Every finding on record at Potomac Falls Health & Rehab Center

Based on interview and record review, the facility failed to ensure the accuracy of a preadmission screening and resident review (PASARR) for 4 (Residents #5, #11, #16, and #140) of 5 sampled residents reviewed for PASARR.Findings included: During an interview on 09/15/2025 at 10:26 AM, the Administrator stated the facility did not have a PASARR policy and followed the guidance in the regulation. 1. An admission Record indicated the facility admitted Resident #11 on 01/18/2023. According to the admission Record, the resident had a medical history that included diagnoses of anxiety disorder and adjustment disorder with anxiety. Resident #11's Virginia Department of Medical Assistance Services MI/MR [mental illness/mental retardation] Supplement Level I dated 01/11/2023, indicated the resident did not have a current serious mental illness. During an interview on 09/15/2025 at 10:50 AM, the Admissions Director (AD) stated the purpose of the PASARR Level I was for new admissions to the facility to be screened for any serious mental illness. The AD reviewed Resident #11's diagnoses list and stated the resident's diagnoses of depression, anxiety, and bipolar diagnoses should have been included in the PASARR Level I and acknowledged that they were not included. The AD stated the facility assumed the PASARR were accurate since the hospital case workers completed them before the resident admission. During an interview on 09/15/2025 at 12:04 PM, the Social Services Director stated if a PASARR did not accurately reflect a resident's mental illness diagnoses it should be updated and resubmitted. During an interview on 09/15/2025 at 2:27 PM, the Administrator stated PASARRs should be validated upon admission, and if found to be inaccurate after diagnoses review, the facility should find out why the PASARR was inaccurate. The Administrator stated Resident #11's PASARR did not indicate their relevant diagnoses. The Administrator stated the hospital usually completed the PASARR and sent them to the facility, and the admissions team was to review them for accuracy. 2. An admission Record indicated the facility admitted Resident #16 on 03/11/2020. According to the admission Record, the resident had a medical history that included diagnoses of anxiety disorder and unspecified psychosis. Resident #16's Screening for Mental Illness, Mental Retardation/Intellectual Disability, or Related Conditions dated 03/11/2020, indicated the resident did not have a current serious mental illness. During an interview on 09/15/2025 at 12:04 PM, the Social Services Director reviewed Resident #16's PASARR and stated the resident's mental illness diagnoses of anxiety disorder and unspecified psychosis should have been captured on the PASARR. During an interview on 09/15/2025 at 2:27 PM, the Administrator stated PASARRs should be validated upon admission, and if found to be inaccurate after diagnoses review, the facility should find out why the PASARR was inaccurate. The Administrator stated Resident #16's PASARR did not indicate their relevant diagnoses. The Administrator stated the hospital usually completed the PASARR and sent them to the facility, and the admissions team was to review them for accuracy. 3. An admission Record indicated the facility admitted Resident #140 on 08/29/2025. According to the admission Record, the resident had a medical history that included a diagnosis of bipolar disorder.Resident #140's Level I Screening for Mental Illness, Intellectual Disability, or Related Conditions dated 08/27/2025, indicated the resident did not have a current serious During an interview on 09/15/2025 at 12:04 PM, the Social Services Director reviewed Resident #140's PASARR and stated the PASARR did not include the resident's diagnosis of bipolar disorder. During an interview on 09/15/2025 at 2:27 PM, the Administrator stated PASARRs should be validated upon admission, and if found to be inaccurate after diagnoses review, the facility should find out why the PASARR was inaccurate. The Administrator stated Resident #140's PASARR did not indicate their relevant diagnoses. The Administrator stated the hospital usually completed the PASARR and sent them to the facility, and the admissions team was to review them for accuracy. 4. An admission Record indicated the facility admitted Resident #5 on 08/14/2025. According to the admission Record, the resident had a medical history that included diagnoses of cyclothymic disorder, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD).Resident #5 Level I Screening for Mental Illness, Intellectual Disability, or Related Conditions dated 08/14/2025, indicated the resident did not have a current serious mental illness. During an interview on 09/15/2025 at 12:04 PM, the Social Services Director reviewed Resident #5's PASARR and stated the resident's diagnoses of cyclothymic disorder, OCD, and PTSD were not listed on the PASARR and they should have been . During an interview on 09/15/2025 at 2:27 PM, the Administrator stated PASARRs should be validated upon admission, and if found to be inaccurate after diagnoses review, the facility should find out why the PASARR was inaccurate. The Administrator stated Resident #5's PASARR did not indicate their relevant diagnoses. The Administrator stated the hospital usually completed the PASARR and sent them to the facility, and the admissions team was to review them for accuracy.

Based on interview and record review, the facility failed to refer a resident to the appropriate state-designated authority for a Level II preadmission screening and resident review (PASARR) when the resident was diagnosed with a new mental illness diagnosis for 2 (Resident #11 and Resident #16) of 5 sampled residents reviewed for PASARRs. Findings included: During an interview on 09/15/2025 at 10:26 AM, the Administrator stated the facility did not have a PASARR policy and followed the guidance in the regulation. 1. An admission Record indicated the facility admitted Resident #11 on 01/18/2023. According to the admission Record, the resident had a medical history that included diagnoses of anxiety disorder and adjustment disorder with anxiety. Per the admission Record, Resident #11 received a diagnosis of depression on 02/17/2023 and bipolar disorder on 01/17/2025. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/02/2025, revealed Resident #11 had a Staff Assessment for Mental Status (SAMS), that indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS revealed the resident had active diagnoses to include anxiety disorder, depression, and bipolar disorder.Resident #11's Care Plan Report, included a focus area initiated 01/27/2023 and revised 11/06/2023, that indicated the resident used psychoactive medication related to depression and anxiety. Resident #11's record revealed no evidence to indicate a PASARR was completed once the resident received new mental illness diagnoses of depression on 02/17/2023 and bipolar disorder on 01/17/2025 .During an interview on 09/15/2025 at 10:50 AM, the Admissions Director (AD) stated she found no other PASARR in Resident #11's record. The AD reviewed Resident #11's diagnoses list and stated the residents' diagnoses of depression and bipolar should be included in the PASARR and acknowledged that they were not. The AD stated residents needed a new PASARR if there was a change in their diagnoses. During an interview on 09/15/2025 at 12:04 PM, the Social Services Director (SSD stated he was unsure why Resident #11'sPASARR was not updated in the past year, since the resident had serious mental illness diagnoses. The SSD stated it should have been caught and changed due to the addition of the bipolar and depression diagnoses. During an interview on 09/15/2025 at 2:27 PM, the Administrator stated Resident #11's PASARR did not indicate their relevant diagnoses. 2. An admission Record indicated the facility admitted Resident #16 on 03/11/2020. According to the admission Record, the resident had a medical history that included diagnoses of anxiety disorder and unspecified psychosis. Per the admission Record, Resident #16 received diagnoses of adjustment disorder, unspecified mental disorder, and cyclothymic disorder (a mild form of bipolar disorder) on 06/01/2020. An annual Minimum Data Set (MDS), with an Assessment Reference Data (ARD) of 06/20/2025, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had active diagnoses to include of anxiety disorder, psychotic disorder, and cyclothymic disorder. Resident #16's Care Plan Report, included a focus area revised 06/19/2025, that indicated the resident received antidepressant medication related to dementia, depression, and insomnia. Resident #16's record revealed no evidence to indicate a PASARR was completed once the resident received new mental illness diagnoses of adjustment disorder, unspecified mental disorder, and cyclothymic disorder on 06/01/2020. During an interview on 09/15/2025 at 12:35 PM, the Regional Social Services Care Coordinator stated PASARRs should be reviewed and updated by social services after admission and if a resident received a new mental illness diagnosis During an interview on 09/15/2025 at 2:27 PM, the Administrator stated Resident #16's PASARR did not indicate their relevant diagnoses.

Based on observation, interview, record review, facility policy review, and drug manufacturer guideline review, the facility failed to ensure the medication error rate was 5 percent (5) or less. The facility had 2 medication errors out of 34 opportunities, which yielded a medication error rate of 5.88% for 1 (Resident #58) of 3 residents observed for medication administration. Findings included: A facility policy titled, General Guidelines for Medication Administration, effective 06/21/2017, indicated, Medications will be administered by legally-authorized and trained persons in accordance to applicable State, Local and Federal laws and consistent with accepted standards of practice. A facility policy titled, Insulin Administration, effective 06/21/2017, indicated, Insulin is a high risk drug and warrants additional precautions for the safe and effective administration. Per the policy, 10. If using pen devices, there are several important considerations: a. Check manufacturer instructions prior to use, as procedures may vary. b. Many pens require priming or an 'air-shot' prior to administration. The manufacturer's guideline titled, Instructions for Use Humalog KwikPen injection, revised 07/2023, indicated, Prime before each injection. Priming your pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and '0' is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the Needle and repeat priming steps 6 to 8. The manufacturer's guideline titled, How to use your Lantus SoloStar pen, dated 08/2022, indicated, Step 3: PERFORM A SAFETY TEST. Dial a test dose of 2 units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection. Never use the pen if no insulin comes out after using a second needle. An admission Record indicated the facility admitted Resident #58 on 08/18/2025. According to the admission Record, the resident had a medical history that included diagnoses of type two diabetes mellitus and long term (chronic) use of insulin. Resident #58's Care Plan Report included a focus area revised 08/19/2025, that indicated the resident had diabetes/blood sugar fluctuations requiring medical and/or dietary management. Interventions directed staff to administer diabetic management medications as ordered (initiated 08/19/2025). Resident #58's Medication Administration Record [MAR], for the timeframe 09/01/2025 to 09/30/2025, revealed the transcription of an order dated 09/10/2025, for Humalog KwikPen 100 units per milliliter (unit/ml) solution pen-injector with instructions to inject as per sliding scale. The instructions indicated that 4 units of insulin was to be administered for a blood sugar result between 201 to 250 milligrams per deciliter (mg/dL). There was also the transcription of an order dated 09/10/2025, for Lantus SoloStar 100 unit/ml with instructions to inject 30 units subcutaneously one time a day at 9:00 AM and to hold if blood sugar was less than 90 mg/dL and notify the physician. During an observation on 09/10/2025 at 8:38 AM, Licensed Practical Nurse (LPN) #3 checked Resident #58's fingerstick blood sugar, which resulted in 209 mg/dL. LPN #3 stated Resident #58 needed 4 units of Humalog per the sliding scale and 30 units of Lantus. LPN #3 prepared both pen-injectors without priming or conducting safety tests. LPN #3 was observed to administer Humalog KwikPen pen-injector and Lantus SoloStar pen-injector to Resident #58. During an interview on 09/11/2025 at 1:32 PM, LPN #3 stated she missed one step on 09/10/2025 when she administered Resident #58's Humalog KwikPen pen-injector and Lantus SoloStar pen-injector. LPN #3 stated she should have primed both insulin pen-injectors with 2 units each and pushed the 2 units out to show that the insulin was going through the needle. LPN #3 stated she primed the insulin pens when she saw bubbles inside the insulin pens or when the insulin pens were new. LPN #3 stated moving forward, she would do the priming/safety check prior to each insulin pen-injector administration. During an interview on 09/12/2025 at 4:41 PM, the Allegheny Unit Manager stated that when preparing insulin pens for medication administration, licensed nurses should prime the insulin to remove the air to avoid injecting air that could travel in the resident's body. During an interview on 09/12/2025 at 4:57 PM, the Interim Director of Nursing (DON) stated LPNs were expected to prime the insulin pens prior to medication administration. The Interim DON stated priming insulin pens avoided air being injected into the resident and made sure the resident received the correct dose. During an interview on 09/15/2025 at 3:42 PM, the Administrator stated the licensed nurses were expected to follow physician orders and manufacturers' guidelines when administering medications.

Based on observation, interview, document review, and facility policy review, the facility failed to ensure multidose vials were dated when opened in 1 (Tidewater Unit) of 4 units medication refrigerators. Findings included: A facility policy titled, Medication Disposal and Returns, dated 06/21/2017, indicated, Policy Nursing staff will date multidose vials and discard opened vials as outlined to decrease the risk of contamination and bacterial or fungal growth from multidose vials. Procedure 1. When initially entering a multidose vial, nursing staff shall date the vial when first entered. If a multi-dose has been opened or accessed the vial should be dated and discarded within 28 days unless the manufacturer recommendation or available literature specifies a different date for that opened vial. 2. Nursing staff is responsible for inspecting medications and their expiration date on a regular basis. Expired drugs should be discarded per policy and procedure, The manufacturer information for Aplisol dated 11/2013, indicated, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. During a concurrent interview and observation of the drug storage refrigerator on the Tidewater Unit with Registered Nurse (RN) #2 on 09/15/2025 at 10:24 AM, there were two opened Aplisol vials stored without labels to indicate when they were opened. RN #2 stated the Aplisol vials did not have information to indicate when they were opened; however, the vials were good for 28 days after opening, but she was not sure when the vials were opened. RN #2 stated she would not use the Aplisol vials since the vials did not specify an opened date. During an interview on 09/15/2025 at 4:03 PM, the Interim Director of Nursing (DON) stated both Aplisol vials should have been dated when they were opened. The Interim DON stated Aplisol vials was used for tuberculin testing, so it was important to indicate the date on the vials as to when they were opened so that there could be no false positives or false negatives.

Based on resident interview, staff interviews, and clinical record review, the facility staff failed to develop and implement a comprehensive person-centered care plan to address the preference of the resident for staff not to pull on her arms/shoulders which introduced pain during bed mobility and transfers for 1 of 45 residents (Resident #39), in the survey sample. The findings included: Resident #39 was originally admitted to the facility 4/30/21 and has not been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/26/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #39's cognitive abilities for daily decision making was intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of two people with bed mobility, transfers, and toileting, extensive assistance of one person with personal hygiene, bathing, and dressing, limited assistance of one person with locomotion and supervision of one person with eating. On 12/1/21 at approximately 5:00 p.m., an interview was conducted with Resident #39. The resident stated during the interview that she has had two rotator repair surgeries to both shoulder joints and just a few days ago she received a cortisone injection to bilateral shoulders due to arthritic pain. The resident also stated approximately two weeks ago during a shower on the stretcher bed she almost slipped off and Certified Nursing Assistant (CNA) #2 pulled on her arm to prevent her from falling to the floor. Resident #2 further stated often during transfers from her bed to the chair and to position her in the bed staff pulls on her arms and it cause them to hurt more than normal. The resident stressed her preference to transfer from the bed to the wheel chair using the sliding board provided by the therapist. Review of the current care plan with a revision date of 10/1/21 read; (name of the resident) demonstrates the need for activities of daily living (ADL) assistance related to chronic leg pain, Post polio syndrome, bilateral rotator cuff arthropathy with chronic shoulder pain, [CONDITION(S)], and [CONDITION(S)]. Resident will at times refused her shower. The goal read; the resident will receive necessary level of ADL assistance through the next review, 12/25/21. The interventions related to transfers read; Provide assistance with transfers as needed. Another care plan with a revision date of 5/10/21 read; (name of the resident) has pain or potential for pain related to chronic pain, [CONDITION(S)], post polio syndrome, complain of Spasms of legs. The goal read; comfort level will be achieved and managed to patient's satisfaction through the next review. The interventions included; administer pain medication as ordered. Report signs and symptoms of potential negative side effects. Assess pain level every shift and as needed and apply interventions as needed. Assist with alternate positioning and other diversional activities to relieve pain. Report breakthrough pain and/or unrelieved pain for further assessment and treatment. Interventions to avoid lifting or pulling on the resident's arms or use of a sliding board for transfers wasn't documented on the care plan or on tools utilized by the direct care staff. An interview was conducted with Certified Nursing Assistant (CNA) #2 on 12/1/21 at approximately 7:15 p.m. CNA #2 stated Resident #39 can transfer with staff assistance using a sliding board but there are times when other modes of transfers are necessary such as the Hoyer lift for showers and two people for positioning in bed. An interview was also conducted with the Unit Manager for The Shenandoah Unit on 12/1/21 at approximately 7:45 p.m. The Unit Manager also stated the pulling on the resident's arms would be addressed, rehabilitation services would be asked to assess and staff educated. On 12/2/21 at approximately 5:30 p.m., the above findings were shared with the Administrator, Assistant Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

