. For Resident #1, the facility staff failed to accurately assess and initiate treatment for [REDACTED]. The findings included: 1. For Resident #2, the facility staff failed to identify a pressure ulcer prior to the area becoming a Stage III pressure ulcer. Resident #2, a female, was admitted to the facility 12/17/12. Her [DIAGNOSES REDACTED]. Resident #2's most recent MDS (minimum data set) with an ARD (assessment reference date) of 7/10/15 was coded as a significant change assessment. Resident #2 was coded as having short and long term memory deficits and required moderate assistance with making daily life decisions. Resident #2 was also coded as needing extensive to total assistance of one to two staff members to perform her activities of daily living. Section M, the area devoted to identification of skin issues, revealed Resident #2 had been diagnosed as having a stage III pressure ulcer. Review of the previous MDS, a quarterly with an ARD of 4/24/15, revealed no pressure ulcer areas had been identified. She was coded as being at risk for the development of pressure ulcers. Resident #2 was observed 9/10/15 at 9:38 a.m. She was out of bed and in her gerichair, alert and verbally responsive. Resident #2 was feeding herself breakfast. Review of Resident #2's clinical record revealed on 6/25/15, Resident #2 had been diagnosed as having a Stage III pressure ulcer. Guidance from NPUAP (National Pressure Ulcer Advisor Panel) defined a Stage III pressure ulcer: Stage III: Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a Stage III pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. A physician's orders [REDACTED]. Review of the weekly skin assessments revealed as early as May, 2015, Resident #2 had a slit area between the buttocks on her sacrum. Documentation on the weekly skin assessments revealed some weeks the area was present and some weeks it was not evident. During May and June, 2015 weekly skin assessments documented: 5/8/15 skin intact, old sacral wound' 5/13/15 skin intact 5/21/15 skin intact 5/28/15 old open area (indicated on sacrum) 6/3/15 pre-existing 6/10/15 open area wound to sacrum 6/11/15 skin intact no redness to sacrum, grion (sp) or elbow area 6/17/15 pre-existing sacrum 6/24/15 pre-existing sacrum While the area was documented on the weekly skin assessments as pre-existing sacrum, no wound assessment was evident until Resident #2 was evaluated and treated by the wound care physician on 6/25/15. Documentation was evident that Resident #2 had been treated with a preventative treatment of [REDACTED]. Guidance at www.dermalsciences.com included indicates the product is produced from a species of plant. Studies by the producer indicate that the product may be used for hard to heal wounds or burns. Documentation revealed Resident #2 was assessed by the wound care physician on 6/25/15. At that time an area was observed on Resident #2's sacrum that was described by the physician as, She presents with a stage 3 pressure wound of the sacrum of at least 1 day duration. There is moderate sero-sanguineous exudate. Wound Size 2 x 1.2 x 0.6 cm (length by width by depth). Exudate Moderate Sero-sanguineous, Yellow Necrotic 20% Granulation 80% The wound care physician ordered on [DATE] Dressing-Once Daily, Calcium Alginate-one daily, Santyl once daily. The staff was to discontinue the use of a protective dressing. He also ordered for Resident #2 to only be sitting up for 30 minutes at time. Review of the clinical record revealed no other wound treatments, other than the [MEDICATION NAME] preventative treatment, prior to the physician orders [REDACTED]. www.santyl.com indicated: [MEDICATION NAME] SANTYL® Ointment is a sterile enzymatic [MEDICATION NAME] ointment which contains 250 [MEDICATION NAME] units per gram of white [MEDICATION NAME] USP. The enzyme [MEDICATION NAME] is derived from the fermentation by ,[MEDICAL CONDITION]. histolyticum. It possesses the unique ability to digest collagen in necrotic tissue. Resident #2's wound care was changed by the wound care physician on 9/9/15 to include the use of cleaning with normal saline, apply calcium alginate to the wound bed, and cover with a foam dressing. Calcium alginate dressings are highly absorbent biodegradable dressings made from seaweed. Resident #2's wound and wound care was observed, 9/10/15 at 11:31 a.m. LPN J performed the current wound care of cleaning the wound with normal saline, packed with calcium alginate, cover with foam dressing. The discarded dressing included tan sero-sanguineous drainage. No redness, [MEDICAL CONDITION], or odor