Every finding on record at Rappahannock Westminster Canterbury

Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 2 kitchens/food preparation/service areas inspected. The findings included: 1. The facility staff failed to store food in a manner consistent with professional standards for food service safety with regard to, labeling and protection from contaminates. On 8/8/23 at 12:45 PM, observations were made in the facility's main kitchen. The facility's dietary manager was present and accompanied Surveyor C. In the storage bin for the dry goods, a foreign object was observed in the seafood breading. The item was scooped out using a scoop and the dietary manager sifted the dry seafood breading into a bowl. Once the object was reached, the dietary manager put on a pair of gloves and was able to remove the breading from the object. The dietary manager and Surveyor C both confirmed that it was a brown bug with wings that was approximately 1/2 inch long. The dietary manager instructed the kitchen staff to discard the entire bin's contents where the bug was found. In the dry storage room several items were noted to be opened and having been used, without an open date being noted. The items were: a 1 qt container of liquid Kitchen Bouquet Browning and Seasoning Sauce, a 12.84 fluid oz container of [NAME] Original Glaze with Balsamic Vinegar of [NAME], and a 25 fluid oz container of [NAME] Ploy Sweet Chili Sauce. The dietary manager (Employee J) and the chef (Employee F) were present and confirmed the observations. The chef said, It is important to date items when opened so you know how long it has been on the shelf and open. Some things have a shelf life we have to go by. The dietary manager acknowledged all the above noted observations and stated that it was of concern to her as well. The facility policy for food storage was requested. The facility provided a policy titled, Storage of Food and Non-Food Supplies. An excerpt from this policy read, .Dry food storage- Dry storage may be in a room or area designated for the storage of dry goods .Controlling temperature, humidity, rodent and insect infestation helps prevent deterioration or contamination of the food . The policy did not address the labeling of items once opened. According to SERV Safe Fourth Edition manual page 7-3 read, When food is stored improperly and not used in a timely manner, quality and safety suffer. Poor storage practices can cause food to spoil quickly with potentially serious results. General Storage Guidelines: Label food. All potentially hazardous, ready-to-eat food prepared onsite that has been held for longer than twenty-four hours must be properly labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. Page 7-4 stated, Discard food that has passed the manufacturer's expiration date. According to the 2017 Food Code published by the U.S. Public Health Service, FDA U.S. Food & Drug Administration chapter 3, section 3-305.11 Food Storage .D. A date marking system that meets the criteria . (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded . Section 3-501.17 Ready-to-eat, Time/temperature control for safety food, date marking read, (A) .refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises . On 8/8/23 and on 8/10/23, during end of day meetings the facility Administrator was made aware of the findings. No further information was provided. 2. The facility staff failed to remove dented cans to prevent the use of the contents, the integrity of the items and determination if the food had been contaminated could not be determined. On 8/8/23 at 12:45 PM, observations were made in the facility's main kitchen. The facility's dietary manager was present and accompanied Surveyor C. In the dry storage area, a rack of canned goods was noted. The dietary manager identified a separate area within the storage room where dented cans are to be placed so that they could notify the vendor and obtain a credit. The items on the rack were available for use. Surveyor C observed a can of apple sauce that had a significant dent on the seam. There was also a dented can of milk chocolate pudding, both items had been received by the facility in June 2023. The dietary manager confirmed that both cans should have been removed from use. The dietary manager was asked why dented cans are a problem and cannot be used. The dietary manager said, It is our policy, and you don't know if it has lost the seal or gotten something in it. The facility policy regarding the storage of food was reviewed. This policy read, .d. Any damaged container, leaking container, or can with rim or seam dents will be rejected at delivery or separated from inventory for return to the vendor for credit . On 8/10/23, during an end of day meeting the facility Administrator was made aware of the findings. No further information was provided.

Based on observation, staff interviews, and facility documentation review, the facility staff failed to maintain an effective pest control program ensure the facility is free of pests in the main kitchen, which has the ability to affect multiple Residents within the facility. The findings included: On 8/8/23 at 12:45 PM, a preliminary inspection was conducted in the main kitchen. Observations were made with the dietary manager present. The following observations were noted: Throughout the entire kitchen an abundance of flies was noted in all food preparation areas. Flies were noted to be on the food prep tables, in the dry storage room and in the dish machine area. In the bin where the seafood breaded was stored, something was noted to be in the breaded. The dietary manager scooped the item out of the bin and sifted it into a bowl to make closer observations. It was noted that a small bug, approximately 3/4 of an inch long, tan in color with wings was noted. The dietary manager instructed the kitchen staff to discard the entire contents of the bin, as it was contaminated. On 8/10/23 at 10:40 AM, Surveyor C made additional observations in the kitchen and observed again an abundance of flies. The kitchen supervisor/Employee G observed the flies as well and commented, I don't know what we are going to do about them, we swat at them all day, they are in the office too. Flies were observed on the clean dishes and throughout the entire kitchen/food storage and food preparation areas. On 8/10/23 at approximately 10:50 AM, observations were conducted of Employee H, a dietary aide using the dish machine. While making observations there were several flies observed on clean dishes. Employee H confirmed that the dishes were clean and would have to be rewashed. When asked about the flies, Employee H said, No matter how many exterminators we get to come in, they are still on everything. I don't know what they are going to do about that. On 8/10/23, the facility staff provided the survey team with pest control records for the year 2023. Review of these documents revealed ongoing and routine pest control visits. The invoices gave no details of the findings observed from the pest control company. On 8/10/23, during an end of day meeting, the facility Administrator and Director of Nursing were made aware of the above findings. Review of the facility policy titled, Health Services Infection Control, Pest Control read, On-going measures are taken to eradicate and contain common household pests. All possible measures are taken, within reason, to maintain as pest-free a facility as possible. All measures, including the use of toxic chemicals, are evaluated for safety . No further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to immediately inform the Resident's physician, and Resident representative of change in condition for 1 Residents (#14) in a survey sample of 19 Residents. The findings included: For Resident #14, who had a decline in condition, the facility staff failed to notify the physician of the Resident's inability to accept administered medications on several occasions. On 8/8/23-8/9/23, a record review was conducted. This review revealed: A progress note dated 08/04/2023 at 11:17 PM, read, Resident received in bed this evening. Has been resting, refused HS meds and fluids offered, nurse attempted to moisten mouth and resident closed and pursed lips. Did not open eyes however did begin to moan in song like manner which is a normal behavior for her indicating desire to be left alone. Skin warm pink and dry. No outward sign or evidence of discomfort. VS 97.1- 84- 18-137/86-96%. Offered Ensure as well which she also refused. On 08/04/2023 at 11:50 PM, a nurse wrote, Resident received in bed this evening. Has been resting, refused HS [bedtime] meds and fluids offered, nurse attempted to moisten mouth and resident closed and pursed lips. Did not open eyes however did begin to moan in song like manner which is a normal behavior for her indicating desire to be left alone. Skin warm pink and dry. No outward sign or evidence of discomfort. VS 97.1- 84- 18-137/86-96%. Has refused all offers of po fluids. Will offer again through out the night [sic]. On 08/08/2023 at 11:18 AM, a progress note was entered into Resident #14's record that read, Resident noted to be lethargic in bed this morning. Has not rec'd medications as of this time due to high level of lethargy and sleepiness. Aide was able to give some orange juice to resident, but she remains mostly asleep at this time. Will continue to monitor. On 08/08/2023 at 01:18 PM, an addendum note read, Addendum Note Resident noted to be lethargic in bed this morning. Has not rec'd medications as of this time due to high level of lethargy and sleepiness. Aide was able to give some orange juice to resident, but she remains mostly asleep at this time. Will continue to monitor. Resident continues lethargic with eyes closed and does not respond to verbal prompts. Medications held at this time. Will continue to monitor. Lastly, on 08/08/2023 at 08:15 PM, a nurse entered the following entry into the clinical record, Resident resting quietly in bed with eyes closed. Not responsive to verbal and only mildly to tactile touch. T-97.3 R- 33 P-82 BP-80/44 and o2 sats 90%. Cannot administer medications safely as she does not respond. She appears without distress. Daughter [name redacted] just called and given an update on her change and will continue to monitor resident for comfort. There was no indication within the chart of the physician or medical provider being made aware of the Resident's decrease in responsiveness and inability to take medications. On 8/9/23, the facility's Director of Nursing (DON) was made aware of the above findings. The DON stated she would expect the doctor to be notified each time a Resident is unable to take medications and when changes are noted. Review of the facility policy titled, Physician and Responsible Party Notification with a revision date of 2/2/15, read, Policy: Staff will know what to report to physician/responsible party and when and how to report observations and changes by fax or phone. Physician and Responsible Party notification of POA and physician will be documented in resident's chart . On 8/9/23 and again on 8/10/23, the facility Administrator and Director of Nursing were made aware of the above concerns during end of day meetings. No further information was provided.