Based on staff interviews, clinical record review and facility document review, the facility staff failed to ensure 1 of 45 residents (Resident #74) in the survey sample were free of significant medication error. The findings included: The facility staff failed to ensure the following significant medication ([MEDICATION(S)]) was administered to Resident #74 on 11/27/21 (3-11 shift) and 11/28/21 (7-3 and 3-11 shift). Resident #74 was admitted to the nursing facility on 10/18/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #74's Minimum Data Set (MDS - an assessment protocol) an annual assessment with an Assessment Reference Date of 10/23/21 coded Resident #74's Brief Interview for Mental Status (BIMS) scored a 13 out of a possible score of 15 indicating no cognitive skills for daily decision-making. Resident #74's person-centered care plan with a revision date 10/25/21 documented resident has pain or potential for pain due to recent fall with fracture and skin breakdown. The goal set for the resident by the staff is to maintain comfort level will be achieved and managed to patient's satisfaction through next review (01/17/22). One intervention/approaches to manage goal included to administer pain medication as ordered and to report sign/symptoms of potential negative side effects. During the review of Resident #74's Controlled Drug Receipt/Record/Disposition Form with License Practical Nurse (LPN) #1 revealed Resident #74's routine [MEDICATION(S)] capsule 50 mg was not signed off as being administered on the following days: 11/27/21 (3-11 shift) and 11/28/21 (7-3 and 3-11 shift). When asked if Resident #74 received her scheduled [MEDICATION(S)] capsule 50 mg on the days mentioned, she replied, It does not appear that she did because the narcotic count is correct. Review of the November 2021 Order Summary Report revealed the following order: [MEDICATION(S)] 50 mg - give 1 capsule by mouth two times a day for [CONDITION(S)] pain. During the review Control Drug Record Disposition Form revealed the medication [MEDICATION(S)] 50 mg was not administered on the following scheduled days: 11/27/21 at 9:00 p.m., 11/28/21 at 9:00 a.m., and 11/28/21 at 9:00 p.m. An interview was conducted with Resident #74 on 11/30/21 at approximately 2:30 p.m., who denies pain or discomfort. When asked if she receives her scheduled pain medication ([MEDICATION(S)]) as ordered by the physician, she replied, Yes, I believe so. On 12/02/21 at approximately 12:15 p.m., an interview was conducted with Registered Nurse (RN) #1 and the Assistant Director of Nursing (ADON). RN #1 was assigned to administer Resident #74 with her scheduled [MEDICATION(S)] on 11/28/21 (7-3 shift). The RN and ADON reviewed and compared the November 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #74. After they reviewed the two documents, the ADON stated, Resident #74's [MEDICATION(S)] was not administered on 11/27/21 (3-11 shift) and 11/28/21 (7-3 or 3-11) shift. The ADON said the Control Drug Record Disposition Form went from 11/27/21 (7-3 shift) to 11/29/21 indicating Resident #74 did not receive her scheduled [MEDICATION(S)] on the days mentioned because the Control Drug Record count is correct. On 12/01/21 at approximately 1:25 p.m., the above findings were discussed with Administrator, Clinical Service Specialist, Regional RAI Consultant and Clinical Service Specialist. The Administrator stated, The expectation is for the nurses to administer medication as ordered by the physician and/or Nurse Practitioner. Definitions 1. [CONDITION(S)] is a condition characterized by pain in your muscles and fibrous tissues (such as the tendons and ligaments), accompanied by fatigue, low mood, and sleep problems (https://www.drugs.com/condition/[CONDITION(S)].html). 2. [MEDICATION(S)] is used to treat pain caused by nerve damage due to diabetes, shingles ([CONDITION(S)] [MEDICATION(S)]) infection, or spinal cord injury (www.webmd.com).

Based on observation and staff interviews the facility staff failed to ensure medications were labeled and stored in accordance with currently accepted professional principles in 1 out of 4 facility medication carts and 1 out of 2 medication refrigerators. The facility staff failed to ensure one [MEDICATION(S)] pen and antibiotic eye drop (Neo/poly ointment) were dated once opened. The facility staff failed to ensure a multi-dose vial of PPD vaccine was dated once opened. The findings included: A. On 12/30/21 at approximately 2:20 p.m., the medication cart on Alleghery Unit (cart 1) was inspected with License Practical Nurse (LPN) #4. Stored inside the medication cart was an open [MEDICATION(S)] (insulin) pen and antibiotic eye drop (Neo/poly ointment) without an open date. The LPN was asked, When was the insulin pen and antibiotic eye drops open she replied, I have no way of knowing since they (insulin and eye drop) does not have a date indicating when they were open. The LPN said, since the insulin and eye drops do not have an open date, they need to be thrown away and a new insulin pen and eye drop need to be ordered. On 12/01/21 at approximately 1:25 p.m., the above findings were discussed with Administrator, Clinical Service Specialist, Regional RAI Consultant and Clinical Service Specialist. The Clinical Service Specialist stated, All insulin and eye drops are to be dated once open. B. On 11/30/21 at approximately @ 10:30 a.m., the medication refrigerator was inspected on the Tidewater Unit (cart 2) with License Practical Nurse (LPN) #1. Stored inside the medication refrigerator was an open multidose vial of [MEDICATION(S)] (PPD) vaccine without a date when opened. The LPN stated the vial of PPD should have been dated once it was opened. The LPN said since the vial is not dated, there is no way of knowing how long the vial has been in the refrigerator. When asked, how long is PPD solution is good for once opened, she replied, 30 days. The LPN stated, The PPD solution need to be dated once open, so the nurse's will know when the vial was first open and when the PPD solution need to be thrown away. On 12/01/21 at approximately 1:25 p.m., the above findings were discussed with Administrator, Clinical Service Specialist, Regional RAI Consultant and Clinical Service Specialist. The Clinical Service Specialist stated, PPD solution is to be dated once open. Definitions 1. [MEDICATION(S)] (insulin [MEDICATION(S)]) is a man-made form of a hormone that is produced in the body. Insulin is a hormone that works by lowering levels of glucose (sugar) in the blood. Insulin [MEDICATION(S)] is long-acting insulin that starts to work several hours after injection and keeps working evenly for 24 hours. Storing opened (in use) [MEDICATION(S)]: Store the injection pen at room temperature (do not refrigerate) and use within 28 days (www.drugs.com/[MEDICATION(S)].html). 2. Neo/poly ointmentmedication is used to treat or prevent bacterial eye infections (https://www.webmd.com/drugs/2/drug-3896/neo-poly-[NAME]-hc-ophthalmic-eye/details). 3. [MEDICATION(S)] ([MEDICATION(S)] PPD, diluted) is a sterile aqueous solution of a purified protein fraction for intradermal administration as an aid in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Manufacture Guidelines: [MEDICATION(S)] (PPD) vials should be inspected visually for both particulate matter and discoloration prior to administration and discarded if either is seen. Vials is use for more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.

Based on resident interviews, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide evidence that two out of 45 residents were invited to attend a care plan meeting, Resident #47 and Resident #120, in the survey sample. The findings included; 1. Resident #47 was originally admitted to the facility 11/26/19 and readmitted [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/06/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #47 cognitive abilities for daily decision making were intact. In section G(Physical functioning) the resident was coded as requiring extensive assistance with one person assistance with bed mobility, dressing eating, toilet use, personal hygiene and bathing. Extensive assistance of two persons with transfers. On 12/01/21 at approximately, 10:33 AM an interview was conducted with Resident #47 concerning care plan meetings. She stated, No. I don't go. On 12/02/21 at approximately 11:41 AM an interview was conducted with OSM (Other Staff Member) #2 and Corporate Clinical Consultant (Corporate Staff #1) concerning care plan meetings. OSM #2 stated, She had one care plan meeting on 8/07/21 but chose not to participate. The other care plan meetings are not documented in the record. Corporate Staff #1 stated, They should complete the care plan documentation in the medical record. On 12/02/21 at approximately, 1:00 PM an interview was conducted with OSM/Social Services Worker #1 concerning care plan meetings. He stated, She usually don't attend these meetings. He was asked by the surveyor who normally attends the care plan meetings. He stated, Dietary, Director of Activities, The Social Services Coordinator, Therapists, Unit Managers. We've had the meetings. I just can't find any records. I'll find them. 2. Resident #120 was originally admitted to the facility on [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/12/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #120 cognitive abilities for daily decision making were intact. In section G(Physical functioning) the resident was coded as requiring supervision of one person with bed mobility, transfers, locomotion, dressing, eating, and toileting. Requiring independence with bathing. Requiring limited assistance of one person with personal hygiene. On 12/01/21 at approximately 9:45 AM an interview was conducted with Resident #120 concerning care plan meetings. He stated, I don't know anything about this. On 12/02/21 at approximately 12:50 PM an Interview was conducted with OSM #1 concerning care plan meetings. He stated, He usually doesn't participate in the meetings. I keep him informed. He doesn't participate in group activities. He should have care plan meetings every quarter or if there's a significant change or an annual review. His last care plan meeting was 6/15/21. He did not attend. According to the OBRA (Omnibus Budget Reconciliation Act). It should be the next quarter. It should have been scheduled in September. unless there was a change in condition. I don't have the CP invite or meeting documentation. On 12/02/21 Received care plan invite letters from the administrative staff for Resident #120 dated 6/09/21, 3/16/21 and 11/25/20. On 12/02/21 at approximately 3:20 p.m., the above findings were shared with the Administrator, The Corporate Consultant, The Social Services Coordinator and The Corporate Clinical Services Specialist. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

Based on resident interview, staff interviews, and clinical record review, the facility staff failed to accommodate the preference of the resident to have showers prior to 6:00 p.m., for 1 of 45 residents (Resident #39), in the survey sample. The findings included: Resident #39 was originally admitted to the facility 4/30/21 and has not been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/26/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #39's cognitive abilities for daily decision making was intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of two people with bed mobility, transfers, and toileting, extensive assistance of one person with personal hygiene, bathing, and dressing, limited assistance of one person with locomotion and supervision of one person with eating. On 12/1/21 at approximately 5:00 p.m., an interview was conducted with Resident #39. The resident stated approximately two weeks ago during a shower on the stretcher bed she almost slipped off. The resident further stated the males can manage her better on the stretcher bed and she had made it known it was her preference to have her shower during the day shift or prior to 6:00 p.m., yet often the staff comes to take her to the shower after 9:00 p.m., therefore she rejects the shower after the preferred time. At 7:00 p.m., on 12/1/21 Resident #39 hadn't received her shower. An attempt was made to interview the CNA responsible for showering the resident but the response was he is still busy with another resident. An interview was conducted with Certified Nursing Assistant (CNA) #2 on 12/1/21 at approximately 7:15 p.m. CNA #2 stated because resident #39 was in a window bed, her shower was scheduled for evenings on Wednesday and Saturdays. CNA #2 stated she wasn't working with the resident tonight but she was aware the resident preferred her shower prior to 6:00 p.m. An interview was also conducted with the Unit Manager for The Shenandoah Unit on 12/1/21 at approximately 7:45 p.m. The Unit Manager also stated because Resident #39 was in a window bed her shower was scheduled for the evenings. The Unit Manager stated it was possible for a resident to have a bath on the evening shift prior to 6:00 p.m., but that time was usually spent preparing residents for the dinner meal. Review of the shower documentation for November 2021 revealed two days of shower refusals, two days of not applicable and two days of total dependence as well as two days not a Wednesday or Saturday documentation. On 12/2/21 at approximately 11:15 p.m. The Unit Manager for the Shenandoah Unit stated she had spoken with Resident #39 and she stated it remained her preference to receive her shower prior to 6:00 p.m., and the facility would make changes as needed to accommodate the resident. On 12/2/21 at approximately 5:30 p.m., the above findings were shared with the Administrator, Assistant Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

3. The facility staff failed to provide Resident #61 the opportunity to formulate an Advance Directive. Resident #61 was re- admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #61 was assessed as having a BIMS score of 13. A Care Plan dated 10/05/21 indicated this resident Focus- was at risk for unresolved pain and multiple medical problems. Goals- Interventions- Assess for side effects of pain medication. observe for constipation: new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls. During an interview on 12/02/21 at 12:36 PM with the Assistant Director of Nursing (ADON) she was asked if Resident #61 or his Representative had been offered the opportunity to formulate an Advance Directive. The ADON stated, not to her knowledge. 4. The facility staff failed to provide Resident #32 with the opportunity to formulate an Advance Directive. Resident #32 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #32 was assessed as having a BIMS score of 0. A Care Plan dated 10/14/21 indicated this resident Focus - [CONDITION(S)] medication. Goals - Compliant with medication -Goals behavior no agitation - Intervention- GDR - no recent impairment in mood and behavior. During an interview on 12/02/21 at 12:36 PM with the Assistant Director of Nursing (ADON) she was asked if Resident #32 or his Representative had been offered the opportunity to formulate an Advance Directive. The ADON stated, not to her knowledge. 5. The facility staff failed to provide Resident #72 with the opportunity to formulate an Advance Directive. Resident #72 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #72 was assessed as having a BIMS score of 14. Focus- Antipsychotic Medication- Goal modify behavior- Interventions- Psychiatric team will monitor mood and behavior, performance measures Neuropsychiatric symptoms and supportive therapy provided. During an interview on 12/02/21 at 12:36 PM with the Assistant Director of Nursing (ADON) she was asked if Resident #72 or her Representative had been offered the opportunity to formulate an Advance Directive. The ADON stated, not to her knowledge. Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to afford 5 out of 45 residents (Residents #33, 45, 61, 32, and 72) in the survey sample were given the opportunity to formulate an advance directive. The findings included: 1. The facility staff failed to execute the opportunity to provide an advance directive for Resident #33. Resident #33 was originally admitted to the facility 06/26/2021 and readmitted [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/18/2021 coded the resident coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #33 cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring extensive assistance of two person for bed mobility, transfers, dressing and toilet use. Requiring Extensive assistance of one person with personal hygiene, bathing and locomotion on the unit. Supervision after set-up with eating. A review of the clinical record on 12/02/21 revealed there were no advance directives in the clinical record on the above resident. 2. The facility staff failed to execute the opportunity to provide an advance directive for Resident #45. Resident #45 was originally admitted to the facility 03/24/2020 and readmitted [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/05/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #45 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded as requiring supervision set-up only with bed mobility, supervision on and off the unit, eating, toilet use and personal hygiene. Requiring one person physical assistance with bathing. Requiring limited assistance of one person with bathing and dressing. A review of the clinical record on 12/02/21 revealed there were no advance directives in the clinical record on the above resident. On 12/02/21 at approximately 11:29 AM an interview was conducted with Corporate Staff #1 concerning Advance Directives. She stated, There were no advance directives. All patients should be at least offered to complete an Advanced Directive on admission, quarterly and annual reviews. It should start with the initial admission contract and then transition to social services. On 12/02/21 at approximately 3:20 p.m., the above findings were shared with the Administrator, The Corporate Consultant, The Social Services Coordinator and The Corporate Clinical Services Specialist. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

Based on clinical record review, staff interview and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 3 residents (Resident #7 and Resident #98) in the survey sample. The findings included: 1. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) and Notice of Medicare Provider Non-Coverage (NOMNC) letter to Resident #7 who was discharged from skilled services with Medicare days remaining. Resident #7 was admitted to the nursing facility on 05/28/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7's Minimum Data Set (MDS) a significant change with an Assessment Reference Date (ARD) date of 08/25/21 coded Resident #7 a 04 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicated severe cognitive impairment. Review of the SNF Beneficiary Notification provided by the facility was noted that Resident #7 was not issued a SNF ABN or NOMNC letter. Resident #7 started Medicare Part A stay on 05/28/21 and the last covered day was on 07/09/21. Resident #7 was discharged from Medicare Part A services when benefit days were not exhausted. Resident #7 had only used 43 days of her Medicare Part A services with 57 days remaining. Resident #7 should have been issued a SNF ABN and NOMNC letter. An interview was conducted with the Social Worker (SW) on 12/01/21 at approximately 11:15 a.m. The SW said Resident #7 should have been issued an ABN and NOMNC letter when discharged from Medicare A services ending on 07/09/21. The SW said he was not able to locate in the resident's clinical record that an ABN or NOMNC letter was every issued when discharged from skill services ending on 07/09/21. 2. Resident #98 was admitted to the nursing facility on 07/19/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #98's Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) date of 11/05/21 coded Resident #98 a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicated no cognitive impairment. Review of the SNF Beneficiary Notification was noted that Resident #98 was not issued the SNF ABN letter. Resident #98 started a Medicare Part A stay on 07/09/21, and the last covered day of this stay was 08/16/21. Resident #98 was discharged from Medicare Part A services when benefit days were not exhausted. Resident #98 only used 32 days of her Medicare Part A services with 68 days remaining. Resident #98 should have been issued a SNF ABN and NOMNC. The resident was only issued a NOMNC. An interview was conducted with the Social Worker (SW) on 12/01/21 at approximately 11:15 a.m. The SW said only the NOMNC was issued when Resident #98 was discharged from Medicare A services ending on 08/16/21. He said Resident #98 should have been issued an ABN letter along with the NOMNC letter when discharged from skill services ending on 08/16/21. The Administrator, Clinical Service Specialist, Regional RAI Consultant and Clinical Service Specialist were informed of the above findings during the debriefing on 12/01/21 at approximately 1:25 p.m. The facility did not have any further questions or present any further information about the findings. The facility did not have a policy on issuing an ABN or NOMNC letter.