were evident. The wound was located at the sacrum, with a ruddy wound base and white fibrous edges. LPN J stated she was unable to stage the wound and the wound care physician would stage and measure the area sometime 9/10/15 when he came. LPN J stated the facility did not have a wound care nurse and that the wound care physician was responsible for staging, monitoring, and measuring any wounds when he came. No documentation was evident that Resident #2's area on the sacrum was assessed for any ongoing wound care. No documentation was evident that prior to 6/25/15, staff at the facility assessed the area. No wound measurements, description, or assessment of efficacy of the wound care were evident within the clinical record. Review of Resident #2's care plan revealed that while a care plan for potential for skin integrity was in place from admission in 2012, the care plan was revised on 6/30/15 and again on 8/18/15. The revision included: 6/30/15 Actual pressure ulcer: related to incon (incontinent) episodes, mobility deficit, requires ext ast (extensive assistance) with turning and repositioning, medications, DM (diabetes mellitus), history of alteration in skin folds, vitamin deficiency, [MEDICAL CONDITIONS] 6/22/15 skin often stay moist from body heat nutritional status, h/o (history of) noncompliant with incontinent care. EST (establish) Stage 4 sacrum, 7/10/15 non compliant with repositioning. The Interventions included: Complete Braden Scale per Living Center Policy (a scaling system to determine risk for the development of pressure ulcers) Conduct weekly skin inspection Consults as indicated Don not massage over bony prominence Encourage out of bed daily-as tolerated-limit sitting 30 min (minute) intervals Indwelling catheter or wound healing per MD orders Labs/Diagnostics as indicated Medicate as indicated/PRN (as needed) Nutritional and Hydration support Provide pressure reducing wheelchair/gerichair cushion as tolerated Provide thorough skin care after incontinent episodes and apply barrier cream prn RD (registered dietician) consult routinely and as needed Skin assessment to be completed per Living Center Policy Specialty alternating pressure mattress Supplements/vitamins as indicated Treatments as ordered, adjust as appropriate Turn and position at least every 2 hours and as needed Turning and repositioning schedule per assessment Weekly wound assessment. Prior to 6/30/15, the only preventative care plan that had been developed included: 12/26/12 Complete Braden Scale 12/26/15 Conduct weekly inspection 6/15/15 Labs/Diagnostics as indicated 12/26/12 Provide pressure reducing wheelchair/gerichair cushion as tolerated 12/26/12 Provide thorough skin care after incontinent episode 12/26/12 Specialty alternating pressure mattress 6/15/15 Supplements/Vitamins as indicated 2/11/13 Treatments as ordered, adjust . CNA (certified nursing assistant) F, the staff member caring for Resident #2, stated 9/11/15 at 1:58 p.m., she had cared for Resident #2 for a long time. CNA F stated she vaguely remembered Resident #2 had a small slit place between her buttocks for awhile. CNA F stated Resident #2 was very cooperative and tried to assist the staff with her care, trying to help when the staff turned or positioned her. CNA F stated she kept an eye on Resident #2's skin and would report to the nurse if there ever was anything different. CNA F stated she would report anything different to the nurse as you never know if the previous person did not report it (a change in the skin). CNA F also said the CNAs have a care card that guided them in caring for Residents. Review of Resident #2's care card revealed while she was HIGH RISK for skin breakdown, there was no guidance to the CNA staff to indicate that as she had a pressure ulcer she was only to be up and sitting 30 minutes at a time. When interviewed, the DON (director of nursing) indicated that at the time of Resident #2's development of a stage III pressure ulcer, the facility did not have a dedicated wound care nurse. The DON stated the DON (at the time) was responsible for assessing, staging, and measuring the pressure ulcer wounds weekly. The DON also stated all of the staff were responsible for reporting any changes in skin integrity to the floor nurse. The floor nurse was to then assess the area and report any need for treatments to the physician to obtain an order. The floor nurses were also responsible for doing a head to toe weekly skin assessment, noting any changes in skin condition. Upon reviewing the weekly skin assessments for Resident #2, the DON said