Based on staff interview, clinical record review and facility documentation review, the facility failed to ensure that a Medicare Advanced Beneficiary Notice (ABN) was completed and issued to 2 Residents (#81, and #82) in a survey sample of 3 ABN Residents. The findings included; For Resident #81, and #82, the facility failed to ensure an effective date of insurance coverage loss was documented on the ABN prior to the loss of coverage. On 8-9-23 during the course of the survey, the Administrator was asked for ABN records for three skilled nursing discharged individuals. The documents were received and revealed that two of the three documents had not been correctly completed. Resident's #81, and #82 received the Advanced Beneficiary notices and signed them without the required area being filled out for Effective date coverage of your current services will end being documented on the notices. This indicated both Residents would be unaware of insurance coverage loss date, and thus have no ability to enact their right to appeal. On 8-9-23 at 5:00 p.m., during the end of day debrief, the Administrator was asked why no date appeared in the 2 Resident documents denoting when the Resident's insurance would lapse, and she stated We will look into that. On 8-10-23 at 3:00 p.m., during the end of day debrief the Administrator was again made aware of the incomplete ABN documents for (names of Residents) Resident's #81, and #82. She stated she had nothing further to provide.

Based on staff interview, facility documentation review, and clinical record review the facility staff failed to complete an assessment that accurately reflects the Resident's status for one Resident (Resident #30) in a survey sample of 19 Residents. The findings included: For Resident #30 the facility staff failed to accurately record on the MDS (Minimum Data Set) (an assessment) where the Resident #30 was admitted from and that a discharge plan was in process. On 8/9/23, a closed clinical record review was conducted of Resident #30's chart. This review revealed that Resident #30 had a discharge minimum data set (MDS) assessment, which was completed 7/27/23. This assessment indicated in section A0310. G., that Resident #30 was an unplanned discharge. Section A1800, was coded that Resident #30 had been admitted from an acute care hospital. Review of the Nursing Admission Comprehensive Assessment for Resident #30 was reviewed. This document read, .Entered From: 01. Community (private home/apt, board/care, assisted living, group home) . The nursing notes didn't indicate any details about where the Resident was discharged to. On 8/9/23, during an end of day meeting, the Director of Nursing (DON) was asked to provide a staff member to the survey team that was present during Resident #30's stay at the facility, because the clinical chart didn't give a lot of details about where he was discharged to. The DON stated she could answer the questions. The DON said that Resident #30 was an urgent admission to the facility from their independent living for IV fluids. The plan was always for him to discharge back to his apartment once the fluids were complete. During the above interview with the Director of Nursing, the coding of the MDS was discussed. The DON confirmed that the coding was not correct. On 8/10/23 at 5:20 PM, an interview was conducted with LPN B, who was the MDS coordinator. LPN B stated that MDS's are coded according to the RAI (Resident Assessment Instrument) Manual. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, updated October 2019, was conducted. The manual read on page 1-7, .The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that: (1) the assessment accurately reflects the resident's status . On 8/10/23, during an end of day meeting, the facility Administrator and Director of Nursing were made aware of the above findings. No further information was provided.

Based on staff interview and clinical record review, the facility staff failed to follow professional standards of nursing for 1 resident (Resident #3) in a sample of 19 residents. The findings include: For Resident #3 the facility staff failed to clarify an order for a PRN laxative. On 8/8/23, during clinical record review, it was noted that Resident #3 had orders that included the following PRN laxative. NATURAL LAXATIVE (30cc) Oral as Needed Starting 08/07/2015 Order Date: 8/7/2015 - CONSTIPATION NOS Notes: For complaint of constipation. On 8/9/23 at 1:00 pm, an interview was conducted with RN D who was asked how many times she could give the Natural Laxative she stated she did not know, as the order did not specify. On 8/10/23 at 3:00 PM, an interview was conducted with the DON who was asked if the facility has standing orders and she indicated that they did. When asked if the nurses knew the protocol for using the standing orders, she stated that they did. When asked if the Natural Laxative order was clear as to how many doses could be administered and she stated that it was not. Per [NAME] Nursing Website [https://www.nursingcenter.com/static?pageid=1101732] Make sure that the ordered medication is appropriate for the patient. Question any unclear or seemingly inappropriate order. If you can't read an order, don't guess; clarify it with the prescriber. When you question an unclear or potentially inappropriate order, document the inquiry. Include the date and time, the prescriber's name, and the prescriber's response. On 8/10/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on staff interview and clinical record review, the facility staff and physician failed to complete a discharge summary to include recapitulation of stay for 1 resident (Resident #30) in the survey sample of 19 residents. The findings included: For Resident #30, the facility staff failed to complete a recapitulation of stay and discharge summary upon the Resident's discharge from the facility. Resident #30 was discharged from the facility on 07/17/23. The Resident's closed record was reviewed on 8/9/23. No discharge summary, nor recapitulation of stay was included in the closed record. On 8/9/23, the survey team requested for the facility to provide the discharge summary and recapitulation of stay for Resident #30. The director of nursing notified the survey team she had no such records available to provide the survey team. The Administrator and Director of Nursing (DON) were notified of the missing discharge summary at the end of day meeting on 8/10/23. No further information was provided by the facility.