Based on resident record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for 2 of 45 residents (Resident #45 and 106) in the survey sample. The findings included; Resident #45 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/05/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #45 cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring supervision set-up only with bed mobility, supervision on and off the unit, eating, toilet use and personal hygiene. Requiring one person physical assistance with bathing. Requiring limited assistance of one person with bathing and dressing. On 12/02/21 at approximately 12:23 PM an interview was conducted with OSM (Other Staff Member) #1 concerning The Ombudsman Notification. He stated, The ombudsman notification was not sent. The Discharge MDS assessments was dated for 10/08/21 - discharged with return anticipated. According to the facility's documentation, on 10/08/21 Resident #45 was transported from [CONDITION(S)] to the local hospital. On 12/02/21 at approximately 3:20 p.m., the above findings were shared with the Administrator, The Corporate Consultant, The Social Services Coordinator and The Corporate Clinical Services Specialist. An opportunity was offered to the facility's staff to present additional information but no additional information was provided. 2. The facility staff failed to ensure the local State Long-Term Care Ombudsman was notified that Resident # 106 was discharged to the hospital on 9/27/21. Resident #106 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #106's most recent Minimum Data Set (MDS) was a significant change with an Assessment Reference Date (ARD) of 10/14/21. Resident #106's Brief Interview for Mental Status (BIMS) was coded as a 10 out of 15, indicating the resident had mild cognitive impairment but was able to perform some daily decision making. Resident #106's Clinical Census was reviewed and revealed the resident was discharged on [DATE]. Resident #106's Nursing Progress Notes were reviewed and are documented in part, as follows: 9/27/2021 13:52 (14:52 p.m.)Transfer Out (Acute/Emergency) Reason for transfer: Evaluation of left toes. 9/28/2021 02:15 a.m. Discharge Summary Note Text: A F/U (follow-up) call made to Name (hospital) to check on patient status, Nurse noted patient is admitted to room [ROOM NUMBER] for observation pending a surgical procedure. On 12/2/21 at 11:00 a.m., the facility Social Worker was asked for documentation to show that the local State Long-Term Care Ombudsman was notified that Resident #106 was discharged to the hospital on 9/27/21. The Social Worker was unable to locate any documents that the Ombudsman had been notified of Resident #106's discharge on 9/27/21. On 12/2/21 at 12:00 p.m. an interview was conducted with the facilities Social Services Care Coordination Specialist regarding documentation that the State Long-Term Care Ombudsman was notified by the facility that Resident #106' was discharged to the hospital on 9/27/21. The Social Services Care Coordination Specialist stated, We have no documentation to support that the Ombudsman was notified of Name (Resident #106) hospital discharge on 9/27/21. The notifications should be sent monthly. Both of our social workers are new. The facility policy titled Notice of discharge date d 9/21 was reviewed and is documented in part, as follows: Policy: Copies of notices for emergency transfers must be sent to the ombudsman, but they may be sent when practicable and may be provided in the form of a list of residents on a monthly basis. On 12/2/21 at 3:00 p.m., a pre-exit debriefing was conducted with the Administrator and the acting Director of Nursing where the above information was shared. Prior to exit no further information was shared.

Based on staff interview and clinical record review, the facility staff failed to offer a bed hold for 1 of 45 Residents, Resident #45. The findings included: For Resident #45 the facility failed to offer the Resident a bed hold when they were discharged to a local hospital. Resident #45 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/05/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #45 cognitive abilities for daily decision making were intact. In section G(Physical functioning) the resident was coded as requiring supervision set-up only with bed mobility, supervision on and off the unit, eating, toilet use and personal hygiene. Requiring one person physical assistance with bathing. Requiring limited assistance of one person with bathing and dressing. The Discharge MDS assessments was dated for 10/08/21 - discharged with return anticipated. According to the facility's documentation, on 10/08/21 Resident #45 was transported from [CONDITION(S)] to the local hospital. The surveyor was unable to locate any information in the Resident's clinical record to indicate a bed hold had been offered. On 12/02/21 at approximately 11:32 AM an interview was conducted with corporate staff #1 concerning the bed hold notice. She stated, No bed hold was sent. It would be expected to be given. Our admissions department would call and offer the bed hold. On 12/02/21 at approximately 3:20 p.m., the above findings were shared with the Administrator, The Corporate Consultant, The Social Services Coordinator and The Corporate Clinical Services Specialist. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

Based on clinical record review and staff interview, the facility staff failed to complete the required discharge Minimum Data Set (MDS) assessment within the required timeframe after a planned discharge from the facility for 1of 45 residents (Resident #2), in the survey sample. The findings included; Resident #2 was originally admitted to the facility 7/7/21 and had never been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/13/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #2's cognitive abilities for daily decision making were intact On 12/1/21, during the finalization of the sample the Resident Assessment task triggered for review. It revealed the Centers for Medicare/Medicaid Services (CMS) identified Resident #2 hadn't had a MDS assessment submitted to the MDS databank for more than 120 calendar days. Review of the clinical record revealed a nurse's dated 08/25/2021 at 12:21 p.m., which read; he resident was discharged home today around 11:45am. She was given discharge paperwork including instructions and prescriptions and she verbalized her understanding. She was reminded of her belongings to take home. On 12/1/21 at approximately 4:40 p.m., an interview was conducted with the MDS coordinator who reviewed Resident #2's MDS history. The MDS coordinator stated the clinical record revealed Resident #2's discharge MDS Tracking Record was dated 8/25/21 and it required transmittal to the CMS databank. The MDS Coordinator stated at approximately 5:45 p.m., the discharge tracker had been submitted and accepted. CMS's Resident Assessment Instrument Version 3.0 Manual, dated October 2019, Chapter 2, page 2-36 instructions read; the Death in Facility Tracking Record must be completed when the resident dies in the facility and it must be completed within 7 days after the resident's death, which is recorded in item A2000. discharge date (A2000 + 7 calendar days). The Tracking Record must be submitted within 14 days after the resident's death, which is recorded in item A2000, discharge date (A2000 + 14 calendar days). On 12/1/21 at approximately 5:30 p.m., the above findings were shared with the Administrator and the Director of Nursing. They were afforded the opportunity to present additional information but; they did not.

The facility staff failed to ensure the one resident (Resident #93's) [CONDITION(S)] communication book was updated timely during [CONDITION(S)] treatments in a survey sample of 43 residents. The findings included: Resident #93 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #93 was involved in an accident while being transported to her [CONDITION(S)] appointment on 11/19/21. Resident #93's [CONDITION(S)] communication book had not been updated since 11/19/21. An Annual Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Speech, Vision and Hearing as being able to understand others. In the area of Cognitive Patterns this resident was assessed in the area of Brief Interview for Mental Status (BIMS) as a (04). In the area of Activities of Daily Living (ADL's) this resident was assessed as a (4/3) for bed mobility - total dependence- two person physical assist. In the area of Transfers - this resident was assessed as a 4/3 - two person physical assist. In the area of Ambulation- this resident was assessed as unable to ambulate. Not able to balance self without physical assistance. This resident was assessed as using a wheelchair for mobility with assistance. A Care Plan dated 08/07/21 indicated: Focus- Resident #93 has pain or potential for pain related to impaired mobility, [CONDITION(S)] and cervical vertebra fracture. Goal- comfort level will be maintained; Interventions- administer pain medication as ordered, note effectiveness, assist with positioning to enhance comfort level. Focus- Resident is on Antiplatelet therapy/blood thinner placing patient at risk for bleeding/brushing. Goal- Resident will not have an avoidable negative outcome from antiplatelet/blood thinner therapy. Interventions- Use extra precautions when providing ADL care and treatment to prevent bleeding or brushing problems. Focus- Resident has renal Disease requiring [CONDITION(S)] - Goal- Resident #93 will receive [CONDITION(S)] services as ordered with no avoidable negative effects. interventions- Coordinate with [CONDITION(S)] center for [CONDITION(S)] treatment as ordered. Communicate with [CONDITION(S)] provider regularly via pre/post treatment notes. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A [CONDITION(S)] Communication Sheet dated 11/19/21 indicated: Weight -pre- 39.0 Weight Post - blank - Labs - No, Change in Condition- None, Changes in medication- none, Diet to Center- blank, Nutrition % Taken - , Signature (NS). Observation of the communication sheet on 12/02/21 did not indicate any communication of Resident #93's accident was recorded. There was no indication that Resident #93 did not receive [CONDITION(S)] treatment on 11/19/21 and was transported to the hospital via 911 on this date. There was no additional communication in the [CONDITION(S)] Communication Book after the entry of 11/19/21. During an interview on 12/02/21 at 11:05 a.m. with the Second Floor Unit Manager, she stated, that was all the documentation. Resident #93 continued to receive [CONDITION(S)] treatments on MWF.

Based on observation, staff interviews, and review of the facility's policy, the facility staff failed to store food under sanitary conditions. The finding included; On 12/01/21 at approximately 11:00 AM., during a follow up visit to the kitchen with OSM/CDM (Other Staff Member/Certified Dietary Manager) #5. An inspection of the dairy cooler was made. Located inside of the dairy cooler were multiple cartons of milk and spilled milk with a strong odor. The CDM stated, A staff member normally keep the cooler clean but due to the Thanksgiving holiday it was not cleaned. He usually cleans it once a week. On 12/02/21 at approximately 3:20 p.m., the above findings were shared with the Administrator, The Corporate Consultant, The Social Services Coordinator and The Corporate Clinical Services Specialist. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

Based on observation, staff interview and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for 1 of 45 residents (Resident #74) in the survey sample. The findings included: The facility staff failed to ensure Resident #74's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #74 was admitted to the nursing facility on 10/18/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #74's Minimum Data Set (MDS - an assessment protocol) an annual assessment with an Assessment Reference Date of 10/23/21 coded Resident #74's Brief Interview for Mental Status (BIMS) scored a 13 out of a possible score of 15 indicating no cognitive skills for daily decision-making. Resident #74's person-centered care plan with a revision date 10/25/21 documented resident has pain or potential for pain due to recent fall with fracture and skin breakdown. The goal set for the resident by the staff is to maintain comfort level will be achieved and managed to patient's satisfaction through next review (01/17/22). One intervention/approaches to manage goal included to administer pain medication as ordered and to report sign/symptoms of potential negative side effects. During the review of Resident #74's Controlled Drug Receipt/Record/Disposition Form with License Practical Nurse #1 revealed Resident #74's routine [MEDICATION(S)] capsule 50 mg was not signed off as being administered on the following days: 11/27/21 (3-11 shift) and 11/28/21 (7-3 and 3-11 shift). When asked if Resident #74 received her scheduled [MEDICATION(S)] capsule 50 mg on the days mentioned, she replied, It does not appear that she did because the narcotic count is correct. During the review Control Drug Record Disposition Form revealed the medication [MEDICATION(S)] 50 mg was not administered on the following days: 11/27/21 at 9:00 p.m., 11/28/21 at 9:00 a.m., and 11/28/21 at 9:00 p.m. During the review of Resident #74's (MAR) for November revealed the following order: [MEDICATION(S)] 50 mg - give 1 capsule two times a day at 9:00 a.m., and 9:00 p.m., for [CONDITION(S)] pain. Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 12/02/21 at approximately 12:15 p.m., an interview was conducted with Registered Nurse (RN) #1 and the Assistant Director of Nursing (ADON). RN #1 was assigned to administer Resident #74 with her scheduled [MEDICATION(S)] on 11/28/21 (7-3 shift). The RN and ADON reviewed and compared the November 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #74. After they review the two documents, the ADON stated, Resident #74's [MEDICATION(S)] was not administered on 11/27/21 (3-11 shift) and 11/28/21 (7-3 or 3-11) shift. The ADON said the control sheet goes from 11/27/21 (7-3 shift) to 11/29/21 indicating Resident #74 did not receive her scheduled [MEDICATION(S)] on the days mentioned because the Control Drug Record count is correct. When asked if the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 12/01/21 at approximately 1:25 p.m., the above findings were discussed with Administrator, Clinical Service Specialist, Regional RAI Consultant and Clinical Service Specialist. The facility did not have any further questions or present any further information about the findings Definitions 1. [CONDITION(S)] is a condition characterized by pain in your muscles and fibrous tissues (such as the tendons and ligaments), accompanied by fatigue, low mood, and sleep problems (https://www.drugs.com/condition/[CONDITION(S)].html). 2. [MEDICATION(S)] is used to treat pain caused by nerve damage due to diabetes, shingles ([CONDITION(S)] [MEDICATION(S)]) infection, or spinal cord injury (www.webmd.com).