she thought the staff were not clear in their documentation of the areas. The DON reported that some of the skin assessments included Resident #2 having some type of skin impairment and some documented her skin was intact. Review of the nursing notes for the same type frame revealed Resident #2's skin was intact on 4/8/15, 4/15/15, 4/18/15, 4/29/15, 5/8/15, 5/18/15, 6/3/15, and 6/18/15. While documentation was evident that Resident #2 had a stage III pressure ulcer on 6/25/15, as documented by the wound care physician, the first nursing note to mention a stage III pressure ulcer was not documented until 6/30/15. Review of the facility's policy entitled Skin Integrity Guideline included: General Guidelines: DNS (director nursing service) or designee will be responsible to implement and monitor the skin integrity program. Wound status is monitored on a weekly basis. The interdisciplinary plan of care will address problems, goals, and interventions directed toward prevention of pressure ulcers and/or skin integrity concerns identified. Documentation and Care Interventions for Skin Integrity Patients/Residents will be observed by the CNA for reddened/open areas, [MEDICAL CONDITION] of feet or sacrum. Changes will be reported to the licensed nurse and documented. Nursing notifies dietary of any patient/resident admitted with pressure ulcer or newly identified acquired pressure ulcers. Documentation completed by Dining Services Manager or Registered Dietician (according to state regulations) occurs on initial notification of a new pressure ulcer and surgical wound and continues monthly for non-healing Stage II or greater areas until healed unless otherwise noted. Documentation of Weekly Skin Evaluation/observation: Licensed nurse to document weekly on identified wounds using the Wound Evaluation Flow Sheet UDA (one UDA per wound identified). Documentation was evident Resident #2 was assessed by the dietitian on 7/1/15, with information included in the note, that indicated Resident #2 had been identified as having a Stage III pressure ulcer. Review of the physician's progress notes revealed documentation the physician had not been aware of any pressure ulcers prior to 6/25/15. The administrator, DON, and corporate consultants were informed of the failure of the staff, for Resident #2, to identify a pressure ulcer before it was diagnosed as a Stage III pressure ulcer. The corporate consultant stated she was unable to provide any documentation Resident #2's stage III pressure ulcer had been present as a pressure ulcer prior to [DIAGNOSES REDACTED].#2. 2. For Resident #25, the facility staff failed to identify a pressure ulcer on the sacrum found as a stage 2 until it was found by surveyors on 9-10-15, and failed to identify a pressure ulcer on the left heel until it was found at Eschar and unstageable resulting in harm. The staff further failed to complete preventive weekly skin checks, every shift skin checks, and did not revise the care plan after an unstageable pressure ulcer developed. Resident #25 was initially admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #25's only MDS (minimum data set) with an ARD (assessment reference date) of 7-16-15 was coded as a full admission assessment. Resident #25 was coded as having a brief interview for mental status (BIMS) score of 2 of a possible 15 points revealing severe cognitive impairment. Resident #25 was also coded as requiring extensive to total assistance of one to two staff members to perform activities of daily living, such as bed mobility, and hygiene. Resident #25 was coded on the 7-16-15 MDS in section M as being at risk for the development of pressure ulcers. Further coding in section M revealed that the Resident had no pressure ulcers. On 9-10-15 at approximately 5:30 p.m., the surveyor requested to see the Resident's heels and sacrum, and the corporate regional RN, and CNA staff stated there is nothing on her sacrum or heels. The wound specialist physician was present, and also stated he was unaware of any wounds except skin tears on the Resident's arms. Staff placed Resident #25 in bed, undressed from the waist down and removed the Resident's shoe and sock to reveal the naked heel for observation. The Resident was found to have a stage 2 open wound on her sacrum, which no staff had previously identified. The left heel wound was black, necrotic tissue, which was oval in shape, located on the lateral aspect of the heel and approximately the size of a lemon, was clean and had no medication or dressing covering it. No measurements of depth were made during the observation. The treatment nurse was asked if any treatments were ordered for the heel and she stated that no treatment of [REDACTED]. Skin prep was ordered 8/29/15 to be applied three times per day. According to Clinical Practice of Guidelines Number 15 treatment of [REDACTED]. Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Both the Wound specialist doctor, and the Corporate Regional RN (Registered Nurse) were interviewed during the observation, and present when the treatment nurse stated that the left heel was identified at eschar and unstageable. Eschar is black dead tissue and cannot be staged or is unstageable. The sacrum was identified during this observation with 2 surveyors present, and found at a stage 2. CNA (Certified Nursing Assistant) G was interviewed on 9-10-15 and stated that she had been an employee for 2 years at the facility and worked on both units. She stated that if any new areas of skin breakdown were found during care, a Stop and Watch form was completed and given to nursing so they would come and assess the area, call the doctor for treatment orders, document it in the chart, and follow up on it. The CNA was asked how the staff knew what kind of needs the Resident had, she responded that they followed a care plan for each resident called the Resident Kardex. This document was requested for review. The Resident's current Kardex revealed that Resident #25 required assistance with all ADL's, and under positioning devices only geri-sleeves were listed. No other pressure reducing devices were listed for the staff to know what devices were to be used for the Resident. Registered Dietician (RD) evaluations were reviewed, and revealed that the RD was not made aware of the unstageable pressure ulcer. The RD documented 2 evaluations being completed, on 7-15-15 and 9-9-15, and list only skin tears under skin status, with the pressure ulcer areas being left blank. No other supplements for wound healing were added. The Resident was being administered calcium and Vitamin D for vitamin deficiencies and [MEDICAL CONDITION] with [MEDICAL CONDITION] from admission ordered 7-10-15 and 7-9-15. On 9-10-15 at 6:00 p.m. the immediate plan of care which was written on the day of admission was reviewed. The initial care plan was replaced with a comprehensive care plan on 7-21-15, which was an 18 page document. A copy was received and denoted the following interventions for skin/wound care: (Focus) 8-29-15 alteration of skin integrity to left heel. No further information was given about this focus statement, and no new revised interventions on this date existed. The Care plan continued with the following dates and interventions which were planned before the 8-29-15 focus date. (Goal) date initiated 7-21-15, revised on 8-10-15, target date 10-9-15. (Interventions) 1.) Monitor for signs and symptoms of infection, date initiated 7-21-15. 2.) Monitor for self injury Picking at skin, date initiated 7-27-15. 3.) Nutritional and hydration support, date initiated 8-10-15. 4.) Provide pressure reducing wheel chair cushion, date initiated 8-10-15. 5.) Provide pressure reduction/relieving mattress, date initiated 8-10-15. 6.) Provide thorough skin care after incontinent episodes and apply barrier cream, date initiated 7-27-15. 7.) Skin assessments completed per Living Center policy (weekly), date initiated 7-27-15. No further revisions to the care plan were made after the identification of the unstageable left heel wound on 8-29-15. A second wound on the sacrum was identified because of the surveyors request to observe the resident's sacral area on 9-10-15. On 9-11-14 at 10:00 a.m. The Director of nursing supplied a second copy of the care plan which was initially obtained on 9-10-15 at 7:00 p.m. after it had been previously reviewed. The care plan had been revised overnight and was now 19 pages with an initiation date of 9-9-15, and target date of 10-9-15. The new document included the addition of the following interventions: Consults as indicated - only the wound specialist consult had been completed. Dietary consult as indicated - one completed 9-9-15, however no wounds were known by the Dietician. Float heels as tolerated Labs/diagnostics as indicated - only labs for high blood pressure were ordered on 9-5-15. Treatments as ordered - skin prep was not signed as completed on (9-4-15) on the 3:00 p.m. to 11:00 p.m. shift, and was not completed twice on (9-10-15) on the 7:00 a.m. to 3:00 p.m. shift and on the 3:00 p.m. to 11:00 p.m. shift Vitamins/supplements as ordered The Medication Administration Record [REDACTED]. Physicians orders since admission were reviewed and revealed an order for [REDACTED].) Pressure redistribution cushion to chair. and 2.) Pressure redistribution mattress. CNA G stated the mattresses for all residents were the pressure redistributing mattresses, and the only different kinds of mattresses were the scoop mattresses to help prevent falling, and the alternating pressure air mattresses which had a machine at the foot of the bed to blow air into the mattress. Resident #25 was not on a pressure alternating air mattress. No other physician's orders [REDACTED]. The 2 telephone orders dated 8-29-15 at 2:29 a.m. were for 1.) Skin prep to left heel every shift related to unspecified disorder of skin & Subcutaneous tissue, and 2.) May have consult with Dr. (doctor's name) Wound Specialist. On 9-3-15 the wound specialist doctor assessed Resident #25's heel wound, 5 days after stated identification, and documented on his form Initial Evaluation, thick adherent black necrotic tissue (Eschar) 100%, unstageable, depth unknown. His orders were to apply skin prep every shift and as needed, float heels in bed, offload wound, and reposition per facility protocol. On 9-10-15 at the end of day meeting, at 7:00 p.m. the DON (Director of Nursing), Administrator, and Corporate RN Consultant were asked to show evidence of how Resident #25's wounds were unavoidable. The response was that they knew they had problems with the prevention, identification of wounds, and care planning, however, they had started a plan of correction. The initial plan had not worked and it was revised, however pressure ulcers were identified at a harm level during the survey by surveyors and staff. An SBAR (situation, background, assessment and recommendation) nursing progress note was documented by a nurse on 9-10-15 at 7:07 pm. and placed in the clinical record at that time. This documentation occurred after the wounds were already assessed by the 2 surveyors, the wound specialist doctor, and the Corporate Regional RN (Registered Nurse) on 9-10-15 at 5:30 p.m. The note stated that the left heel is dark and hard measuring 4 cm x 3 cm (centimeters) doctor made aware, new order for skin prep every shift. The pressure ulcer was first identified in the note on 8-29-15 at 10:02 p.m according to the late entry nursing progress note. The note said nothing about the sacral wound which had just been identified by surveyors. On 9-11-15 a second copy of the same MAR/TAR's for September was delivered to surveyors at 10:00 a.m. This copy revealed that the skin prep treatments for 9-10-15 which were omitted were now signed on this copy by staff as completed. The Regional Corporate RN was made aware of the documentation on this TAR, and the addition of one page of information to the care plan which was initially 18 pages, and the second copy was 19 pages. Her response was that she didn't believe they intended to alter the documents, and felt it was just an accidental error. The facility policy and procedure was reviewed The policy Skin Integrity Guideline Purpose to decrease pressure ulcer and wound formation by identifying those patients/residents who are at risk, and implementing appropriate interventions. Assess those at risk weekly and document findings. The interdisciplinary plan of care will address problems, goals, and interventions directed toward prevention of pressure ulcers and/or skin integrity concerns identified. If there is a decline in skin integrity pressure redistribution surfaces will be reviewed for appropriateness. CNA's will observe daily for areas on the feet or sacrum and report changes to the licensed nurse and document. Refer to therapy as needed. Notify the Dietician. The Weekly skin integrity reports were written by hand on 8-22-15, and 9-7-15. The Weekly skin review sheets were completed in the computer on 8-4-15, 8-11-15, 8-18-15, 8-25-15, and 9-2-15. Surveyors requested the weekly skin review sheet for the current week, as the computer program listed under skin assessments 9-10-15 in red bold lettering, 1 day overdue. The Corporate Regional RN stated it hasn't been completed. At no time, did the 2 forms used, document any wounds, of any kind. The Nursing progress notes were reviewed on 9-10-15 at 6:30 p.m., and no documentation from the date of admission on 7-9-15 to this date, documented any pressure ulcers being identified at any stage. The surveyors asked how with weekly skin assessments and daily bathing, these wounds could have gone unnoticed, and the MDS coordinator RN stated We knew she had the heel wound and