Based on observation, interview, clinical record review and facility documentation facility staff failed to provide treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection for 1 Resident (#19) in a survey sample of 19 Residents. The findings include: For Resident #19 the facility staff failed to provide adequate monitoring and treatment to prevent infection from developing in venous stasis wound. On 8/8/23, during clinical record review, it was found that Resident #19 had a document entitled Wound Assessment, excerpts are as follows: Date wound Identified - 3/2/23 Type of Wound - Vascular - Facility Acquired. Right Anterior Foot. Closed dark purple red in color. 2.1 cm x 0.8 cm The wound was documented weekly and by 7/13/23 the wound was 2.2 cm x 1 cm and opened at the base. The wound was not documented again until 7/27/23 (14 days later) when it was measured at 5.0 cm x 5.0 cm. Described as Vascular other description of wound color, drainage or progress was given. The next measurement was during survey on 8/10/23 (14 days later) it was documented as 8.5 cm x 1.0 cm. No other descriptions were given. On 8/10/23 a review of the clinical record revealed the following note: Late entry from 7/26/234 1:45 PM [MD name redacted] in to assess resident noted redness and swelling to right proximal. Wound with serous drainage and yellow slough noted to the center of wound. Dr. [MD name redacted] gave N.O. for Santyl to wound to right proximal foot X 7 days, Levaquin 500mg x 7 days, C&S to right proximal foot and send to [hospital name redacted]. Labs sent as ordered. [Resident #19 spouse name redacted] resident's wife made aware of all N. O.'s. 7/29/23 3:03 PM- Call rec'd from [hospital name redacted] lab with critical value for wound culture. Light Pseudomonas aeruginosa MD immediately texted with result. MD responded. Requested Sensitivity information. Sensitivity results requested from Lab, received, sent to MD. The sensitivity report showed the antibiotic Resident #19 was prescribed was effective against the Pseudomonas aeruginosa bacteria therefore no change was needed in treatment. On 8/9/23 at approximately 2 PM, an interview was conducted with Registered Nurse C (RN C) who was asked how wounds were documented. RN C stated that when wounds are discovered, the wound assessment sheet would be initiated by the nurse and the Director of Nursing (DON), MD, and Responsible Party (RP) would be made aware, and treatments would be initiated per physician order. When asked how frequently the assessments were done on existing wounds RN C stated weekly. When asked what types of description would be typically included, RN C stated that the presence or absence of slough, drainage, odor, and redness were what was usually documented. When asked what the presence of those could indicate, RN C stated they could indicate worsening of wound or infection in the wound. On 8/10/23 at approximately 1:00 PM an interview was conducted with the DON who was asked the procedure when a wound is discovered. The DON stated the wound assessment is filled out and the MD, RP and DON are notified. When asked if it is expected that the assessment be filled out completely, the DON stated it was. When asked if the wound assessment included measurements as well as descriptions of wound, the DON stated that it was. On 8/10/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on staff interview and clinical record review, the facility staff failed to accurately account for controlled medication for 1 resident (Resident #7) in a survey sample of 19 residents. The findings included: For Resident # 7 the facility staff failed to accurately account for controlled medication. On 8/9/23 at approximately 9:00 AM during med pass it was observed that Resident #7's controlled count sheet for morphine was not accurate. The controlled sheet reflected 24.75 ml (milliliters) of liquid morphine and the bottle contained 30 ml. A review of the controlled sheet revealed that on 7/25/23 at 10:34 AM, the initial dose was given from the bottle. There was no nurse's signature; only date, time, amount given, and the quantity left in the bottle were filled in. Upon closer inspection the controlled sheet was found to have a mathematical error that only accounted for an overage of 1 m. On 7/26/23 at 9:45 PM the nurse signed out 0.25 ml and that left 29.25 in the bottle. On 7/27/23 at 9:58 PM the nurse gave 0.25 ml and instead of writing that there was 29 ml left in the bottle she put 28 ml. It appears to be the only mathematical error and it appears that others just deducted their next dose and did not look at the bottle to reconcile the sheet and the bottle. On 8/9/23 at approximately 9:10 AM an interview was conducted with RN F who was asked about the discrepancy in the bottle and the sheet. RN F stated the pharmacy must have overfilled the bottle. When asked if the controlled count sheet was accurate when it reflected that there was 24.75 ml in the bottle, she stated the sheet was inaccurate. When asked if the nurses are supposed to look at the bottle to reconcile it with the sheet, she stated that they should. When asked if there is a discrepancy in controlled count what are you supposed to do, she stated we are supposed to tell the DON. When asked if this had been reported to the DON, she stated that she did not know. On 8/9/23 at approximately 10 AM, the DON was interviewed and asked about the discrepancy in controlled count, and she stated that the nurses claim the pharmacy overfills the bottle. The facility allowed surveyors to observe opening a new bottle of morphine from the stat box and it was filled just above the 30-cc mark. When asked how the controlled sheets are recorded, she stated that the nurses fill out the sheet when the medication comes in. When asked what information is put in by the nurses she stated the Rx number, Resident name, Physician name, Name of medication, and directions for use. and the quantity received. When asked if the controlled sheet should read 30 ml if the pharmacy overfilled the bottle, she stated that it should accurately reflect the amount received by the pharmacy and the amounts given by nurses. When asked if the expectation is that nurses look at the bottle and reconcile it with the sheet, she stated it was. On 8/11/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from unnecessary psychotropic's for 1 Resident (#3) in a survey sample of 19 Residents. The findings included: For Resident #3, the facility staff failed to ensure the As Needed (PRN) Ativan was only ordered for 14 days without proper documentation. On 8/8/23 a review of the clinical record revealed that Resident #7 had orders for PRN Ativan (an anti-anxiety medication) the order read as follows: Lorazepam 2 mg (milligrams)/mL(milliliter) oral concentrate (.25 ml) PRN Every 4 Hours for 60 Days. Order Date: 7/25/2023- ICD-10: F41.9 - ANXIETY DISORDER, UNSPECIFIED Notes: For agitation, psychotic disturbance, anxiety, and/or mood disturbance. On 8/9/23 at approximately 10 AM, an interview was conducted with the Director of Nursing (DON) who was asked how long a PRN order for Psychotropic medication should be, the DON stated it should be only for 14 days then reevaluated. The DON stated that Resident #3 got an order from hospice for 14 days then Resident #3 got the order from the physician. When asked for the documentation in the resident's medical record for the rational and indication of the duration for the PRN order, the DON only could provide the original order from hospice for the Ativan. On 8/11/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on staff interview, facility documentation and clinical record review, the facility staff failed to provide consistent basic life support, including CPR for 1 Resident (Resident #35) in a survey sample of 27 Residents. This resulted in Immediate Jeopardy at Level 4 isolated on [DATE]. After reviewing the facility documentation, Immediate Jeopardy was determined to be removed at past non-compliance on [DATE]. The findings included: 1. For Resident #35, the facility staff failed to continue cardiopulmonary resuscitation (CPR) on [DATE]. Also, the facility staff failed to activate Emergency Medical Services (EMS) when CPR was initiated. Resident #35 was a full code. Resident # 35 was admitted to the facility on [DATE] and expired on [DATE]. Resident # 35's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 35's most recent MDS (Minimum Data Set) assessment with an Assessment Review Date of [DATE] was coded as an Admission Assessment and coded Resident # 35 as having a BIMS (Brief Interview of Mental Status) score of 2 indicating severe cognitive impairment. Resident # 35 was coded as requiring extensive assistance of one staff person for all aspects of ADL (activities of daily living) care except for bathing which was coded as requiring total assistance of one staff person. Resident # 35 had a Full Code status. On [DATE] at 10:40 a.m., a review of the closed electronic clinical record for Resident # 35 was conducted and revealed Resident # 35 expired in the facility on [DATE]. Review of the Nursing Progress Notes revealed the following entries (in order of writing): Progress Note Clinical Notes [DATE] 11:30 (EST) [DATE] 1:14 (EST) [written by LPN-B name redacted] Late entry. Resident medicated with Tylenol 650 mg for complaint of generalized discomfort all over. Mobile image here for X-ray. Resident alert and oriented to name. Awaiting X-ray results. Nursing Progress Note Clinical Notes [DATE] 3:33 (EST) [DATE] 3:36 (EST) [Written by RN-D name redacted] [name of Doctor of Nursing Practice redacted] in with Residents wife for final view. [name redacted] funeral home called to pick up remains. [name of Funeral Home redacted] arrived and took remains into their care. Nursing Progress Note Death Clinical Notes [DATE] 1:19 (EST) [DATE] 1:26 (EST) [Written by RN-D name redacted] Resident is without Apical pulse, BP, or respirations. Pupil non responsive. At first resident still making some gasping attempts then stopped at 0040. Large amounts of black emesis was expelled from his mouth and nose and PDP [private duty person] described it as projectile. large puddle also on floor. Resident was wet with perspiration. DNP notified at 0045 and Wife at 0114. Nursing Progress Note Clinical Notes [DATE] 0:30 (EST) [DATE] 9:22 (EST) [Written by LPN-B name redacted] Late Entry. Called to room resident covered in dark emesis and unresponsive. Compression given and resident remained on responsive and mouth continued to fill with emesis with each compression. Resident turned to side a more produced. [Sic] Charge RN in and no apical pulse. DNP aware. Nursing Progress Note Clinical Notes [DATE] 19:14 (EST) [DATE] 19:15 (EST) [written by RN-F name redacted] BP-,d+[DATE], apical pulse 76, [MEDICATION(S)] held per orders, MD and RP aware Resident lying in