Based on observation, resident interview, staff interview and review of facility documents, the facility's staff failed to have the call bell accessible and functional for resident's use. For 1 of 45 residents (Resident #47), in the survey sample. The Findings included; Resident #47 was originally admitted to the facility [DATE] and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Fracture of Upper and Lower End of the Right Fibula and Hypertensive [CONDITION(S)] with Heart Valve. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #47cognitive abilities for daily decision making were intact. In section G(Physical functioning) the resident was coded as requiring extensive assistance one person assistance with bed mobility, dressing eating, toilet use, personal hygiene and bathing. Extensive assistance of two persons with transfers. On [DATE] at approximately 10:21 AM an interview was conducted with Resident #47 concerning her care. She stated, I am hurting can you please get my nurse, She was asked by the said surveyor to push her call bell to notify nursing staff of her pain. Resident #47 then stated, I can't use my right hand well do to having a stroke. The call bell was observed clamped to the sheet near Resident's left shoulder. The said surveyor pushed the call bell but noticed the light on the wall didn't light up. The surveyor informed resident that she will let the nurse know that she needs her. On [DATE] at approximately 10:25 AM., Licensed Practical Nurse (LPN) #3 was notified that resident needed assistance and immediately entered the room. She repositioned the resident and reminded her that she had given her pain medication almost an hour ago. She pushed the call bell and notice that it was only working if pushed from the wall. LPN #2 entered room shortly there after (10:26 AM) stating that she will let maintenance know that the call bell isn't working. The call light would only work if pushed at the wall. Resident is not close to the wall. Call Bell Timeline below reads: [DATE] 12:07 PM Surveyor entered room. Call bell not working. Call bell not within reach. No substitute given. [DATE] 1:02 PM entered Resident's room (Surveyor). Call bell still not working. No alternative call system given to resident to alert staff was seen. [DATE] at approximately 1:05 PM, LPN #2 states that she put the order in and had called maintenance. No substitute call bell was observed. [DATE] 1:35 PM Followed up on nurse LPN #3 concerning call bell. Asked her if she would follow up with surveyor once maintenance repairs the call bell. She stated that she will call downstairs to try to get maintenance. She also stated that the resident's nurse is on another unit but will return later. [DATE] 1:50 PM Nurse informed me that maintenance is in the residents' room fixing her call bell. Spoke to maintenance (OSM/Other Staff Member) #3 he stated, The call bell unit had to be replaced from the wall with new cord. On [DATE] at approximately, 1:55 PM an interview was conducted with LPN #2 and LPN #3. They were asked moving forward what should have been done concerning Resident #47 and her call bell. LPN #3 stated, that she would have continued to call maintenance. They were also asked if they could have offered resident an alternative to the call bell. LPN #2 stated. I checked on the resident often. LPN #3 stated, We could have used a bell. A review of the call bell work order reads: Created on [DATE] at 10:22 AM. Time Log: 30 minutes by OSM #3. OSM #3: The light was broken inside and then I replaced the plate and the cord for the call light. The facility's policy: Call Lights: Accessibility and Timely Response. Dated: [DATE]. Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. 5. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed. 6. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied . (Examples include: replace call light, provide a bell or whistle, increase frequency of rounding, etc.) On [DATE] at approximately 3:20 p.m., the above findings were shared with the Administrator, The Corporate Consultant, The Social Services Coordinator and The Corporate Clinical Services Specialist. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

Based on information gleamed during a complaint investigation, staff interviews, clinical record review, and review of facility documents, the facility's staff failed to follow a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #4), in the survey sample. The findings included: Resident #4 was originally admitted to the facility 7/27/21, and was discharged from the facility 8/1/21, after a change in status was observed. Resident # 4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The five day Prospective Payment System (PPS) Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/1/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 4 out of a possible 15. This indicated Resident #4's cognitive abilities for daily decision making was severely impaired. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, eating, personal hygiene and bathing and extensive assistance of one person transfers, personal hygiene, off unit locomotion, toileting, dressing and bed mobility, limited assistant with walking in room, supervision of one person with eating and on unit locomotion. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give one tablet by mouth once daily as needed for a systolic blood pressure greater than 150 mmHg. Review of Resident #4's vital signs revealed on 7/30/21 a blood pressure reading of 168/84 at 00:58. There was no signature of documentation indicating the administration of the as needed [MEDICATION(S)] Hcl for a systolic blood pressure greater than 150 mmHg. On 8/1/21 at 10:21 the resident had a blood pressure reading of 157/84. There was no signature of documentation indicating the administration of the as needed [MEDICATION(S)] Hcl for a systolic blood pressure greater than 150 mmHg. On 8/1/21 at 22:09 the resident was with a blood pressure reading of 217/121. Documentation stated the resident was transferred to a local hospital. An interview was conducted with the Registered Nurse Clinical Services Specialist at approximately 1:00 p.m. The Registered Nurse Clinical Services Specialist stated audits are conducted for residents who are discharged and the audit revealed there were medication discrepancies for Resident #4 and as a result of this resident's chart audit other resident audits were conducted and staff education was performed. On 8/19/21 at approximately 1:30 p.m., the above findings were shared with the Administrator and the Registered Nurse Clinical Services Specialist. They understood the concern and provided documentation of the audit conducted by the facility revealing medication administration concerns.

Based on observation, resident and staff interviews and clinical record review the facility staff failed to ensure 3 of 5 residents (Resident #1, #2 and Resident #3) who were unable to carry out activities of daily living (ADL) receive the necessary services to include showers. The Findings Included; 1. Resident #1 was admitted to the facility on [DATE] and have never been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Minimum Data Set (MDS), a Quarterly assessment with an Assessment Reference Date (ARD) of 05/01/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #1 cognitive abilities for daily decision making were moderately impaired. In section G(Physical functioning) the resident was coded as requiring supervision of one person with bed mobility, transfers, dressing, eating, toileting and personal hygiene. Requires physical help of one person with bathing. The care plan reads: FOCUS: Resident #1 demonstrates the need for ADL (Activity of Daily Living Assistance) due to a recent hospitalization , history of [CONDITION(S)] (Urinary Tract Infections, pain and impaired immobility. Date Created: 10/02/20. Date Revised: 05/07/21. GOAL: Resident #1 will receive necessary level of ADL assistance through the next review. INTERVENTIONS: Provide assistance with bathing and hygiene as needed. Dated Initiated and Created: 10/02/20. During the initial tour on 8/17/21 at approximately 3:10 PM, Resident #1 was observed resting in her bed. She was asked if she was receiving showers. She stated, I'd like a shower. I think I get them on Wednesdays. On 8/18/21 an interview was conducted at approximately 10:45 AM with Resident #1 concerning showers. She stated, I think I received only one shower a month ago. They never ask me if I want one. I feel okay about getting more showers. On 8/18/21 at 3:30 PM an interview was conducted with LPN (Licensed Practical Nurse) #1 concerning showers. She stated, Resident #1 refuses showers sometimes. If a resident refuses showers the Nurses Aide will let the nurse know and the nurse will verify with the resident. It should be documented in the care tracker. A review of the shower schedule for Resident #1 reads: Evening Shift (3-11).Wednesday and Saturdays room [ROOM NUMBER] W (Window bed). According to the ADL shower documentation record Resident #1 did not receive a shower on her scheduled shower days: 08/04/21 (na recorded) 8/07/21 (na recorded) 8/11/21 BB (Bed Bath), 8/14/21 (rr/resident refused), 8/18/21 (left blank). On 8/18/21 at approximately 4:50 PM an interview was conducted with CNA (Certified Nurse's Aide) #7 concerning showers. She stated. Residents should get showers twice a week. The door residents take showers on Monday and Thursdays and the Window residents take showers on Wednesday and Saturdays. If they refuse showers we will tell the nurse. The nurse will talk to the resident and if they still refuse the nurse documents it and we will see if they will let us give them a bed bath instead. 2. Resident #2 was originally admitted to the facility 04/14/21 and has never been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 07/21/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #2 cognitive abilities for daily decision making were intact. In section G(Physical functioning) the resident was coded as requiring extensive assistance of two persons with bed mobility, transfers, locomotion, dressing, toileting, personal hygiene. Resident is total dependent with bathing. Requires supervision of one person with eating. The care plan reads: FOCUS: Resident #2 demonstrates the need for ADL Assistance due to impaired mobility and physical limitation. Dated: 4/14/21. Revised on 4/23/21. GOAL: Will receive necessary level of ADL assistance through the next review. Date Created and Initiated: 4/14/21. INTERVENTIONS: Provide assistance with bathing and hygiene as needed. Created and Revised on: 4/14/21. On 8/18/21 at approximately 4:30 PM during the initial tour Resident #2 was observed resting in her bed. She was asked if she was receiving showers. She stated, I've only had one shower since I've been here. It would sure help me if I could get a shower. On 8/18/21 at 4:40 PM an interview was conducted with CNA (Certified Nurse's Assistant) #7 concerning Resident's receiving showers. She stated, Resident #2 refuses showers. If a resident refuses showers we tell the nurse in charge of them and we document they refused. On 8/19/21 at approximately 10:48 AM an interview was conducted with LPN #3 concerning resident showers. She stated, Resident #2 received a shower last week. I saw CNA's giving her a shower. I wasn't her nurse on yesterday evening but I'm her nurse today. She's known to refuse showers. On 8/19/21 at approximately 11:05 AM CNA #5 was observed by the said surveyor entering Resident #2's room with a shower bed and quickly exiting the room with the shower bed. CNA #5 was approached by the surveyor concerning what took place. She stated, I thought Resident #2 was requesting a shower, but she wasn't. She was scheduled to get her shower on yesterday but she refused it. I documented it in the Care Tracker. A review of the shower schedule for Resident #2 reads: Evening Shift (3-11). Wednesday and Saturdays room [ROOM NUMBER] W (Window bed). According to the ADL documentation record for August 2021. Resident #2 did not receive any scheduled showers on Wednesday August 4th, Saturday August 7th, Saturday August 14th, and Wednesday August 18th, 2021. There were no record of showers documented for Resident #2 on any day from 08/01/21 to 08/19/21. 3. Resident #3 was admitted to the facility on [DATE] and discharged on [DATE] to an acute care facility and readmitted back to the Long Term Care Facility on 05/07/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Minimum Data Set (MDS), a discharged assessment with an Assessment Reference Date (ARD) of 05/29/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of 15. This indicated Resident #3 cognitive abilities for daily decision making were intact. In section G(Physical functioning) the resident was coded as requiring extensive assistance of two persons with bed mobility, transfers, dressing, eating, toileting, personal hygiene and bathing. Requires extensive assistance of one person for walking. Requires limited assistance of one person with locomotion on and off the unit. Requires supervision with eating, set-up help only. The Careplan dated 5/08/21 reads: FOCUS: Resident #3 demonstrates the need for ADL (Activities of Daily Living) assistance r/t (relating to) [CONDITION(S)], [CONDITION(S)], CAD ([CONDITION(S)]), muscle weakness and dementia. Date Initiated and Created on: 5/07/21. Goal: Resident #3 will receive necessary level of ADL assistance through the next review. Date Created on 04/26/21. Date Created on 05/07/21. INTERVENTION: Provided assistance with bathing and hygiene as needed. Date Initiated and Created on: 04/26/21. A review ADL (Activities of Daily Living) document record reveal Resident #3 shower schedule reads: room [ROOM NUMBER] W, Wednesdays and Saturday, Evening shift (3-11). Resident #3 received only one bed bath on 04/27/21 during the 3-11 shift. No documentation of a shower was recorded from 04/25/21-04/30/21. According to the ADL documentation record Resident #3 showers were assigned to be given on Tuesday and Friday evening shift (3-11) Resident #3 did not receive his required two showers a week until 5/18/21 (Tuesday) 5/21/21 (Friday) 5/25/21(Tuesday) and 5/28/21 (Friday). Resident #3 had returned to the facility from an acute care facility on 05/07/21 and should have continued to receive his required showers. On 8/19/21 at approximately 12:15 PM an interview was conducted with RN (Registered Nurse) #1 concerning Resident #3 receiving ADL care including showers. She stated, He had periods that he didn't take medications. His wife would call concerning his showers, there was a time Resident #3 refused showers and being shaved. We don't have the refusal documented anywhere. This mostly happened when he was first admitted here and in a different room. When he went out to the hospital and was admitted back to another room he didn't refuse care. A couple of times I asked the nurses to make sure to document refusals. We educated the CNAs (Certified Nursing Assistants) to offer a bed bath if they refused. The CNA would tell the nurses they we would document the refusal in the clinical record. On 8/19/21 at 12:30 PM an interview was conducted with CNA (Certified Nurse Assistant) #6. Concerning the above allegations. She stated, Sometimes he wouldn't want to shower. When he returned back to my unit (after hospital admission) he had showers. We offer bed baths if they refuse showers. He brushed his own teeth. When he came the first time I gave him a bed bath in the room. He took showers twice a week. Policy: Activities of Daily Living (ADLs). Date Implemented: 1/01/21. Date Reviewed/Revised: 7/31/21. The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. This includes the resident's ability to: (1). Bathe, dress, and groom. On 8/19/2021 At approximately 1:00 PM an interview was conducted with the administrator concerning the above allegations. She stated, Me and the Social Services Coordinator had spoken to the complainant on several occasions concerning Resident but did not document the conversations. On 08/19/21 at approximately 1:05 PM an interview was conducted with RN #1 reviewing Resident #3's ADL sheet. She stated, I don't see a code to delineate RR (Resident Refusal). We should see that the resident refused ADL Care on the document. I see NA's (Not Applicable) documented instead of the putting (rr/Resident Refused). That's not acceptable. We would expect the CNA's to document refusal and not NA in regards to baths and showers and ADL care. We have since educated the staff on the proper way to document on the ADL sheet. On 08/19/21 at approximately 2:00 p.m., the above findings were shared with the Administrator, The Acting Director of Nursing and Corporate Clinical Specialist. An opportunity was offered to the facility's staff to present additional information but no additional information was provided. Complaint Deficiency