were getting ready to do a significant change assessment on her because of it. The MDS coordinator supplied an email notification dated 9-8-15 about the wound which had been sent to the corporate office (10 days after stated identification) notifying MDS personnel of the wound. She further stated that the Left heel wound was found by facility staff at unstageable, and 100% necrotic eschar. The administrator, Director of Nursing (DON), and Corporate RN Consultant were told on 9-10-15 and on 9-11-15 at the end of the day conferences, of the failure of the staff to revise available Care Plan intervention measures, including, appropriate assessment and treatment to prevent the development of, and heal two pressure ulcers. On 9-11-14 at 10:00 a.m. The Director of nursing supplied a second copy of the care plan which was initially obtained on 9-10-15 at 7:00 p.m. after it had been previously reviewed. The care plan had been revised overnight and was now 19 pages with an initiation date of 9-9-15, and target date of 10-9-15. The new document included the addition of the following interventions; No documentation or assessment of the wound appeared in the clinical record up to the 9-10-15 observation by surveyors of the unstageable heel wound, and identification of the sacral wound except a doctor's telephone order dated 8-29-15. Guidance provided at www.NPUAP.com defined an unstageable pressure ulcer as follows: The goal for revising the definition of unstageable ulcers was to reduce the tendency to classify an ulcer with any necrotic tissue as unstageable, when the depth of the ulcer can be seen. The new definition is Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Note the phrase the base of the ulcer is used to denote the inability to determine the depth. If necrotic tissue is present, for example, on the edge of the ulcer, but the base is bone, the ulcer should be staged as a Stage IV. Further description of Stage IV ulcers include these phrases: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar serves as ' the body's natural (biological) cover' and should not be removed. The administrator, Director of Nursing (DON), and Corporate RN Consultant were advised on 9-10-15 and on 9-11-15 at the end of the day conferences, of the failure of the staff to institute measures, including, appropriate assessment and treatment to prevent the development of two avoidable pressure ulcers resulting in harm for Resident #25. 3. For Resident #4, the facility staff failed to identify and treat a pressure sore prior to it becoming Stage 3, resulting in harm. Resident #4 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #4's [DIAGNOSES REDACTED]. The Minimum Data Set, which was Quarterly Assessment with an Assessment Reference Date of 5/26/15, coded Resident #4 as sometimes being able to understand and be understood by others. Resident #4 was coded for requiring the extensive assistance of 1 person for eating, dressing, and bathing. She was coded as having Range of Motion limitations in both her upper and lower extremities, and she was frequently incontinent of bowel and bladder. The resident was coded 0 for no pressure sores. The significant change assessment, dated 7/17/15, coded the resident with one unhealed stage 3 pressure sore. On 9/9/15 at 3:15 P.M. an observation was made of Resident #4 asleep in her bed, which had a pressure reduction mattress. On 9/10/15 a review was conducted of Resident #4's clinical record, revealing the following Care Plan, 7/10/15. Pressure ulcer actual. Estimated Stage 3 sacral. Assistance required in bed mobility. [DIAGNOSES REDACTED]. According to Mosby ' s Fundamentals of Nursing, 7th Ed. Page 1282, a Stage 3 Pressure Ulcer is defined as, Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Resident #4 ' s wound was observed 9/11/15 at 11:15 a.m. LPN (licensed practical nurse) D positioned Resident #4 on her left side and removed the old dressing. Minimal pink/yellow drainage was observed on the old bandage. No redness, odor, or [MEDICAL CONDITION] was observed around the wound bed on Resident #4 ' s sacral area. The wound base was vascular with white fibrous tissue around the edges. The Nurse Progress notes read, 7/2/15 -[MEDICATION NAME] daily foam dressing Stage 3 wound sacrum. There were no measurements or description of the wound. The wound was not identified and treated prior to it being at a stage 3. The Physician order [REDACTED]. According to the facility's instructions on Santyl, Santyl ointment is used for removing dead skin from wounds and burned areas. The clinical record did