bed this evening with spouse at bedside Resident's abdomen round firm bladder scanned Review of the Physicians Orders revealed an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan revealed the following entries: ADVANCED DIRECTIVES: Please review my Advanced Directives with me, my representative, and/or my family STATUS: Active (Current) [name redacted] Advanced Directives will be reviewed STATUS: Active (Current) GOAL DATE: [DATE] I desire to remain a Full Code. STATUS: Active (Current) All Disciplines Please review my Advanced Directive/Living Will if I am unable to make decisions for myself and enforce my wishes & desires. RESPIRATORY: Resident had a change in condition. Noted audible gurgling, increased respirations 24/min at times, then slows down when eyes closed, skin warm to touch - temp 97.8 non contact. Dr. [name redacted] notified with new orders. Possible aspiration as he had been coughing during lunch. On [DATE] @ 24:30ish [Sic] resident unresponsive with large amount of dark emesis on him, the floor, etc. CPR started without success. Emesis con't [Sic] to produce during each compression. Pronounced deceased at 24:40. STATUS: Active (Current) Thorough review of the Nurses Progress Notes revealed evidence that CPR was started with compressions but no evidence of CPR being continued In addition, there was no evidence of Emergency Medical Services being called . Review of the Nurse Practitioner's Discharge Final Progress Note reads the following. [DATE] [Resident # 35's name redacted] Discharge Notified at 1242am that resident had passed. Large amount of dark emesis and rapid death. Breathless, pulseless. Suspect this represents stress ulcer with GI (gastrointestinal) hemorrhage. Patient had complex course with underlying advanced [CONDITION(S)], at time of admission had [CONDITION(S)], developed [CONDITION(S)] bladder with indwelling catheter. Recent clinical change + CXR [Chest x ray] bibasilar pneumonia suspected aspiration with MODS as noted in Dr. [name redacted] notes. Negative urine culture. On [DATE] at 10:50 a.m., an interview was conducted with the Administrator who stated Resident # 35 expired in the facility. The Administrator stated the facility staff did not continue to perform CPR for Resident # 35 and Emergency Medical Services was not called to the facility to assist with the emergency. The Administrator stated the Licensed Practical Nurse (LPN-B) initiated CPR and Registered Nurse (RN-D) called the physician to notify of the resident's death in the facility. The Administrator stated the incident was very upsetting to all involved. The facility staff should have called EMS and continued to perform CPR until EMS arrived. On [DATE] at 11:15 a.m., an interview was conducted with the Director of Nursing who stated her expectation was for the CPR (Cardiopulmonary Resuscitation) policy to be followed by the staff, activated EMS (Emergency Medical Services and continue CPR until EMS arrives. The Director of Nursing stated the incident with Resident # 35 involved two nurses LPN-B (Licensed Practical Nurse-B) and RN-D (Registered Nurse-D) working night shift that night. One of the nurses (LPN-B) usually was assigned to day shift. It was reported that the private duty person working with Resident # 35 came to the nurses stated the resident was vomiting. The nurses, LPN-B (Licensed Practical Nurse-B) and RN-D (Registered Nurse-D), observed excessive vomiting, no pulse and breathless. The nurse (RN-D) called the Nurse Practitioner who was on the phone with them when CPR was determined to be futile and CPR was stopped. The Director of Nursing stated that was where it seemed to be a misunderstanding. The Nurse Practitioner thought the staff was just telling her the resident had expired. The Director of Nursing stated that the Nurse Practitioner did not give an official order to stop CPR. The Director of Nursing stated through the facility's investigation it was determined that the Nurse Practitioner was under the impression that Resident # 35 was already deceased when the call was placed and the call was for notification but not for orders to be obtained. On [DATE] at approximately 2:45 PM, a meeting was held with the Administrator, Director of Nursing and the Corporate Chief Operations Officer. They were made aware of the concerns with staff not following standard CPR/BLS (Basic Life Support) procedures for Resident # 35 and that it constituted Immediate Jeopardy. They were asked to provide any and all documentation regarding the facility's response to this incident. The Administrator stated when she was informed of Resident # 35's death, she immediately asked if EMS had been called. The Administrator stated she and the Director of Nursing came to the facility immediately to address the issue, educated the staff on the CPR Policy and instituted a new policy entitled Medical Emergency Response on [DATE]. The Administrator stated the facility staff should have followed the CPR policy, called 911 to access the Emergency Medical Services and that CPR should have continued until the EMS arrived to take over. The Administrator stated she submitted a FRI (Facility Reported Incident) to the State Agency. The Administrator stated nothing like this incident had ever happened before and they realized the importance of correcting the problem. The Administrator stated both nurses involved in this incident were suspended pending investigation. Both nurses were referred to the Department of Health Professions for review. The Administrator stated LPN-B had been employed over [AGE] years and Registered Nurse-D for [AGE] years. Both employees were suspended. Immediate Jeopardy was called on [DATE] at 2:45 PM. Documentation was received and reviewed. The facility's removal plan included: Under Corrective Action Following Event: On [DATE], the CPR (Cardiopulmonary Resuscitation) policy was reviewed, the Emergency Medical Response policy was adapted and both policies in serviced with staff and placed on all shifts to review and acknowledge. [DATE] Both directly involved staff members placed on administrative leave pending investigation. ,d+[DATE]-,d+[DATE] Investigation of incident performed; staff statements collected Review of the facility's documentation revealed: Nurses scheduled to work from [DATE] through [DATE] were educated on the facility's CPR policy, the Medical Emergency Response Policy Date implemented [DATE] (to include calling 911, notifying the physician, and performing continuous CPR until care is transferred) prior to the start of their next scheduled shift. There was education provided to staff on Communication Book Information Sheet on [DATE] and [DATE]. Both inservices were repeated for staff scheduled to work on their next scheduled shift. Review of the Facility documentation revealed the following policy: Policy name: Medical Emergency Response, date implemented: [DATE] Policy: It is the policy of this facility to respond to medical emergencies for residents, staff and visitors. Policy Explanation and Compliance Guidelines: 1. The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance. 2. CPR will continue unless: a. There is a DNR order in place b. There are obvious signs of clinical death (rigor mortis, dependent lividity, decapitation, transection or decomposition. c. Initiating CPR could cause injury or peril to the rescuer 3. A nurse will a. Assess the situation and determine the severity of the emergency. b. Stay with the resident. c. Designate a staff member to announce a Code Blue if necessary, call 911 as needed, notify the physician. 4. A Code Blue will be announced over the intercom system, if necessary. 5. All available staff will respond to the emergency accordingly. 6. The RN supervisor or Charge Nurse of the unit will take the Emergency Cart to the code site, ensure accurate documentation of the event and delegate any other duties or tasks needed. 7. This will continue until emergency personnel arrive and resident is transported to the emergency room by the EMS 8. If the resident experiences [CONDITION(S)], the facility must provide basic lice support, including CPR prior to the arrival of emergency medical services and : a. In accordance with the resident's advance directives, or b. In absence of advance directives or a Do Not Resuscitate order, and c. If the resident does not show obvious signs of clinical death. 9. The RN supervisor or designee will ensure emergency medications and equipment are inventoried and restocked. 10. The facility will ensure that CPR certified staff are available at all times. 11. Current certified staff must maintain CPR-Certification for Healthcare Providers through a CPR provider whose training includes hands-on skills practice and in-person assessment and demonstration of skills. Online certification is not acceptable. The survey team verified the removal plan by doing the following: Staff at the facility were interviewed for training on the Emergency Response policy and CPR Policy and Mock Codes. Nurses who were not at the facility were called and interviewed. The survey team reviewed copies of the Emergency Policy received by nurses and Certified Nursing Assistants. The survey team reviewed copies of CPR Cards for nursing staff. The survey team confirmed that staff had been educated about CPR, knew to call 911 so that EMS could respond and that CPR would continue uninterrupted until EMS took over after arriving on-site. The survey team reviewed the staff education/training on the CPR Policy and Emergency Response Policy. The survey team reviewed charts of current Residents to ensure the code status was correctly identified in the charts. Review of the facility staff listing revealed that all Nurses had current CPR certification. Therefore, trained staff would be available to provide CPR until EMS arrived in the event of a Resident with a Full Code Status being found unresponsive. The Immediate Jeopardy was determined to be Past Non-compliance and removed on [DATE] at 5:00 PM. On [DATE] at approximately 5:30 PM, the facility Administrator was asked if she had any further information regarding the incident for Resident # 35. The Administrator reported she had no further records or information to provide. The Administrator, Director of Nursing, MDS Coordinator and Chief Operations Officer were informed of the findings that the facility failed to provide CPR to the Resident with a FULL Code order and Advance directive. The facility failed to ensure the staff was familiar with the facility's policies regarding basic life support and CPR and staff failed to confirm Resident # 35's code status in an emergency resulting in Immediate Jeopardy. On [DATE] at 6:45 PM, the facility Administrator, the Director of Nursing and Chief Operation Officer were made aware that Immediate Jeopardy was being cited at Past Non-compliance. No further information was provided.