Based on observations, staff interviews, clinical record review, and facility document review the facility staff failed to provide an environment that was free of hazards to prevent accidents for 13 of 47 residents in the survey sample, Resident's #12, #18, #19, #20, #21, #25, #26, #27, #28, #29, #30, #31, and #32 resulting in the identification of Immediate Jeopardy. The facility staff failed to ensure safe coffee temperatures on 6/23/16 to prevent an avoidable accident for Resident #18 resulting in second degree abdominal burns after spilling hot coffee on self, and on 3/22/17 during this survey coffee served to Resident's #12, #19, #20, #21, #25, #26, #27, #28, #29, #30, #31, and #32 during the lunchtime meal in all four dining rooms was identified at temperatures sufficient to cause tissue injury and third degree burns resulting in the identification of Immediate Jeopardy. The findings included: On 3/22/17 at approximately 12:15 p.m. after completing food temperatures in the main facility kitchen the facility prepared food carts left the kitchen for the 4 individual unit dining room steam tables. Surveyor #1 and the Director of Dietary Services followed the food cart enroute to the Tidewater Unit resident dining room. After the lunchtime food was retemped in the steam table, the staff began serving. One resident was observed being served a cup of hot tea. The surveyor asked the Director of Dietary Services to pour a second cup of hot tea and obtain a temperature. The cup of hot tea was 139 degrees Fahrenheit. Next the surveyor observed Resident #28 being served a cup of coffee without a lid and resident began drinking it. The Director of Dietary Services was then asked to pour another cup of coffee and obtain a temperature. The temperature of the coffee was 169.3 degrees Fahrenheit. The Director of Dietary Services stated, That's much better than the hot tea temperature. When asked why by the surveyor, the Director of Dietary Services stated, Because it's a lot hotter than the tea well maybe it's too hot. The surveyor asked the Director of Dietary Services if she was aware of the federal guidelines for hot liquids and serious burns. The Director of Dietary Services stated, No. The surveyor made the Director of Dietary Services aware that hot liquid at 155 degrees Fahrenheit with skin exposure of 1 second had the potential to cause a third degree burn jeopardizing residents. The Director of Dietary Services stated, This coffee is too hot; it has to be cooled down before we can serve it. Immediately after the Director of Dietary Services made the last comment an Occupational Therapist (OT) grabbed a coffee cup and poured a cup of the coffee from the same container that was just temped at 169.3 degrees Fahrenheit for Resident #19. The Director of Dietary Services immediately told the OT, The coffee is too hot to serve; it needs to be cooled down first. The OT stated, It's fine I will get her some cream for it. The OT took the cup of hot coffee and immediately walked approximately 25 feet into Resident #19's room and placed it on her lunch tray. The OT never obtained or added any creamer to Resident #19's cup of coffee prior to placing on her lunch tray and did not verbalize to the resident that the coffee was hot. After placing the coffee on the resident's lunch tray the OT walked out of the room. This surveyor was standing in the hallway at Resident #19's door when the OT exited. The surveyor asked the OT why she had dismissed the warnings of the Director of Dietary Services that the coffee was too hot to be served and needed to be cooled down before it could be served. The OT stated, I'm going to get her some cream to cool it off. The surveyor stated, But you had knowledge the coffee was too hot and you placed it on the residents tray and walked out? At this point the Director of Dietary Services was standing with us and the OT stated, What, are we just not supposed to give her the coffee then. The Director of Dietary Services stated to the OT, I told you the coffee was too hot and needed to be cooled down before it could be served. The industrial coffee maker in the Tidewater dining room was broken so the coffee for lunch was obtained from the Piedmont dining room industrial coffee maker and brought over in a tall pump thermos container. Coffee was not removed from the residents after staff had knowledge of extreme hot temperatures. Resident #28 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS) assessment was an Admission with an Assessment Reference Date (ARD) of 3/2/17. The Brief Interview for Mental Status (BIMS) was conducted by a staff assessment which indicated Resident #28 was modified independent regarding tasks of daily living. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating = the resident was coded as requiring supervision with 1 person physical assist. Under G0400 Functional Range of Motion the resident was coded as having upper extremity and lower extremity impairment on 1 side (right). Resident #19 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS) assessment was an Admission with an Assessment Reference Date (ARD) of 2/20/17. The Brief Interview for Mental Status (BIMS) was a 15 out of a possible 15 which indicated Resident #19 was cognitively intact and capable of daily decision making. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating = the resident was coded as requiring supervision with setup help only. On 3/22/17 at approximately 12:30 p.m. in the Piedmont Unit dining room during lunch, immediately after Resident #31 and #32 received coffee from the industrial coffee maker, the Surveyor #2 asked the Dining Services staff member to obtain the temperature of a cup of coffee. The temperature of the coffee was 160 degrees Fahrenheit. The Dining Services staff member stated to the surveyor, Staff never temps coffee. There was no staff to assist either resident. Coffee was not removed from the residents after staff had knowledge of extreme hot temperatures. Resident #31 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS) assessment was an Admission with an Assessment Reference Date (ARD) of 2/20/17. The Brief Interview for Mental Status (BIMS) was a 15 out of a possible 15 which indicated Resident #31 was cognitively intact and capable of daily decision making. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating= the resident was coded as requiring supervision with setup help only. Resident #32 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS) assessment was an Admission with an Assessment Reference Date (ARD) of 3/14/17. The Brief Interview for Mental Status (BIMS) was a 14 out of a possible 15 which indicated Resident #32 was cognitively intact and capable of daily decision making. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating = the resident was coded as being independent with setup help only. On 3/22/17 at approximately 12:30 p.m. in the Allegheny Unit dining room during lunch Residents #12, #20, #21, #25, #26, and #27 were observed being served and drinking coffee from the industrial coffee maker. The Surveyor asked the Dining Services staff member to obtain the temperature of a cup of coffee from the industrial coffee maker; the coffee temperature was 171 degrees Fahrenheit. Coffee was not removed from the residents after staff had knowledge of extreme temperatures. Resident #12 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS) assessment was an Admission with an Assessment Reference Date (ARD) of 8/12/16. The Brief Interview for Mental Status (BIMS) was an 8 out of a possible 15 which indicated Resident #12 was moderately impaired with cognitive skills for daily decision making. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating = the resident was coded as requiring supervision with setup help only. Resident #20 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS) assessment was an Annual with an Assessment Reference Date (ARD) of 8/10/16. The Brief Interview for Mental Status (BIMS) was conducted by a staff assessment which indicated Resident #20 had long and short term memory problems and was moderately impaired with cognitive skills for daily decision making which includes making poor decisions and required cues and supervision. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating= the resident was coded as requiring limited 1 person physical assist. Under G0400 Functional Range of Motion the resident was coded as having upper extremity and lower extremity impairment on 1 side. Resident #21 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS) assessment was an Annual with an Assessment Reference Date (ARD) of 10/16/16. The Brief Interview for Mental Status (BIMS) was conducted by a staff assessment which indicated Resident #21 had long and short term memory problems and was moderately impaired with cognitive skills for daily decision making. Which includes making poor decisions and required cues and supervision . Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating = the resident was coded as requiring supervision with 1 person physical assist. Under G0400 Functional Range of Motion the resident was coded as having upper extremity and lower extremity impairment on 1 side. Resident #25 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS) assessment was an Annual with an Assessment Reference Date (ARD) of 12/3/16. The Brief Interview for Mental Status (BIMS) was a 13 out of a possible 15 which indicated Resident #25 was cognitively intact and capable of daily decision making. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating = the resident was coded as requiring supervision with setup help only. Resident #26 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS) assessment was an Admission with an Assessment Reference Date (ARD) of 10/3/16. The Brief Interview for Mental Status (BIMS) was a 13 out of a possible 15 which indicated Resident #26 was cognitively intact and capable of daily decision making. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating = the resident was coded as requiring supervision with one person physical assistance. Resident #27 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS) assessment was an Annual with an Assessment Reference Date (ARD) of 7/8/16. The Brief Interview for Mental Status (BIMS) was a 9 out of a possible 15 which indicated Resident #27 was moderately impaired with cognitive skills for daily decision making. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating= the resident was coded as requiring limited one person assistance. On 3/22/17 at approximately 12:20 p.m. in the Shenandoah Unit dining room during lunch Surveyor #3 observed Resident's #29 and #30 being served coffee from the industrial coffee maker. The Surveyor asked the Dining Services staff member to obtain the temperature of a cup of coffee from the industrial coffee maker, the coffee temperature was 167 degrees Fahrenheit. Coffee was not removed from the residents after staff had knowledge of extreme temperatures. Resident #29 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS) assessment was an Admission with an Assessment Reference Date (ARD) of 10/22/16. The Brief Interview for Mental Status (BIMS) was a 00 out of a possible 15 which indicated Resident #29 was severely cognitively impaired and incapable of daily decision making. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating = the resident was coded as requiring supervision with one person physical assistance. Resident #30 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS) assessment was an Admission with an Assessment Reference Date (ARD) of 12/15/16. The Brief Interview for Mental Status (BIMS) was conducted by a staff assessment which indicated Resident #30 had long and short term memory problems and was moderately impaired with cognitive skills for daily decision making. Which includes making poor decisions and required cues and supervision. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating = the resident was coded as requiring limited 1 person physical assist. According to an American Burn Association document entitled Fire and Burn Safety for Older Adults Educator's Guide, under the heading 'General Background Information .Risk Factors .Physical Changes', the document read Older adults experience a myriad of physical and cognitive changes associated with the aging process that makes them more vulnerable to fire and burn injuries . there are significant changes in sensory perception. The ability to see, hear and feel potential fire and burn dangers diminishes proportionally as one gets older .Since older adults also have thinner skin, they may experience a much deeper burn than a younger person, when exposed to the same amount of flame or other burn injury source Under the heading 'Working with the Older Adult Population', the document continues With 12.5 % of the population age 65 and older, there is a need to assess and address injury risks affecting them as they age. According to a document based on the above Burn Association Kit, found at http://www.ameriburn.org/Prevent/2000Prevention/Scald2000PrevetionKit.pdf: The severity of injury with scalds depends on two factors - the temperature to which the skin is exposed and the length of time that the hot liquid is in contact with the skin . When the temperature of a hot liquid is increased to 140o F / 60o C. it takes only five seconds or less for a serious burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180o F./ 71-82o C. degrees, resulting in almost instantaneous burns that require surgery to heal. The two factors addressed above are underscored in a Burn Foundation document retrieved from the Internet : Which states Hot Water Causes a Third Degree Burns . .in 1 second at 156º .in 2 seconds at 149º .in 5 seconds at 140º .in 15 seconds at 133º. https://www.burnfoundation.org/programs/resource.cfm?c=1&a=3 On 3/22/17 at approximately 1:22 p.m. the Administrator was asked if the facility had a hot liquid policy, and if there had been any resident incidents with hot liquids. On 3/22/17 at approximately 3:40 p.m. the Administrator confirmed that there was no facility policy on hot liquids. On 3/22/17 at approximately 4:00 p.m. the Administrator provided the surveyor with an incident report dated 6/23/16 for Resident #18 which is documented in part, as follows: Incident Location: Resident's Room Incident Description: Private caregiver provided by family reported to the writer that patient spilled hot coffee on self and have burn at 17:30 (5:30 p.m.) Immediate Action Taken: The writer assessed the patient. Noted burn on bilateral lower quad. On the left quad is blister. On right quad is scar. Patient denies any pain. Cold compress applied. MD (Medical Doctor) notified with order for wound consult. R/P (Responsible Party) aware. Supervisor aware. Injuries Observed at Time of Incident: Injury Type: Burn Injury Location: Abdomen Mobility: Wheelchair bound Resident #18 was a [AGE] year old admitted to the facility initially on 6/10/05 and current admission date of [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS) assessment was an Annual with an Assessment Reference Date (ARD) of 6/3/16. The Brief Interview for Mental Status (BIMS) was a 13 out of a possible 15 which indicated Resident #18 was cognitively intact and capable of daily decision making. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating = the resident was coded as requiring extensive 1 person physical assist. Under G0400 Functional Range of Motion the resident was coded as having upper extremity and lower extremity impairment on both sides. Resident #18's Care Area Assessment (CAA) of the above MDS signed and dated on 6/7/16 by the facility's Registered Dietitian documented in part, as follows: Is this problem/need: Actual Nature of the problem/condition: Patient with a Body Mass Index (BMI) of 31.8, classified as obese. Patient is on a pureed diet with honey thickened liquids. Functional problems that affect ability to eat: Partial or total loss of arm movement. Functional limitation in range of motion. [DIAGNOSES REDACTED]/hemiparesis. Inability to perform Activities of Daily Living (ADLs) without significant physical assistance. Cognitive, mental status, and behavior problems that can interfere with eating: Poor memory. Communication problems: Difficulty making self understood. Difficulty understanding others. Care Planning Considerations: Maintain current level of functioning. Minimize risks. Resident #18's current Comprehensive Care Plan with last review date of 3/13/17 documented in part, as follows Focus: (Name of Resident #18) has actual impairment to skin integrity, open blisters on abdomen from hot coffee. Date Initiated: 6/29/16 Created on: 6/29/16 Created by: (Name of Unit Manager LPN (Licensed Practical Nurse) #1) Resolved Date: 9/20/16 Goal: (Name of Resident #18) will have no complications r/t (related to) blisters of the abdomen through the review date. Date Initiated: 6/29/16 Created on: 6/29/16 Created by: (Name of Unit Manager LPN #1) Resolved Date: 9/20/16 Interventions/Tasks: *Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Date Initiated: 6/29/16 Created on: 6/29/16 Created by: (Name of Unit Manager LPN #1) Resolved Date: 9/20/16 *Follow facility protocols for treatment of [REDACTED]. Date Initiated: 6/29/16 Created on: 6/29/16 Created by: (Name of Unit Manager LPN #1) Resolved Date: 9/20/16 Focus: Brain injury, disturbed sensory perception. Resident often has varying levels of attention span or ability to focus on a task, safety awareness, sociable communications within recreational activities. Date Initiated: 8/20/14 Created on: 6/29/16 Focus: (Name of Resident #18) has [DIAGNOSES REDACTED] r/t Brain Injury Date Initiated: 3/29/12 Created on: 3/29/12 Revision on: 9/25/12 Goal: (Name of Resident #18) will remain free of complications or discomfort related to [DIAGNOSES REDACTED] through review date. Target Date: 6/4/17 Focus: (Name of Resident #18) has Epilepsy r/t Brain Injury. Date Initiated: 3/29/12 Created on: 3/29/12 Revision on: 9/16/16 Goal: (Name of Resident #18) will be free of injury from seizure activity through the review date. Date Initiated: 3/29/12 Created on: 3/29/12 Revision on: 6/23/16 Target Date: 6/4/17 Focus: (Name of Resident #18), his caregivers and his family will be advised that he remains at risk for burns related to decreased sensation, seizure disorder, thickened liquids when drinking hot liquids (enjoys coffee). Date Initiated: 3/22/17 Created on: 3/22/17 Created by: Director of Nursing Goal: (Name of Resident #18) will remain free from burns related to hot liquids over next review. Date Initiated: 3/22/17 Created on: 3/22/17 Created by: Director of Nursing Target Date: 6/4/17 Interventions: *Education will be provided to family and caregivers about risk of injury from hot liquids. *Encourage use of adaptive cup with lid will be advised to decrease risk of injury. Date Initiated: 3/22/17 Created on: 3/22/17 Created by: Director of Nursing Resident #18's physician progress notes [REDACTED]. Physical Exam: Abdomen: Soft, Normal bowel sounds. Musculoskeltal: Contractures Assessment and Plan: 1. S/P (status [REDACTED]. 2. Seizure 5. Dysphagia secondary to TBI: c/w (continue with) pureed diet and honey thick liquid. Resident #18's Braden Scale dated 6/2/16 was reviewed and is documented in part, as follows: SENSORY PERCEPTION: 3. Slightly Limited: Responds to verbal commands, but cannot always communicate discomfort or the need to be turned, OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. Resident #18's Abnormal Involuntary Movement Scale (AIMS) dated 5/23/16 was reviewed and is documented in part, as follows: Examination Procedure: 3. Have resident sit in chair with hands on knees, legs slightly apart, and feet flat on floor. Look at entire body for movements while in this position. *Resident unable to perform. 7. Ask resident to tap thumb, with each finger, as rapidly as possible for 10-15 seconds: separately with right hand, then with left hand. *Resident unable to perform. 8. Flex and extend resident's left and right arms, one at a time. Note any rigidity and rate it. *Right side rigid 3/10 Extremity Movements: 5. Upper (arms, wrists, hands, fingers). Include movements that are choreic (rapid, objectively purposeless, irregular, spontaneous) or athetoid (slow, irregular, complex, serpentine). Do not include tremor (repetitive, regular, rhythmic movements). *1. Minimal (may be extreme normal) Resident #18's Body Audits were reviewed and is documented in part, as follows: Date: 6/17/16 Skin integrity intact: 1) yes Date: 6/24/16 Skin integrity intact: 2) No Site: 14) Abdomen Description: Open area on bilateral lower quad (Burn) Signed By: LPN #3 Date: 7/1/16 Skin integrity intact: 2) No Site: 19) Right iliac crest (front), Other: Description: opened area-tx (treatment) in place Site: Other: Middle lower abd (abdomen), Description: opened area, tx in place. Date: 7/8/16 Skin integrity intact: 2) No Site: Other Description: Open area on abdomen, treatment in place. Date: 7/15/16 Skin integrity intact: 2) No Site: 14 Abdomen Description: Opened area, treatment in place. Date: 7/23/16 Skin integrity intact: 2) No Site: Other Description: Opened area on abdomen, almost healed. Date: 7/30/16 Skin integrity intact: 2) No Site: 14 Abdomen Description: Open area (Tx in place) Date: 8/6/16 Skin integrity intact: 2) No Site: Other Description: 2 reddened areas on abdomen. Date: 8/20/16 Skin integrity intact: 2) No Site: 14 Abdomen Description: Old burn scars. Date: 8/17/16 Skin integrity intact: 1) yes Resident #18's Dietary Meal Preference slip was reviewed and is documented in part, as follows: Texture: Pureed Special Diets: Thick Fluids-Honey Breakfast: 6 fluid ounces Coffee-Honey Alerts: Blank Lunch: 6 fluid ounces Coffee-Honey Alerts: Blank Dinner: 6 fluid ounces Coffee-Honey Alerts: Blank Resident #18's Nursing Progress Notes were reviewed and are documented in part, as follows: 6/22/16 11:30 a.m.: Resident had a seizure that lasted less than 10 seconds. MD and RP (responsible party) notified. Will continue to monitor. 6/24/16 12:10 a.m.: Private caregiver provided by family reported to the writer that patient spilled hot coffee on self and have burn at 17:30 (5:30 p.m.) The writer assessed the patient. Noted burn on bilateral lower quad. On the left quad is blister. On right quad is scar. Patient denies any pain. Cold compress applied. MD (Medical Doctor) notified with order for wound consult. R/P (responsible party) aware. Supervisor aware. Signed: LPN #3 6/24/14 11:44 a.m.: Assessed skin on left upper thigh. Small area of discoloration of skin noted, no open areas or blister noted today. Resident denied any discomfort. Signed: LPN #1 Unit Manager 6/28/16 23:32 (11:32 p.m.): abrasions noted on his stomach, was seen by evening cna (Certified Nursing Assistant), endorsed to night on duty nurse. 6/29/16 12:27 p.m.: Wound nurse asked to assess open areas on abdomen. Two open areas noted on abdomen that appear to be open areas from a previous blister, areas cleaned and foam dressing applied. Call place to resident's mother, undated on open areas and treatment. Mother voiced understanding. Talked with mother about the possibility of the seat belt of wheelchair causing the blister. Signed: LPN #2 Wound Nurse at time. 6/29/16 12:44 p.m.: (Name of Nurse Practitioner) made aware of open areas on abdomen and new treatment. Signed: LPN #2 Wound Nurse at time. 3/22/17 18:52 (6:52 p.m.): This writer and social worker spoke with patient and his full time caretaker, patients mother and father on the precautions needed when consuming hot liquids. Lids will be used so it cannot be as easily spilled and other precautions will be put in place. All were in agreement and understood. Signed By: LPN #1 Unit Manager. 3/23/17 14:12 (2:12 p.m.): This nurse measured scarring to the patient lower abdominal area. Site #1-is to the RLQ (right lower quadrant) of abdomen measures: 6.0 x 7.5 x 0 centimeters the skin is intact, no observable tenderness to the area, no redness or thickening observed. Site #2- is beneath the umbilicus to the LLQ (left lower quadrant) measures: 3.3 x 3.0 x 0 centimeters the skin is intact, no observable tenderness to the area, no redness or thickening observed. Signed By: LPN #4 Current Wound Nurse Resident #18's Telephone Physician order [REDACTED]. 6/23/16: Wound Consult: DX (diagnosis) Burn (bilateral lower quad) On 3/22/17 at approximately 4:15 p.m. an interview was conducted with Resident #18's Attending Physician that ordered the above Wound Consult on 6/23/16. The Attending Physician was asked, When you give and order for a Wound Consult what is your expectation of the facility? The Attending Physician stated, For the Wound Doctor to be called to come in and assess the resident's wound. This facility has a Wound Doctor that comes in to the facility weekly. The Surveyor asked, So it's not your intention for the facility wound nurse to assess the wound based on that order? The Attending Physician stated, No, the Wound Doctor should access the wound. The Attending Physician was made aware that the Wound Doctor was never made aware of the order and never treated the resident and if he had been made aware that his order had not been followed and carried out. The Attending Physician stated, No, I was not aware. Resident #18's Treatment Administration Record for June 2016 was reviewed and only indicated one treatment order for the month and is documented in part, as follows: Foam dressing to open blister areas on abdomen every 3 days to prevent infection. Start Date: 6/30/16 at 9:00 a.m. Discontinue Date: 8/5/16 at 7:49 p.m. On 3/23/17 at 9:20 a.m. a phone interview was conducted with Resident #18's mother. The surveyor asked her about her knowledge of a coffee spill in June 2016. Resident #18's mother stated, They told me he had a hot coffee spill on his stomach. When (Name of caregiver) brought him home to visit I saw his stomach and I was shocked because it was so bad of a burn. It took a long time to heal. His belly it was big, open, and bleeding. It was awful for a long time. They said it happened and it was no ones fault. He is an epileptic, he has seizures. They are not supposed to leave him with hot things because his seizures can happen anytime, any place,and any day. Some days he has 2-3 seizures he should be with somebody. I don't like it what happened, but I'm elderly, that's why we have a caregiver for him since day one. On 3/23/17 at 10:15 a.m. an interview was conducted with Unit Manager LPN #1. The Unit Manager was asked to tell the surveyor what happened on 6/23/16 when Resident #18 got burned. The Unit Manager stated, (Name of Resident's private caregiver) went to get coffee and poured thickener in it, took it to the room and handed it to the resident. The resident went to drink it and dropped it on his lower abdomen. Basically he is a brain injury resident and his last seizure was on 22 of June. I saw the area the next day and the area was red and the blister was still there. The Wound Nurse looked at it and put things in place. The surveyor asked, What was put into place? The Unit Manager stated, Leave it open to air. The surveyor asked, What does the facility do when a Physician gives an order for [REDACTED].? The Unit Manager stated, We get the wound nurse to look at it and no, I have never asked the doctor. The Surveyor asked, What caused the resident's burn and what degree of a burn was it? The Unit Manager stated, He spilt the coffee and he got burned, it was a 3rd or 2nd degree burn. On 3/23/17 at 10:30 a.m. an interview was conducted with LPN #2 previous Wound Nurse and the Director of Nursing asked to be present as well. LPN #2 was asked to explain what was observed when she accessed Resident #18's burn. LPN #2 stated, I read the nurse's note from the previous night and it said burn on quad. I thought it was on the leg so I went to look and I didn't see anything on the leg so I didn't proceed. The someone said a few days later he had areas on his abdomen an I went up and looked. It was two blistered areas that had opened. I called his mom with an update and told her the blister areas had opened and it had been reported by the CNA the night before. I got a new order. It took a while to heal. What happened was I just looked at the wrong area at first, I looked at his leg because I was thinking quad was leg and I never looked at his abdomen where the burn had occurred. That's how I missed it. The surveyor asked, Did you ever measure the two open blister burn areas so yo

Based on observations, staff interviews, clinical record review, and facility document review the facility staff failed to provide the necessary care and services for a 2nd degree abdominal burn in a timely manner to maintain the highest practicable physical wellbeing for 1 of 47 resident in the survey sample, Resident #18. The facility staff failed to properly assess, and follow Physician orders [REDACTED]. The findings include: Resident #18 was a [AGE] year old admitted to the facility initially on 6/10/05 and current admission date of [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS) assessment was an Annual with an Assessment Reference Date (ARD) of 6/3/16. The Brief Interview for Mental Status (BIMS) was a 13 out of a possible 15 which indicated Resident #18 was cognitively intact and capable of daily decision making. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating = the resident was coded as requiring extensive 1 person physical assist. Under G0400 Functional Range of Motion the resident was coded as having upper extremity and lower extremity impairment on both sides. Resident #18's Care Area Assessment (CAA) of the above MDS signed and dated on 6/7/16 by the facility's Registered Dietitian is documented in part, as follows: Is this problem/need: Actual Nature of the problem/condition: Patient with a Body Mass Index (BMI) of 31.8, classified as obese. Patient is on a pureed diet with honey thickened liquids. Functional problems that affect ability to eat: Partial or total loss of arm movement. Functional limitation in range of motion. [MEDICAL CONDITION]/[MEDICAL CONDITION]. Inability to perform Activities of Daily Living (ADLs) without significant physical assistance. Cognitive, mental status, and behavior problems that can interfere with eating: Poor memory. Communication problems: Difficulty making self understood. Difficulty understanding others. Care Planning Considerations: Maintain current level of functioning. Minimize risks. On 3/22/17 at approximately 4:00 p.m. the Administrator provided the surveyor with an incident report dated 6/23/16 for Resident #18 which documented in part, as follows: Incident Location: Resident's Room Incident Description: Private caregiver provided by family reported to the writer that patient spilled hot coffee on self and have burn at 17:30 (5:30 p.m.) Immediate Action Taken: The writer assessed the patient. Noted burn on bilateral lower quad. On the left quad is blister. On right quad is scar. Patient denies any pain. Cold compress applied. MD (Medical Doctor) notified with order for wound consult. R/P (Responsible Party) aware. Supervisor aware. Injuries Observed at Time of Incident: Injury Type: Burn Injury Location: Abdomen Mobility: Wheelchair bound The Administrator was asked for a copy of the Facility Reported Incident (FRI) that was sent to the Office of Licensure and Certification regarding Resident #18's burn from the hot coffee on 6/23/16. The Administrator stated, I didn't do a FRI. The Administrator was then asked for the investigation documentation and plan put in place by the facility for Resident #18's burn from hot coffee on 6/23/16. The Administrator stated, We didn't do an investigation and we didn't put a plan in place. Resident #18's current Comprehensive Care Plan with last review date of 3/13/17 is documented in part, as follows Focus: (Name of Resident #18) has actual impairment to skin integrity, open blisters on abdomen from hot coffee. Date Initiated: 6/29/16 Created on: 6/29/16 Created by: (Name of Unit Manager LPN(Licensed Practical Nurse) #1) Resolved Date: 9/20/16 Goal: (Name of Resident #18) will have no complications r/t (related to) blisters of the abdomen through the review date. Date Initiated: 6/29/16 Created on: 6/29/16 Created by: (Name of Unit Manager LPN (Licensed Practical Nurse) #1) Resolved Date: 9/20/16 Interventions/Tasks: *Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Date Initiated: 6/29/16 Created on: 6/29/16 Created by: (Name of Unit Manager LPN(Licensed Practical Nurse) #1) Resolved Date: 9/20/16 *Follow facility protocols for treatment of [REDACTED]. Date Initiated: 6/29/16 Created on: 6/29/16 Created by: Name (Unit Manager LPN #1) Resolved Date: 9/20/16 Focus: [MEDICAL CONDITION], disturbed sensory perception. Resident often has varying levels of attention span or ability to focus on a task, safety awareness, sociable communications within recreational activities. Date Initiated: 8/20/14 Created on: 6/29/16 Focus: (Name of Resident #18) has [MEDICAL CONDITION] r/t [MEDICAL CONDITION] Date Initiated: 3/29/12 Created on: 3/29/12 Revision on: 9/25/12 Goal: (Name of Resident #18) will remain free of complications or discomfort related to [MEDICAL CONDITION] through review date. Target Date: 6/4/17 Focus: (Name of Resident #18) has [MEDICAL CONDITION] r/t [MEDICAL CONDITION]. Date Initiated: 3/29/12 Created on: 3/29/12 Revision on: 9/16/16 Goal: (Name of Resident #18) will be free of injury from [MEDICAL CONDITION] activity through the review date. Date Initiated: 3/29/12 Created on: 3/29/12 Revision on: 6/23/16 Target Date: 6/4/17 Focus: (Name of Resident #18), his caregivers and his family will be advised that he remains at risk [MEDICAL CONDITION] to decreased sensation, [MEDICAL CONDITION] disorder, thickened liquids when drinking hot liquids (enjoys coffee). Date Initiated: 3/22/17 Created on: 3/22/17 Created by: Director of Nursing Goal: (Name of Resident #18) will remain free [MEDICAL CONDITION] to hot liquids over next review. Date Initiated: 3/22/17 Created on: 3/22/17 Created by: Director of Nursing Target Date: 6/4/17 Interventions: *Education will be provided to family and caregivers about risk of injury from hot liquids. *Encourage use of adaptive cup with lid will be advised to decrease risk of injury. Date Initiated: 3/22/17 Created on: 3/22/17 Created by: Director of Nursing Resident #18's physician progress notes [REDACTED]. Physical Exam: Abdomen: Soft, Normal bowel sounds. Musculoskeltal: Contractures Assessment and Plan: 1. S/P (status [REDACTED]. 2. [MEDICAL CONDITION] 5. Dysphagia secondary to TBI: c/w (continue with) pureed diet and honey thick liquid. Resident #18's Braden Scale dated 6/2/16 was reviewed and documented in part, as follows: SENSORY PERCEPTION: 3. Slightly Limited: Responds to verbal commands, but cannot always communicate discomfort or the need to be turned, OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. Resident #18's Abnormal Involuntary Movement Scale (AIMS) dated 5/23/16 was reviewed and is documented in part, as follows: Examination Procedure: 3. Have resident sit in chair with hands on knees, legs slightly apart, and feet flat on floor. Look at entire body for movements while in this position. *Resident unable to perform. 7. Ask resident to tap thumb, with each finger, as rapidly as possible for 10-15 seconds: separately with right hand, then with left hand. *Resident unable to perform. 8. Flex and extend resident's left and right arms, one at a time. Note any rigidity and rate it. *Right side rigid 3/10 Extremity Movements: 5. Upper (arms, wrists, hands, fingers). Include movements that are choreic (rapid, objectively purposeless, irregular, spontaneous) or athetoid (slow, irregular, complex, serpentine). Do not include tremor (repetitive, regular, rhythmic movements). *1. Minimal (may be extreme normal) Resident #18's Body Audits were reviewed and is documented in part, as follows: Date: 6/17/16 Skin integrity intact: 1) yes Date: 6/24/16 Skin integrity intact: 2) No Site: 14) Abdomen Description: Open area on bilateral lower quad (Burn) Signed By: LPN #3 Date: 7/1/16 Skin integrity intact: 2) No Site: 19) Right iliac crest (front), Other: Description: opened area-tx in place Site: Other: Middle lower abd (abdomen), Description: opened area, tx (treatment) in place. Date: 7/8/16 Skin integrity intact: 2) No Site: Other Description: Open area on abdomen, treatment in place. Date: 7/15/16 Skin integrity intact: 2) No Site: 14 Abdomen Description: Opened area, treatment in place. Date: 7/23/16 Skin integrity intact: 2) No Site: Other Description: Opened area on abdomen, almost healed. Date: 7/30/16 Skin integrity intact: 2) No Site: 14 Abdomen Description: Open area (Tx in place) Date: 8/6/16 Skin integrity intact: 2) No Site: Other Description: 2 reddened areas on abdomen. Date: 8/20/16 Skin integrity intact: 2) No Site: 14 Abdomen Description: Old burn scars. Date: 8/17/16 Skin integrity intact: 1) yes Resident #18's Dietary Meal Preference slip was reviewed and is documented in part, as follows: Texture: Pureed Special Diets: Thick Fluids-Honey Breakfast: 6 fluid ounces Coffee-Honey Alerts: Blank Lunch: 6 fluid ounces Coffee-Honey Alerts: Blank Dinner: 6 fluid ounces Coffee-Honey Alerts: Blank Resident #18's Nursing Progress Notes were reviewed and are documented in part, as follows: 6/22/16 11:30 a.m.: Resident had a [MEDICAL CONDITION] that lasted less than 10 seconds. MD and RP (responsible party) notified. Will continue to monitor. 6/24/16 00:00 a.m.: Private caregiver provided by family reported to the writer that patient spilled hot coffee on self and have burn at 17:30 (5:30 p.m.) The writer assessed the patient. Noted burn on bilateral lower quad. On the left quad is blister. On right quad is scar. Patient denies any pain. Cold compress applied. MD (Medical Doctor) notified with order for wound consult. R/P (responsible party) aware. Supervisor aware. Signed (LPN #3) 6/24/16 11:44 a.m.: Assessed skin on left upper thigh. Small area of discoloration of skin noted, no open areas or blister noted today. Resident denied any discomfort. Signed: (LPN #1 Unit Manager) 6/28/16 23:32 (11:32 p.m.): abrasions noted on his stomach, was seen by evening cna (Certified Nursing Assistant), endorsed to night on duty nurse. 6/29/16 12:27 p.m.: Wound nurse asked to assess open areas on abdomen. Two open areas noted on abdomen that appear to be open areas from a previous blister, areas cleaned and foam dressing applied. Call place to resident's mother, undated on open areas and treatment. Mother voiced understanding. Talked with mother about the possibility of the seat belt of wheelchair causing the blister. Signed: (LPN #2 Wound Nurse at time) 6/29/16 12:44 p.m.: (Name of Nurse Practitioner) made aware of open areas on abdomen and new treatment. Signed: (LPN #2 Wound Nurse at time) 3/22/17 18:52 (6:52 p.m.): This writer and social worker spoke with patient and his full time caretaker, patients mother and father on the precautions needed when consuming hot liquids. Lids will be used so it cannot be as easily spilled and other precautions will be put in place. All were in agreement and understood. Signed By: (LPN #1 Unit Manager) 3/23/17 14:12 (2:12 p.m.): This nurse measured scarring to the patient lower abdominal area. Site #1-is to the RLQ (right lower quadrant) of abdomen measures: 6.0 x 7.5 x 0 centimeters the skin is intact, no observable tenderness to the area, no redness or thickening observed. Site #2- is beneath the umbilicus to the LLQ (left lower quadrant) measures: 3.3 x 3.0 x 0 centimeters the skin is intact, no observable tenderness to the area, no redness or thickening observed. Signed By: (LPN #4 Current Wound Nurse) Resident #18's Telephone Physician order [REDACTED]. 6/23/16: Wound Consult: DX (diagnosis) Burn (bilateral lower quad) On 3/22/17 at approximately 4:15 p.m. an interview was conducted with Resident #18's Attending Physician that ordered the above Wound Consult on 6/23/16. The Attending Physician was asked, When you give an order for [REDACTED]. This facility has a Wound Doctor that comes in to the facility weekly. The Surveyor asked, So it's not you intention for the facility wound nurse to assess the wound based on that order? The Attending Physician stated, No, the Wound Doctor should access the wound. The Attending Physician was made aware that the Wound Doctor was never made aware of the order and never treated the resident. The Attending Physician stated, No, I was not aware. Resident #18's Treatment Administration Record for June 2016 was reviewed and only indicated one treatment order for the entire month and is documented in part, as follows: Foam dressing to open blister areas on abdomen every 3 days to prevent infection. Start Date: 6/30/16 at 9:00 a.m. Discontinue Date: 8/5/16 at 7:49 p.m. On 3/23/17 at 9:20 a.m. a phone interview was conducted with Resident #18's mother. The surveyor asked about her knowledge of a coffee spill in June 2016. Resident #18's mother stated, They told me he had a hot coffee spill on his stomach. When (Name of caregiver) brought him home to visit I saw his stomach and I was shocked because it was so bad of a burn. It took a long time to heal. His belly it was big, open, and bleeding. It was awful for a long time. They said it happened and it was no one's fault. He is an epileptic, he has [MEDICAL CONDITION]. They are not supposed to leave him with hot things because his [MEDICAL CONDITION] can happen any time, any place,and any day. Some days he has 2-3 [MEDICAL CONDITION]; he should be with somebody. I don't like it what happened, but I'm elderly, that's why we have a caregiver for him since day one. On 3/23/17 at 10:15 a.m. an interview was conducted with Unit Manager LPN #1. The Unit Manager was asked what happened on 6/23/16 when Resident #18 got burned. The Unit Manager stated, (Name of Resident's private caregiver) went to get coffee and poured thickener in it took it to the room and handed it to the resident. The resident went to drink it and dropped it on his lower abdomen. Basically he is a [MEDICAL CONDITION] resident and his last [MEDICAL CONDITION] was on 22 of June. I saw the area the next day and the area was red and the blister was still there. The Wound Nurse looked at it and put things in place. The surveyor asked, What was put into place? The Unit Manager stated, Leave it open to air. The surveyor asked, What does the facility do when a Physician gives an order for [REDACTED]. The Surveyor asked, What caused the resident's burn and what degree of a burn was it? The Unit Manager stated, He spilt the coffee and he got burned, it was a 3rd or 2nd degree burn. On 3/23/17 at 10:30 a.m. an interview was conducted with LPN #2 previous Wound Nurse and the Director of Nursing asked to be present as well. LPN #2 was asked to explain what was observed when she accessed Resident #18's burn. LPN #2 stated, I read the nurse's note from the previous night and it said burn on quad. I thought it was on the leg so I went to look and I didn't see anything on the leg so I didn't proceed. Then someone said a few days later he had areas on his abdomen and I went up and looked. It was two blistered areas that had opened. I called his mom with an update and told her the blister areas had opened and it had been reported by the CNA the night before. I got a new order. It took a while to heal. What happened was I just looked at the wrong area at first, I looked at his leg because I was thinking quad was leg and I never looked at his abdomen where the burn had occurred. That's how I missed it. The surveyor asked, Did you ever measure the two open blister burn areas so you could monitor for healing? LPN #2 stated, No, I never measured them. The surveyor asked, Was the blister areas from a seatbelt? LPN #2 stated, No, they were from the coffee burn. The surveyor asked, Did the Wound Doctor ever assess the resident's burn wounds as ordered by the Attending Physician? LPN #2 stated, No. The Director of Nursing stated, He should have been assessed by the Wound Doctor as ordered. After LPN #2 left the room the Director of Nursing stated, It's because of things like that she failed to do why she is no longer in the Wound Nurse position. The Director of Nursing provided the surveyor with the following statement documented in part, as follows: Expectations re: Nurse's taking Physician Orders Physician Orders 1) Any order written by a physician will either be carried out by the nurse taking the order. 2) This nurse will pass the order on to the following shift. 3) If the order is not carried out, the nurse will get the order discontinued. On 3/23/17 at 1:10 p.m. an interview was conducted with LPN #3. LPN #3 was asked to explain what happened to Resident #18 on 6/23/16. LPN #3 stated, (Name of Private Caregiver) came to me around 5:30 p.m. because the resident has spilled his coffee. The caregiver had gotten the coffee from the kitchen and he had spilled it. So I pulled his shirt up to do an assessment. I looked at the left and right quads. The left quad had a blister and the right had a scar from the burn it was pink. After I did my assessment I called the doctor and his mom and dad. The doctor gave an order for [REDACTED]. On 3/23/17 at 1:30 p.m. an interview was conducted with Resident #18's Private Caregiver. The Caregiver was asked to explain what happened the night Resident #18 was burned from a coffee spill. The Caregiver stated, (Name of Resident #18) has [MEDICAL CONDITION]. That day he said he liked to drink some coffee, so I went to the kitchen and got the coffee from the machine and I put thickener in it. After that I gave it to him and he had a [MEDICAL CONDITION]. His hand went down and the coffee went all over his abdomen. I toweled him off and told the nurse he had a [MEDICAL CONDITION] and spilt his coffee. Everytime he has a [MEDICAL CONDITION] I tell the nurse. She came in and checked him; he had blisters all over his belly. They never put anything on it. But the belly got worse bleeding and raw. It was 3-4 days later they came in and put a bandage on it, his skin had two open spots. It took more than a month to heal. It would bleed and when I took him to the shower he said I have pain and pointed to his belly. I have been with him for over [AGE] years he is like a brother to me. The surveyor asked if anyone had said anything to him about giving the resident coffee recently. The Caregiver stated, Yes, yesterday (Name of Unit Manager) told me if I give him coffee just put a lid on it. On 3/23/17 at 2:00 p.m. an interview was conducted with Resident #18. The resident was asked to tell the surveyor about the day he spilled his coffee on his belly. Resident #18 stated, (Name of caregiver) got me some coffee and when I started to drink it I had a [MEDICAL CONDITION] and dropped my coffee in my lap and it burned me. I'm scared to drink it by myself now. Resident asked if surveyor could look at his abdomen, he agreed and his caregiver lifted his shirt revealing the abdomen. The surveyor noted two well defined lower abdominal scars and asked the caregiver if they were the burn scars from the result of the hot coffee spill. The Caregiver stated, Yes, those are the scars from the hot coffee. CDC (Centers for Disease Control) DEFINITION OF TYPES OF BURNS: (2) First-Degree Burns: First-[MEDICAL CONDITION] the top layer of skin. Sunburn is a first degree burn. Signs: * Red * Painful to touch * Skin will show mild swelling Second-Degree Burns: Second-[MEDICAL CONDITION] the first two layers of skin. Signs: * Deep reddening of the skin * Pain * Blisters * Glossy appearance from leaking fluid * Possible loss of some skin Third-Degree Burns: A third-degree burn penetrates the entire thickness of the skin and permanently destroys tissue. Signs: * Loss of skin layers * Often painless * Skin is dry and leathery * Skin may appear charred or have patches that appear white, brown, or black According to an American Burn Association document entitled Fire and Burn Safety for Older Adults Educator's Guide, under the heading General Background Information .Risk Factors .Physical Changes, the document read Older adults experience a myriad of physical and cognitive changes associated with the aging process that makes them more vulnerable to fire and burn injuries . there are significant changes in sensory perception. The ability to see, hear and feel potential fire and burn dangers diminishes proportionally as one gets older .Since older adults also have thinner skin, they may experience a much deeper burn than a younger person, when exposed to the same amount of flame or other burn injury source Under the heading 'Working with the Older Adult Population', the document continues With 12.5% of the population age 65 and older, there is a need to assess and address injury risks affecting them as they age. According to a document based on the above Burn Association Kit, found at http://www.ameriburn.org/Prevent/2000Prevention/Scald2000PrevetionKit.pdf: The severity of injury with scalds depends on two factors - the temperature to which the skin is exposed and the length of time that the hot liquid is in contact with the skin . When the temperature of a hot liquid is increased to 140o F / 60o C. it takes only five seconds or less for a serious burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180o F./ 71-82o C. degrees, resulting in almost [MEDICAL CONDITION] require surgery to heal. The two factors addressed above are underscored in a Burn Foundation document retrieved from the Internet: Which states Hot Water Causes a Third [MEDICAL CONDITION]. .in 1 second at 156º .in 2 seconds at 149º .in 5 seconds at 140º .in 15 seconds at 133º. https://www.burnfoundation.org/programs/resource.cfm?c=1&a=3 The facility policy titled BURNS last reviewed 10/26/16 is documented in part, as follows: Purpose: [MEDICAL CONDITION] scalds are treated immediately to provide comfort and prevent infection. Policy: 3. [MEDICAL CONDITION] scalds should be seen by a physician. Procedure: 6. Assess the burned area: a) First Degree: Redness; not serious unless a large area of the body is involved. b) Second Degree: Blisters form; superficial layers of skin are destroyed; hospitalization may be required if large area of the body are affected; classified as a major burn if over 30% of the body is burned. c) Third Degree: Destruction of full thickness of the skin, and often underlying fat, muscles and bone; hospitalization is required immediately; classified as a major burn if over 10% of the body is burned. 8. Protect the burn area as quickly as possible with a sterile dressing. 13. Document in detail in Nursing Notes and on 24-Hour Report. 14. Update the Care Plan. 15. Complete incident report. 16. The DON or designee will report to the state health department if appropriate. The facility policy titled Investigative Analysis of Incidents last reviewed 10/26/16 is documented in part, as follows: Purpose: It is the intent of the center to maintain a safe and abuse-free environment for all residents. The facility is committed to a comprehensive investigation of all incidents or unusual occurrences. Corrective and preventive action to minimize recurrence will be developed and implemented on an individual resident and center basis. Outside entities, including regulatory agencies, ombudsman, protective services, and legal investigators will be notified an involved as appropriate to the situation. Procedure: 4. Upon completion of the investigation, the QA (Quality Assurance) Committee will review the incident and facility response to the incidents or unusual occurrences. The meeting may be at the discretion of the administrator and/or corporate representative, but consideration should be given for the potential of recurrent risk or risk to other residents. The facility policy titled Unusual Occurrences last reviewed 10/26/16 is documented in part, as follows: Policy: Unusual incidences or occurrences will be investigated and, if applicable, reported to the Office of Licensure and Certification, Adult Protective Services, local Ombudsman, and possibly law enforcement. Examples of Unusual Occurrences may include: 6. Accidents or injuries of known origin that are unusual, such as a resident falling out of a window, a resident exiting the facility and sustaining an injury on facility property, or a resident being burned. Procedure: 2. The Administrator or Director of Nursing is to be notified immediately. 4. The Administrator, Director of Nursing, or their designee, must begin a documented investigation of the cause of the unusual occurrence using the Commonwealth Care Investigative Report form. 5. The investigation will include interviews with the resident, all staff involved (directly or indirectly), any family, visitors, or volunteers which may have had contact with the resident and may help with the investigation. 6. The Office of Licensure and Certification must be notified immediately (within 24 hours of knowledge of the event) by faxing the Facility Self Report form. 8. A complete investigation must be initiated by the Administrator. Every effort is to be made to determine the cause of the unusual occurrence. 9. A letter outlining the findings of the investigation, conclusions drawn, actions taken, and steps to prevent future reoccurrence will be submitted to the Office of Licensure and Certification within 5 working days. On 3/23/17 at 5:30 p.m. a Pre-exit debriefing was conducted with the Administrator, the Director of Nursing, the Clinical Services Specialist, and the Regional Director of Operations where the above findings were presented. The Clinical Services Specialist stated, Life isn't without risk, everyone has the opportunity to drop coffee, I don't thinks it's considered an unusual occurrence. While this surveyor was reading the interviews verbatim to the attendees regarding the investigation of Resident #18's second degree [MEDICAL CONDITION] a hot coffee spill during a [MEDICAL CONDITION] the Regional Director of Operations stated, We get it, we understand, this is getting emotional for us. We take it personal. Prior to exit no further information was shared. (1) [MEDICAL CONDITION]: a hyperexcitation of neurons in the brain leading to abnormal electric activity that causes a sudden, violent involuntary series of contractions of a group of muscles. (2) [MEDICAL CONDITION]: paralysis of one side of the body. (3) Dysphagia: difficulty in swallowing, commonly associated with obstructive motor disorders of the esophagus. (4) [MEDICAL CONDITION]: a group of neurologic disorders characterized by recurrent episodes of convulsive [MEDICAL CONDITION], sensory disturbances, abnormal behaviors, loss of consciousness, or all of these. The above definitions are derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition.