Based on observation, staff interview and facility documentation review, the facility staff failed to store food in a manner to identify the food item and the date opened or to be used by, in 2 of 4 food storage areas inspected. The findings included: On 1/11/22 at 2:59 PM, observations were made in the facility kitchen. Surveyor C was accompanied by Employee F, the dietary manager. In the walk-in freezer, two bags of mixed vegetables and a bag of green peas were open to air, not secured in a manner to protect from environmental contaminates, and had no date. A bag of green beans were observed to be wrapped in saran wrap and had no date. Observations of the walk-in freezer labeled as #4 contained an item in a zip lock bag that Surveyor C was not able to identify. It had no labeling and no date. Employee F, the dietary manager identified the item as, Muffin mix dough. Employee F confirmed all of the observations as they were being made and stated .I expect every item opened to be labeled and dated, properly wrapped and sealed after each use. The potential risks of not doing this is, if they [Residents] are allergic, it could cause allergic reaction, reaction to outdated products and the quality of the product isn't good. Review of the facility policy titled, Storage of Food and Non-Food Supplies, was conducted. This policy read, .2. d. Opened containers of food will be stored in tightly closed non-corrosive containers or in sealed plastic bags. No exposed food will be stored in the storeroom, refrigerators or freezer. Open and use-by-dates will be placed on these items 4. l. All food items in refrigerators are properly dated, labeled, and placed in containers with tight fitting lids, or are wrapped . Items are dated with received date and use-by-date per manufacturer's guidelines or expiration date. m. Once opened, frozen food is dated, labeled, and wrapped. Moisture-proof, right fitting materials are used to prevent freezer burn and use-by-dated per manufacturer's expiration date or guidelines. The CFR [Federal code] read, 3-305.11 Food Storage .D. A date marking system that meets the criteria .(2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded . On 1/11/22 and on 1/12/21, during end of day meetings, the facility Administrator was made aware of the findings. No further information was provided.

Based on observation, resident interview, staff interviews and clinical record review, the facility staff failed to ensure the environment was free of accident hazards by allowing Resident access to medication/treatment and sharps for 1 Resident (Resident #6) in a survey sample of 27 Residents. The findings included: A clinical record review for Resident #6 was conducted. This review revealed that Resident #6 had the following diagnosis: Alzheimer's disease with late onset, visual hallucinations and auditory hallucinations. Resident #6's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 10/7/21, was coded as an annual assessment. On this assessment Resident #6 was coded as having had a BIMS (brief interview for mental status) score of 6, which indicated severe cognitive impairment. Resident #6 was also coded on this assessment as having had hallucinations and delusions. Resident #6 required extensive assistance of one staff person for personal hygiene. Resident #6's clinical record revealed no physician orders for self-administration of medications. On 01/11/22 at 04:24 PM, observations of Resident #6's room were conducted. Surveyor C noted a razor in bathroom on the sink which did not have a cap on it. On 01/11/22 at 04:41 PM, an interview was conducted with Resident #6. During this interview it was noted that Resident #6 was confused and had trouble answering questions. On 01/12/22 at 12:36 PM, observations were again made in Resident #6's room. This observation revealed the razor was still in bathroom and a medicine cup was also on the bathroom sink and contained what appeared to be a white cream within. On 01/12/22 at 12:37 PM, an interview was conducted with LPN C. LPN C accompanied Surveyor C into Resident #6's room and was asked to identify the medicine cup with the white cream. LPN C said, I don't know what it is, but it shouldn't be there. LPN C then went to the nursing station to discard of the cup of cream and looked into Resident #6's electronic health record. LPN C said, she gets remedy twice a day, I went in this morning and put it on her, I can only assume that is what it is. LPN C confirmed that Resident #6 is not able to self-administer medications and they do have Residents who wander into other Resident's rooms at times. LPN C further confirmed that Resident #6's safety awareness varies. LPN C stated she had not noticed the razor but razors are considered sharps and should be disposed of in the sharps container and I wouldn't leave it in the room. LPN C said the risks are someone could cut themselves. On 01/12/22 at 12:46 PM, RN C, the Supervisor, was in Resident #6's room. RN C observed the razor in the bathroom and she removed it and said It should be disposed in the sharps container. On 1/13/33 at 9:29 AM, Surveyor C was provided a tube of the Remedy Cream. This cream revealed the following warnings on the product tube: For external use only. When using this product do not get into eyes. Keep out of reach of children. If swallowed get medical help or contact Poison Control Center right away. On 1/13/21 at approximately 11:50 AM, an interview was conducted with RN A. RN A said razors are supposed to be discarded in the sharps container because there is a danger of them [Residents] hurting themselves. It is for everybody's safety. On 1/13/21 at 11:57 AM, an interview was conducted with CNA B. CNA B said she was assigned to care for Resident #6. CNA B confirmed that she had never shaved Resident #6. She said she disposes of razors in the sharps containers so no one gets cut or injured. CNA B said, Someone could wander in and get hurt if it is left out. CNA B confirmed that they do currently have residents who wander into other resident's rooms. The facility policy regarding the disposal of sharps was reviewed. This policy didn't address the disposal of razors. The facility policy regarding the Administration of medications was reviewed. This policy read, .9. Administering medication to resident: .G. Do not leave medication on a table in bedroom or on table in dining room . The Administrator and Director of Nursing were made aware of the safety hazards on 1/12/22 at 3:30 PM, during the end of day meeting. The Director of Nursing confirmed that razors left in Resident's rooms pose a potential safety hazard. No further information was provided.

Based on observation, staff interview, and facility documentation the facility staff failed to maintain infection control practices in accordance with the Center for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommendations to prevent the spread of COVID-19 in 2 of 5 areas of the facility. The findings included: The facility staff failed to properly wear personal protective equipment (PPE) to prevent the spread of COVID-19. On 6/9/2020 at approximately 11:55 AM Surveyor C observed Employee F and Employee G in the laundry room folding clean laundry with their face masks removed from their face and resting below their chin. When Surveyor C questioned this, Employee F and Employee G stated they had removed the masks because they were hot. On 6/9/2020 at approximately 12:05 PM Surveyor C observed CNA B in the doorway of a Resident room, assisting a Resident in a wheelchair. CNA B lowered her mask to talk to a co-worker and the Resident. CNA B then attempted to put the mask back on, but failed to cover the nose. CNA B only covered their mouth. Surveyor C asked CNA B about removing her mask and CNA B stated, she removed the mask because they couldn't hear her when she spoke. Surveyor C asked CNA B if she had received training on the COVID-19 virus and proper use of PPE? CNA B responded yes she had. CNA B then pulled the mask up and adjusted it over her nose and mouth. The observations on 6/9/2020 by Surveyor C were made in the presence of the facility Director of Nursing (DON). Surveyor C asked the DON what is your process with staff and masks? The DON stated, staff always wear masks while in the building. On 6/9/2020 at 3:19 PM a telephone conference was held by Surveyor B with the facility Administrator and DON. The DON and Administrator indicated that the facility supply of personal protective equipment (PPE), including masks was adequate. When asked about their expectation on use of masks they stated, healthcare workers put them on upon entry and wear throughout their shift, if it becomes soiled or dirty they are able to change it, otherwise they wear it the duration of their shift and then dispose it at the end of their shift. When the Administrator and DON were asked about the importance of wearing a mask, the DON stated, to continue to keep us at zero cases and minimize source control for COVID. The facility management was asked if they expect staff to wear masks in a manner that would cover their mouth and nose and both responded, yes. Review of the facility document titled employee COVID-19 Daily Screening it stated, you must wear a mask on entry. The facility DON was asked what this meant and she stated, the staff put it on when they come in and wear it all day. On 6/9/2020 a review of the facility policy titled Emergent Infectious Diseases (EID) Employee Prevention and Protection Plan with a revision date of 4/5/2020 read, Follow CDC (Center for Disease Control) guidelines regarding the need for employees to wear protective equipment. Per the CDC's guidance stated healthcare personnel (HCP) should wear a facemask at all times while they are in the facility. When available, facemasks are generally preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Cloth face coverings should NOT be worn by HCP instead of a respirator or facemask if PPE is required. CDC recommendations/guidelines accessed online 6/9/2020 at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare-facilities%2Fprevent-spread-in-long-term-care-facilities.html CMS's COVID-19 Long-Term Care Facility Guidance dated April 2, 2020, read: For the duration of the state of emergency in their State, all long-term care facility personnel should wear a facemask while they are in the facility. accessed online 6/9/2020 at https://www.cms.gov/files/document/4220-covid-19-long-term-care-facility-guidance.pdf The facility Administrator and DON were made aware of the findings during the end of day meeting held on 6/9/2020. No further information was provided.

Based on staff interview, facility documentation and clinical record review the facility staff failed to ensure freedom from accident hazard for 1 Resident in a survey sample of 18 Residents. For Resident # 91 the facility failed to ensure foot rests were in place on wheelchair while transporting Resident in wheelchair. The findings include: Resident #91 a [AGE] year old woman was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to last (Minimum Data Set) MDS (screening tool) with an (Assessment Reference Date) ARD date of [DATE], Resident #91 was coded as having a (Brief Interview of Mental Status) BIMS score of 3 indicating severe cognitive impairment. She was also coded as requiring extensive assistance of 2 person physical assistance with all aspects of (Activities of Daily Living) ADL care to include transfers and bed mobility. The Resident used a wheelchair for locomotion in facility however was unable to propel self needed staff assistance to push wheelchair. The investigation was conducted as a result of a (Facility Reported Incident) FRI sent to the Office of Licensure and Certification on [DATE]. The report was in the category of injury of unknown origin. The FRI stated Resident #91 was found with bruising and swelling to the proximal tibia and fibula (lower leg). The investigation was conducted as closed record as Resident expired in facility on [DATE]. According to the FRI the Resident was fine until she was brought down to activities on [DATE] when a staff member noticed she was hurting when she repositioned her in the chair. According to the care plan the Resident she would often say ouch or complain of pain when ADL care was being performed. According to the FRI the staff noticed bruising to the Residents foot and left ankle. This was then reported to the Nurse and DON and she was subsequently sent to the ER for X-Rays when they realized she had extensive bruising up her left leg. On [DATE] the Administrator provided the facility investigation which included statements from staff. The injury of unknown origin was submitted as bruising discoloration and swelling to lower leg. According to written statement, dated [DATE], in the investigation file RN B (no longer employed at facility) states: Staff nurse on the Blue Marlin (unit) came to this nurse about 10:00 AM stating that (employee name redacted) in activities had brought to her attention that (Resident #91) was complaining of pain and expressing discomfort by calling out. Staff nurse and I asked Resident multiple times where she hurt, but the Resident's dementia prevents her from being able to be specific and expressive. Took Resident to supervisor's office to check her feet, because when the foot was moved she expressed pain. Dermasavers (skin sleeves) prevented seeing up to the knee, but at that time did not see bruising about the ankle. This nurse took Resident to lunch at noon and the Resident did drag left foot, and at one point had it behind the right foot, had to stop and place her foot in a better position, but Resident did not express anything but discomfort, not outright pain at the time. She quite often expressed dislikes and discomfort when moving her from her bed to W/C (wheelchair) and also when ambulating in her W/C. Staff laid Resident in her bed after lunch and noted more bruising at the top of Dermasaver, so she removed the Dermasaver and noted the swelling just below the left knee and extensive bruising. (Name of NP Redacted) was called and Administrator was in the building and she was informed. DON called and statements taken. (NP name Redacted) in to evaluate and new orders for X-rays and scheduled Tylenol. According to the nurses notes dated [DATE] at 6:21 PM the RP (responsible party) wanted the Resident evaluated at the Hospital and the Resident was taken to the emergency room at 5:45 PM According to X ray results dated [DATE] at 6:28 PM: FINDINGS: 4 views of the left knee demonstrate a non-displaced [MEDICATION NAME] fracture involving the proximal Tibial metaphysis. No other acute fracture or dislocation is seen. There is osteopenia. [MEDICAL CONDITION] is present in the knee and there is anterior soft tissue swelling. IMPRESSION: Non-displaced [MEDICATION NAME] Tibial metaphysis with overlying tissue swelling. Signed [DATE] 7:28 PM (MD name redacted) Upon care plan review it was noted that the family was advised that the Resident should have the Hoyer Lift used when moving between bed and chair. According to the care plan the family stated they felt she should use a turn and pivot with the assistance of 2 staff to avoid the anxiety of using the lift. They felt she would be afraid or anxious about using the lift. They wrote a statement that they expected some bumps or bruises from using 2 staff vs using the lift would like to Avoid this as long as possible. On [DATE] an interview with the DON was conducted. The DON was asked about the incident involving Resident #91 if she remembered the resident and the incident to which she answered, yes. She was asked regarding the statement by Nurse B who admitted that the Resident dragged her left foot while being transported in the wheelchair at lunchtime that day, did that mean she had no foot rest on her wheelchair, she responded, yes. She went on to explain that Resident #91 was a small framed woman and she would sit in the wheelchair and hold her feet up as the staff propelled her in the wheelchair. The DON stated again that the Resident did not like to have the foot rest on the chair and would hold up her feet. When asked if this was the normal procedure for using a wheelchair. She stated no, ideally we would like the foot rests to be on. Review of care plan did not mention the use of the wheelchair without foot rests. The DON was asked if there were any reason she could think of why there should be foot rests on the wheelchair and she stated yes for safety. On [DATE] the Administrator was notified of the issue with not using the wheelchair foot rests and no further information was provided.