Based on a complaint review, closed record review, and staff interviews, the facility staff failed to provide the necessary treatment and services to prevent the development of pressure areas for two residents (Residents #27 and #2) in the survey sample of 30 residents. The findings included: 1. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #27 acquired a stage III pressure area on the sacrum. Resident #27 was assessed as having redness on coccyx, right and left buttocks on admission. Resident #27's Braden Scale for predicting Pressure Sores Risk was scored a 7. In the area of Sensory perception -Ability to respond meaningfully to pressure-related discomfort was scored a (1)- Completely limited: Unresponsive (does not moan, flinch, or grasp) to painful stimuli due to diminished level. Moisture- Degree to which skin is exposed to moisture (1) Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. Activity- Degree of physical activity (1) Bedfast: Confined to bed. Mobility- Ability to change and control body position (1) Completely Immobile: Does not make even slight changes in body or extremity position without assistance. Nutrition- Usual food intake pattern- (2) Probably inadequate: Rarely eats a complete meal and generally eats on ,[DATE] of any food offered. Friction and Shear- (1) Problem: Requires moderate to maximum assistance in moving. A wound Care Specialist Initial Evaluation dated [DATE] indicated: " History of Present Illness- chief complaint- Consulted for a wound by physician [AGE] year old female patient has a stage 3 pressure wound of the sacrum of unknown days duration. There is heavy serous exudate associated with the wound. There is no indication of pain associated with this condition. Review of Systems Gastrointestinal system: Appetite Good Musculoskeletal system de-conditioning Stage 3 Pressure Wound of the Sacrum - wound size 6 x 9 x. 03 surface area 54.00 cm2 peri-wound radius surrounding DTI (deep tissue injury) (purple/maroon) exudate: heavy serous Thick adherent devitalized necrotic tissue- 40 % granulation tissue 40 % A facility generated investigation dated [DATE] regarding complaints Resident #27's family expressed indicated the following: "Resident 327 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. medical [DIAGNOSES REDACTED]. An initial Minimum Data Set ((MDS) dated [DATE] did not assess Resident #27 for a stage III pressure area. A Care Plan dated [DATE] indicated: keep skin clean and dry, pericare after each incontinent episode, provide supplements, calories and or vitamins as ordered. turn and reposition resident. Findings: Facility Acquired Pressure Ulcer Inadequate/delayed treatment and lack of follow-up of skin breakdown (redness on coccyx, right and left buttocks) on admission. Admission Assessment [DATE] Resident's skin was intact but fragile with several redness and bruising on upper extremities, redness on right lower front extremities, and left lower bruising. Resident's right heel was dry and flaky and with redness on coccyx, right and left buttock per nurse. Braden Scale [DATE] Resident is very high risk for skin breakdown with a score of 7.0. Body Audits for were completed on ,[DATE] and [DATE] Body Audits for [DATE] and ,[DATE] were not completed. Body Audit on [DATE] indicated that skin integrity was intact. The Body Audit on [DATE], indicated stage III on the sacrum per outside facility wound nurse. Pressure Ulcer Report: [DATE] per (outside facility wound nurse) stage III pressure ulcer to sacral wound with 20% skin and 40% granulation, 40% necrosis with heavy serous exudates. Noted DTI 6 X 9 X 0.3 CM . Assessment & Plan Stage 3 pressure wound of the sacrum - initial evaluation -Recommendation: limit sitting to 60 minutes, reposition per facility protocol, air mattress. Care Plan for Skin Integrity: ,[DATE], ,[DATE] and [DATE] [DATE]: keep skin and dry, pericare per incontinent episode, provide supplements, calories and or vitamins, and turning and positioning. Medications and Treatments Supplements such as [MEDICATION NAME] Acid, Folic Acid, [MEDICATION NAME], and Multivitamins were initiated on admission, ,[DATE]. After the Stage III pressure ulcer was found on on the resident's sacrum on [DATE], Prostat AWC (a protein supplement) 30 ML daily was not initiated on ,[DATE]. Boost Plus supplement was started on ,[DATE]. Treatments to the wound were initiated on ,[DATE] when stage III on the sacrum was found, and included: Cleanse sacral wound with NSS (normal saline solution), pat dry, apply [MEDICATION NAME] AG and cover with [MEDICATION NAME] island dressing QD (every day); air mattress daily; and heel boots at all times. [MEDICATION NAME] Cream ,[DATE].05% BID X 14 days for perirectal rash was initiated on ,[DATE] and skin prep to bilateral heels BID. After the Stage III pressure ulcer was identified on [DATE], the off in the Skilled Nursing Notes still did not identify the resident as having the prssure ulcer on ,[DATE] (x 3); Pressure Area was not checked ,[DATE] (x 1), ,[DATE] (x 2), ,[DATE] (x 1) and ,[DATE] (x 1). It was checked off as bruise and non-pressure and other days were not checked off. Lab results dated [DATE] showed and elevated WBC and CXR (Chest X ray) showed positive for pneumonia. Resident #27 lab results dated [DATE] also indicated: Critical High Potassium. Resident #27 had also been started on [MEDICATION NAME] (diuretic) on [DATE] for [MEDICAL CONDITION] and showed a decrease in the amount of [MEDICAL CONDITION], therefore, showed a weight loss of 12 pounds through the date of discharge, (Resident #27 was discharged on [DATE] to the hospital and did not return to the facility. Resident #27 expired on [DATE]). During an interview with the Administrator and the Chief Clinical Officer on [DATE] at 10:00 A.M. they were asked if a wound nurse was on duty during Resident #27's stay, They stated, they were not sure but the wound nurse may not have been in the building during this time period. The staff was asked if there was documentation indicating Resident #27 was assessed and treated prior to [DATE] for pressure relieving devices to her sacrum area and they stated, "No, we cannot find any information prior to [DATE]." Resident #27 ' s family was called on [DATE] at 10:10 A.M, there was no answer. A message was left. A facility provided Body Audits tool assessment indicated: Body Audits- to be completed weekly by Licensed nurse -Identify areas of wounds, bruising, skin tears, redness, Identify site- are any areas new? The facility staff stated Resident #27 did not have body audits performed on [DATE] and [DATE]. The facility staff failed to provide Resident #27 with the necessary care and services to prevent a stage III pressure area. 2. Resident #2 was a [AGE] year old with an admitted [DATE]. [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed a Quarterly Minimum Data Set (MDS), with an ARD (assessment reference date) of [DATE]. The resident's BIMS's (brief interview for mental status) score was a 13 which indicates the resident was moderately impaired. She was further coded as being extensively to totally dependent for her ADL's (activities of daily living). She was also coded as being incontinent of bladder and bowel. Resident #2 had mobility and ambulation issues and was bedfast unless ambulated by staff. On [DATE] the attending physician wrote the following order: Offload heels (under pillows, towels and/or cushion device), when in bed every shift every day. The plan of care under the Potential For Decline in Skin Integrity section with a target date of [DATE] had follow physician orders [REDACTED]. On [DATE] at 8:30 AM, during observations of the Resident #2 while appearing sleep in bed, it was evidenced that both heels were not offloaded (with pillows, towels and/or cushion device). On [DATE] at 2:40 PM during observations of Resident #2 while in bed, it was observed both heels had been not offloaded (with pillows or cushion devices). During an interview with CNA #2 on [DATE] at 2:48 PM, she stated Resident #2 never had her heels offloaded for at least several months while in bed During an interview with the Administrator, Director of Nursing(DON), and the Nursing Unit manager on the Administrator stated that if the residents did not need to have her heels offloaded or would not keep her heels offloaded, then the attending physician should be notified. The Nursing Unit Manager stated she was surprised that the nursing staff did not advise her the resident heels were not being offloaded. COMPLAINT DEFICIENCY