Based on staff interview and clinical record review, the facility staff failed to ensure the physician signed and dated all orders at each visit for three Residents (Residents' #4, #7 and #6) in a survey sample of 11 Residents. 1. For Resident #4, no Physician's Orders ( a recapitulation of the plan of care) was signed after 11/1/16 (101 days); 2. For Resident #7, no Physician's Orders were signed by the physician after 11/28/16; and 3. For Resident # 6, the facility staff failed to ensure Physicians orders were signed timely. No signed Physicians orders were noted between 11/2/2016 and 2/4/2017 resulting in 94 days between the last signed orders. The findings included: 1. For Resident #4, no Physician's Orders ( a recapitulation of the plan of care) was signed after 11/1/16 (101 days). Resident #4, a female, was admitted to the facility 8/10/16. Her [DIAGNOSES REDACTED]. Resident #4's most recent MDS (minimum data set) with an ARD (assessment reference date) of 2/16/17 was coded as a quarterly assessment. Resident #4 was coded as having short term memory deficits and required moderate assistance with making daily life decisions. She was coded as requiring limited to extensive assistance of one staff member to perform her activities of daily living with the exception of bathing. For bathing she was coded as requiring total assistance. Review of Resident #4's clinical record revealed no Physician's Orders were signed by the physician after 11/1/16. The Physician's Orders were evidence the physician had reviewed and approved the total plan of care, including medications and treatments, for Resident #4. A progress note was apparent that the physician had been in to the facility and examined Resident #4 on 2/15/17. Upon review of the clinical record, the Physician's Orders for the months after 11/1/6 were in the electronic medical record, however no signature was evident on the orders. When interviewed 3/9/17 at 2:52 p.m., Other A and Other B stated they were responsible for creating the Physician's Orders within the computer. Other A and Other B stated they printed the Orders and gave them to the physician's to review and sign. Other A stated sometimes the physician's would take the listing with them and complete the orders at their offices. The physician's would then send the orders back to the facility for scanning into the electronic record. Other A and B stated the orders for 11/1/16 were the last signed orders they could find for Resident #4. The administrator and DON (director of nursing) were informed of the failure of the physician's to sign and date orders at each visit, 3/9/17 at 3:35 p.m. 2. For Resident #7, no Physician's Orders were signed by the physician after 11/28/16. Resident #7, a male, was admitted to the facility 9/28/16. His [DIAGNOSES REDACTED]. Resident #7's most recent MDS with an ARD of 12/22/16 was coded as a quarterly assessment. Resident #6 was coded as having short and long term memory deficits and required total assistance with making daily life decisions. Resident #4 was also coded as needing limited assistance of one to two staff members to perform his activities of daily living with the exception of bathing. For bathing he was coded as requiring total assistance of one staff member. Review of Resident #7's clinical record revealed no Physician's Order signed by the physician since 11/28/17. A thorough review of Resident #7's clinical record revealed he was seen and examined by the physician 9/28/16, 10/28/16, 12/16/16, and 3/5/17. Other A and Other B stated 3/9/17 at 2:52 p.m., the orders signed by the physician 11/28/16 were the only orders signed by the physician that were evident in the electronic medical record. The administrator and DON were informed of the failure of Resident #7's physician to signed and date all orders with each visit, 3/9/17 at 3:35 p.m. 3. For Resident # 6, the facility staff failed to ensure Physicians orders were signed timely. No signed Physicians Orders Sheets were noted between 11/2/2016 and 2/4/2017 resulting in 94 days between the last signed orders. Resident # 6, an [AGE] year old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a Quarterly Assessment with an ARD (assessment reference date) of 2 /2/2017. Resident # 6 was coded as having a BIMS (Brief Interview for Memory Status) score of 5 indicating severe cognitive impairment. Resident # 6 was coded as requiring minimal assistance of one staff person for her ADLs (activities of daily living), except requiring extensive assistance of one staff person for bathing. Resident # 6 was coded as being frequently incontinent of bladder and occasionally incontinent of bowel. Review of Resident # 6's clinical record revealed her most recently signed POS (Physicians Orders Sheets) were dated as having been signed on 2/4/2017 to recapitulate and reinstitute the Resident's medication, and treatment orders. A thorough review of Resident #6's clinical record revealed the previously signed Physicians Orders Sheets were dated on 11/2/2016. On 3/8/2017 at 2:42 PM, an interview was conducted with the Director of Nursing who stated the expectation was that the Physicians would sign Physicians Order sheets every 30 days for the first 90 days and then every 60 days. On 3/8/2017 at 4 PM, the Administrator and Director of Nursing were informed that the last signed Physicians Orders Sheet noted in the electronic medical record was dated on 2/4/2017 and the one prior was dated on 11/2/2016. The surveyor asked for a copy of the most recent signed Physicians Order Sheets. On 3/9/2017 at 2:52 PM, an interview was conducted with the two unit secretaries (Other A and Other B) who stated they work together on the task of generating a list on the computer that keeps up with which residents are due to be seen by the physicians. Both Other A and Other B stated they would send a note to the physician, the nurse in charge was supposed to pull the Physicians Orders Sheet form off of the chart. Both stated that some physicians would sign the Physicians Orders sheets while they were in the facility, one would sign orders electronically, while other physicians would sign the orders and mail them back in to the facility. Other A and Other B stated they would scan the returned signed POS form into the electronic records. Other A and Other B stated the expectation was that the Physicians would sign Physicians Order sheets at least every 60 days. During the end of day debriefing on 3/9/2017 at 3:10 PM, the facility Administrator, Administrator in Training (Admin C) and the Director of Nursing were informed of no signed Physicians Orders between 11/2/2016 and 2/4/2017. No further information was provided.

Based on staff interview and clinical record review, the facility staff failed to ensure the physician visited the Residents in a timely manner for two Residents (Residents' #4 and #5) in a survey sample of 11 Residents. 1. For Resident #4, the physician had not examined and completed a progress note between 11/1/6 and 2/15/17 (106 days); and 2. For Resident # 6, the facility staff failed to ensure physicians' visits were completed in a timely manner. Resident # 6 was not seen by the physician between 11/3/2016 and 2/3/2017 resulting in 92 days between visits. The findings included: 1. For Resident #4, the physician had not examined the Resident and completed a progress note between 11/1/6 and 2/15/17 (106 days). Resident #4, a female, was admitted to the facility 8/10/16. Her [DIAGNOSES REDACTED]. Resident #4's most recent MDS (minimum data set) with an ARD (assessment reference date) of 2/16/17 was coded as a quarterly assessment. Resident #4 was coded as having short term memory deficits and required moderate assistance with making daily life decisions. She was coded as requiring limited to extensive assistance of one staff member to perform her activities of daily living with the exception of bathing. For bathing she was coded as requiring total assistance. Review of Resident #4's clinical record revealed no evidence was present that Resident #4 had been examined by her physician between 11/1/16 and 2/15/16. No progress notes for visits within the dates in question was evident. When interviewed 3/9/17 at 2:52 p.m., Other A and Other B stated they were responsible for scanning the physician progress notes [REDACTED]. Other A stated the progress notes evident within Resident #4's electronic medical record were all the progress notes available. The administrator and DON (director of nursing) were informed of the failure of the physician's to conduct timely physician visits for Resident #4, 3/9/17 at 3:35 p.m. 2. For Resident # 6, the facility staff failed to ensure physicians visits were completed in a timely manner. Resident # 6 was not seen by the physician between 11/3/2016 and 2/3/2017 resulting in 92 days between visits. Resident # 6, an [AGE] year old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a Quarterly Assessment with an ARD (assessment reference date) of 2/2/2017. Resident # 6 was coded as having a BIMS (Brief Interview for Memory Status) score of 5 indicating severe cognitive impairment. Resident # 6 was coded as requiring minimal assistance of one staff person for her ADLs (Activities of Daily Living), except requiring extensive assistance of one staff person for bathing. Resident # 6 was coded as being frequently incontinent of bladder and occasionally incontinent of bowel. Review of Resident # 6's clinical record was conducted on 3/8/2017 at 8:45 AM. Review of the Physicians Progress notes revealed the last signed Progress note sheet was