Based on observation, staff interview and clinical record review it was determined the facility staff failed to ensure 1 of 25 residents (Resident #7) in the survey sample received the proper care and services to prevent the development of and promote the healing of pressure ulcers. The findings include: 1. The facility staff failed to assess the resident's increase risk factors for skin breakdown after significant changes were identified. Resident #7 was an [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) a significant change with assessment reference date of 6/16/11 indicated the resident had long and short-term memory deficits and moderately impaired daily decision making skills. Resident #7 was completely dependent on staff for transfers, personal hygiene, and bathing, and required extensive assistance of two staff for bed mobility, and toileting. The resident was incontinent of both bladder and bowel. Functional limitation of range in motion was impaired to both upper and lower extremities. Resident #7 had an unplanned significant weight loss of greater then 10% in the last 180 days, the resident weighed 67 pounds. Under skin conditions the resident was identified at risk for developing pressure ulcers. No pressure ulcers were noted on this assessment or the prior assessment. A pressure ulcer reducing device for chair was checked off under skin and ulcer treatments. There were no physical behaviors identified that would put the resident at risk for physical injury or interfere with care. Review of the clinical record failed to evidence a clinical nursing assessments for increased risk factors for skin breakdown after 2 separate significant change in condition were identified. The resident was diagnosed with [REDACTED]. A significant weight loss greater then 10% in the last 180 days was identified on 7/20/11 according to the registered dietician progress notes. A risk assessment tool (Braden Scale) for skin breakdown was not found in the clinical record. According to the facilities policy revised 1/27/09 indicates a Braden Scale will be completed by a licensed nurse with a 14 day assessment, quarterly and with any significant change in condition. Review of the clinical record failed to evidence Braden Scales were done on the resident for 2011. On 7/28/11 at approximately 9:30 A.M., the director of nurses (DON) and the director of clinical and patient services (DCPS) was asked to provide documentation of the assessment's for Resident #7's increased risk factors for skin breakdown (Braden Scale). At 11:15 A.M., the DCPS stated they could not find evidence that Braden Scale assessments were done. According to the U.S. Department of Health and Human Services Clinical Practice Guideline Number 3 titled Pressure Ulcers in Adults: Prediction and Prevention reads the following: Risk assessment tools and risk factors identify at-risk individuals needing prevention and the specific factors placing them at risk. A systematic risk assessment can be accomplished by using a validated risk assessment tool such as a Braden Scale or Norton Scale. Pressure ulcer risk should be reassessed at periodic intervals. 1b. The facility did not obtain treatment orders or provide ongoing assessments of a facility acquired stage II pressure ulcer for Resident #7 from 7/7/11 through 7/27/11. Review of the clinical record nursing notes dated 7/7/11 indicated the resident was noted with a newly acquired stage II pressure ulcer on her left buttock. The wound measured 1.9 cm x 1.1 cm. The nurse documented the physician was notified by fax and was awaiting a response. A Stage II pressure ulcer is characterized by partial-thickness skin loss involving the epidermis or dermis, The ulcer is superficial and appears as an abrasion, blister, or shallow crater. Review of the clinical record on 7/27/11 failed to evidence the faxed communication report sent by the nurse on 7/7/11, or a response from the physician. Review of the July 2011 TAR's failed to evidence a treatment was being administered or applied to the stage II pressure ulcer from 7/7/11 through 7/27/11. Review of the clinical record failed to evidence weekly documentation of ongoing assessment of the stage II pressure ulcer from 7/7/11 through 7/27/11. On 7/27/11 with the assistance of a certified nurse aide the left buttock pressure ulcer was observed. The wound bed was covered by a dark crusted substance. The wound did not have a dressing on. Review of the resident's care plan on 7/27/11 failed to evidence a revision of the care plan to include the newly acquired stage II pressure ulcer or treatment to promote healing. On 7/28/11 at 3:37 P.M., the above findings was shared with the unit manager. The nurse who documented she had notified the physician via fax on 7/7/11 was interviewed along with the unit manager. The nurse (licensed practical nurse #7) stated she faxed the physician on 7/7/11 (at the end of her shift). The nurse was asked if there was treatment in place for this pressure ulcer she stated,"No". The unit manager stated she would call the physician's office. Following this interview the unit manager and the surveyor assessed the resident's left buttock pressure ulcer. The wound bed was now noted to be pink, without a dressing on and a small amount of serosanguinous drainage was noted on the resident's brief. The wound was approximately 1 cm in diameter. On 7/29/11 at approximately 9:30 A.M., the above findings were discussed with the DON and the DCPS. The DON stated there was no treatment order for the stage II pressure ulcer or ongoing assessments found. According to the U.S. Department of Health and Human Services Clinical Practice Guideline Number 15 titled Pressure Ulcer Treatment reads the following: Assess the pressure ulcer (s) initially for location, stage, size (length, width, depth)...Reassess pressure ulcers at least weekly. 1c. The facility staff failed to implement ongoing assessments of Resident #7's right great toe and left lateral foot pressure ulcers, and notify the attending physician of the change in status of these ulcers. Review of the clinical record evidenced on 6/6/11 the resident was diagnosed with [REDACTED]. Review of the nurses notes dated 6/22/11 indicated 16 days after the resident sustained [REDACTED]. The physician was notified and the following orders were obtained, "Cleanse blisters on resident's left foot and right great toe with normal saline and dressing daily, if blisters open suggest [MEDICATION NAME] and dressing twice a daily. The July 2011 treatment administration record (TAR) evidenced the blisters on the left foot and right great toe had opened as indicated by the nurses initialing the usage of [MEDICATION NAME] and a dressing twice a day from 7/1/11 through 7/8/11. There was no evidence in the nursing notes to indicate when the blisters opened. Review of the clinical record failed to evidence ongoing weekly assessment of these pressure ulcers from 6/22/11 through 7/8/11. On 7/8/11 the resident was assessed by a wound physician. The wound physician documented the following: 1. Right toe wound, etiology pressure, with 100% thick adherent black necrotic tissue (eschar), measuring 2.1 cm x 1.6 cm (centimeters). The right toe pressure ulcer was debrided using a curette (a curette is a surgical instrument designed for scraping biological tissue or debris in a biopsy, excision, or cleaning procedure.) 2. Left lateral foot wound, etiology pressure, with 40% thick adherent black necrotic tissue (eschar), measuring 6 cm x 1.1 cm. The left lateral foot wound was unstageable. The wound physician changed the treatment orders on 7/8/11 as follows: 1. Cleanse the right great toe with normal saline, pat dry and apply Santyl (an enzymatic [MEDICATION NAME] agent), 4 x 4 and wrap with kling every day. 2. Apply skin prep to left lateral foot wounds twice daily. There was no evidence found in the clinical record indicating the attending physician was notified of the change of condition (development of eschar) in these wounds prior to the wound physician findings documented on 7/8/11 (16 days after the initial findings of the pressure ulcers). On 7/28/11 at 4:30 P.M., the above findings was shared with the administration team. The DON stated she would have expected the nurses to have identified the change in status of the wounds before the wound physician consult on 7/8/11, and would have expected weekly wound assessments to be done. According to the U.S. Department of Health and Human Services Clinical Practice Guideline Number 15 titled Pressure Ulcer Treatment reads the following: If the condition of the patient or wound deteriorates, reevaluate the treatment plan as soon as any evidence of deterioration is noted. 1d. Review of Resident #7's care plan on 7/27/11 failed to evidence a revision to include new interventions to promote the healing of these pressure ulcers to include pressure reduction or relieving devices/surfaces specific for the resident's ulcers on her feet to promote healing. On 7/27/11 at 8:30 A.M., and 3:49 P.M., the resident was observed in bed. The resident's feet were laying directly on the perimeter bed mattress, there was no pressure relieving device in use. Two pillows were observed at the foot of the bed. The resident was noted to lay in a fetal like position with her feet raised to her chest. On 7/28/11 at 11:30 P.M., the surveyor and the unit manager observed the resident sitting up in her room in the wheelchair. Her feet were lying against the hard board surface of the wheelchair leg extension board. Pillows were noted half off the board and not in proper position to prevent pressure. The above findings was shared with the director of nurses (DON), the director of clinical and patient services (DCPS) and the certified nurse consultant on 7/28/11. The DON indicated the facility should have implemented interventions such as an air mattress and pressure reduction /relieving device for her feet such as "bunny boots". On 7/29/11 at 8:27 A.M., the resident was observed in bed, laying on her left side in a fetal like position. Her gown was up around her neck area exposing her chest area. Her left lateral foot pressure ulcer was exposed and laying directly against the parameter mattress surface. A pillow was noted between the resident's knee's, the right great toe pressure ulcer was exposed, and without a dressing. On 7/29/11 at approximately 9:30 A.M., the DCPS stated she did not believe the ulcers on the resident's feet were related to pressure. She stated the resident has behaviors such as rubbing her feet together and this could have caused the skin breakdown (review of the clinical record did not provide documentation to support this behavior or interventions to reduce potential for breakdown due to this behavior). According to the U.S. Department of Health and Human Services Clinical Practice Guideline Number 15 titled Pressure Ulcer Treatment: Managing Tissue Loads reads the following: The goal of the tissue load management is to create an environment that enhances soft tissue viability and promotes healing of the pressure ulcer (s). Positioning techniques and support surfaces for patients in bed are important factors in the management of tissue loads. Avoid positioning patients on a pressure ulcer. Use a positioning device to raise a pressure ulcer off the support surface. On 7/29/11 at 9:45 A.M., during the interview for the quality assurance (QA) program, the DON stated the facility had identified as a result of a recent mock survey concerns with the pressure ulcer program. Concerns identified were in the area of assessment, documentation and follow through. The facility wound nurse was subsequently terminated. As a result of the findings the facility incorporated the assistance of 3 certified wound care nurses from a sister facility. These nurses performed a full head to toe body skin assessment on all the resident's who would allow them on 7/6, 7/7 and 7/8/11 . As a result of the sweep she indicated new pressure ulcers were identified that had not been previously identified. She stated the next action was to ensure documentation of the pressure ulcers supported the facilities policy. The DON indicated this quality care concern is a current QA (quality assurance) issue, and collected data was to be introduced to the QA committee today. She stated inservices were conducted on 7/20/11 with the wound care supply vendor for the nurses, and the wound physician was scheduled to provide an inservice today.