dated on 2/15/2017 by the nurse practitioner for [MEDICAL CONDITION] med. The prior Progress note was dated 2/3/2017 for recertification. Further review of her clinical record revealed a clinician's visit by the nurse practitioner was made on 11/16/2016 for a sick visit for a rash corners of mouth and Resident # 6 was seen by her physician on 11/3/2016 for recertification. There were no other visits documented in the clinical record between 11/3/2016 and 2/3/2017 resulting in 92 days between physician visits for recertification. On 3/8/2017 at 2:42 PM, an interview was conducted with the DON who stated the expectation was that physicians would write Progress Notes at least every 60 days. On 3/8/2017 at 4 PM, the Administrator , Director of Nursing, and Administrator in Training (Admin C) were informed that the last signed Progress Note for recertification noted in the electronic medical record was dated on 2/3/2017 and the prior Progress Note for recertification was dated on 11/3/2016. On 3/9/2017 at 11 AM, Admin C stated no other Progress Notes for recertification were found in the electronic record between 11/3/2016 and 2/3/2017. On 3/9/2016 at 3:00 PM during the end of day debriefing, the administrator, Admin C and Director of Nursing were informed of the failure of the staff to ensure Resident #6 was seen by her physician and a progress note written in a timely manner. No further information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to effectively wear hair restraints in the kitchen. The facility staff failed to effectively wear hair restraints in the kitchen. The Findings included: On 2/16/16 at 6:50 P.M. an observation was made of the kitchen. The Executive Chef (Employee H) met the surveyor at the door, and led a tour of the kitchen. The Executive Chef wore a baseball cap that did not effectively restrain his hair. The hair below the top of his ears on the side and back of his head was unrestrained. In addition, his moustache and approximately one and one-half inch long beard were uncovered. He was not wearing a beard restraint while walking around the kitchen. When asked why he wasn't wearing hair restraints, he stated that he had been working in the office. He did not state why he didn't wear hair restraints during the tour of the kitchen. Also, the Dietary Aide (Employee J) was removing dishes from the dishwasher and putting them away. He did not have a hair restraint on his head, or a beard restraint covering his moustache, which was approximately 1/2 inch long, and beard, which was approximately 1 inch long. The hair on his head was approximately 2 inches long. When asked why he was not wearing a hair restraint, Employee J stated, My hairnet fell off. He did not respond when asked why he wasn't wearing a beard restraint. When asked about the importance of wearing a hair restraint, he stated, So your hair won't fall on food. It can get on resident's plates. They can eat it. On 2/17/16 at 2:20 P.M. an interview was conducted with the Registered Dietician (Employee I). She stated, I expect them to wear hairnets. We have daily handwashing meetings. On 2/17/16 a review was conducted of facility documentation. It read, Employee Sanitation Policies. Date: 2008. All kitchen employees will practice standard sanitary procedures. All employees shall wear hair restraints and clean clothes. On 2/17/16 at 3:00 P.M. the Administrator (Employee A) was informed of the findings. No further information was received.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to obtain an x-ray, and to assess for and adequately treat pain associated with an undiagnosed fracture from 9-5-14 to 9-16-14, for 1 Resident (Resident #1) of 14 residents in the survey sample resulting in harm for that Resident. Resident #1 had more than minimal pain (moaning, yelling out in pain with movement or repositioning, crying out, groaning, facial grimacing) during care. Resident #1's pain level was not assessed before care. Care was continued even with the Resident's verbalizations of pain, and anxiety behaviors. No x-ray was obtained from onset of pain on 9-5-14 until 9-15-14, although the doctor stated on 9-5-14 that if pain continued to obtain the x-ray. The findings included: Resident #1 was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The following is the resident's Quarterly MDS assessment, with an assessment reference date of 7-2-14: BIMS unable with severe cognitive impairment Transfer total assist of 2 staff Dressing total assist of 2 staff Eating extensive assist of 1 staff Hygiene and bathing total assist of 1 staff Range of motion impaired upper and lower on both sides Always incontinent of bowel and bladder, and no toileting program. Bed mobility extensive assistance of 2 staff Toileting total assist of 1 staff Also, the Resident #1's most recent MDS (minimum data set) with an ARD (assessment reference date) of 10-30-14 was coded as a significant change full assessment. Resident #1 was coded as severely impaired cognitively. Resident #1 was coded as requiring extensive to total assistance of one to two staff persons for physical assistance with all activities of daily living (ADL's) such as transferring, bed mobility, eating, incontinence care, and bathing. Resident #1 was coded as always incontinent of bladder and of bowel, and had no toileting program. The MDS was coded to reveal that Resident #1 did not reject care, and had no abnormal behaviors. Resident #1 was coded as receiving scheduled pain medication. However, the resident did not receive as needed (PRN) pain medication, which was available for use and not offered. The Resident did not receive non medication interventions for pain. The Resident was coded as having indicators of pain, including facial expressions and protective body movements or postures. Review of the nursing notes revealed that beginning on 9-5-14 Resident #1 was yelling out and guarding her left leg, stating "it hurts". The Resident was given as needed pain medication and the doctor was made aware of the Resident's complaints at 11:43 a.m. That same day the Resident's doctor told staff at approximately 1:45 p.m. to monitor the Resident's pain and if it continued, to order a mobile imaging x-ray of the left hip and leg, as the resident had a history of [REDACTED]. Further review of the nursing notes revealed an injury causing 8 Bruises on the arms and ankle of Resident #1 of an unknown origin which was reported by staff on 9-9-14. Also, the Left knee was swollen and painful when moved. Pain in the left leg was noted and reported originally on 9-5-14. These injuries were significant in number and not reported to the state agency until 9-11-14. The Femur fracture of unknown origin was diagnosed by x-ray on 9-15-14 at 6:29 p.m., however the Resident's doctor was not made aware of the results until 9-16-14 at 4:19 p.m. during the doctor's visit to the Resident. The fracture of unknown origin found 9-15-14 was not reported to the state agency until 9-17-14. The Resident had complained of pain in the left leg since 9-5-14, and had symptoms from 9-5-14 through 9-15-14 which included; daily complaints of pain, multiple nursing notes of swelling, warmth, and discoloration. Nursing notes revealed that Resident #1 complained of pain in the left leg on 9-5-14, 9-6-14, and 9-7-17. There was no nursing note for 9-8-14, but there were nursing notes for 9/5 through 9/15/14 describing that the pain was present and Resident #1 complained of it. Notes revealed during these 12 days the Resident yelled "ouch", guarding, "it hurts", yelling again, and again, touching left leg, moaning, crying out in pain during care and nodding in agreement that she had pain, Hollering out when repositioned stating "oh, it's just terrible", calling out in pain during incontinence care and when moved, when knee flexed moaned in pain, while rolling Resident yelling out, hollering out in pain with transfers, Resident stated "it's so bad" with repositioning and transfers, rubbing thighs and expressing pain, yells out if attempt is made to straighten left leg, continues to yell out in pain when left leg is moved, facial grimacing and moaning, from 9-5-14 through 9-16-14. Review of the X-ray diagnostic report dated 9-15-14 revealed findings of "Acute, impacted fracture, distal femur, in near anatomical alignment." Review of the physician's orders [REDACTED]. The four orders for pain and anxiety medication were reviewed, and the orders were as follows; 1.) Routine [MEDICATION NAME] liquid oral solution 100 mg (milligrams) /per 5 ml (milliliters) equaling (20 mg/ml) give __mg/__ml SL (sublingually) under the tongue three to four times per day for pain. The dosage for this medication changed 5 times between 3-24-14 and 10-21-14, and were as follows; a) ordered 2-24-14 discontinued 9-15-14 (5 mg/0.25 ml) three times per day. Dosage increased after left femur (leg) Fracture x-rayed 9-15-14, but not begun until 9-16-14. b) Increase ordered 9-15-14 discontinued 10-7-14 (10 mg/0.5 ml) four times per day. c) Decrease ordered 10-7-14 discontinued 10-17-14 (5 mg/0.25 ml) four times per day. d) Increase ordered 10-17-14 discontinued 10-21-14 (8 mg/0.4 ml) four times per day. e) Increase again ordered 10-21-14 and was the current order through date of survey (10 mg/0.5 ml) four times per day. 2.) As Needed (PRN) [MEDICATION NAME] liquid oral solution 100 mg (milligrams) /per 5 ml (milliliters) equaling (20 mg/ml) give __mg/__ml SL (sublingually) under the tongue every three to four hours per day as needed for pain. The dosage for this medication changed 2 times between 3-3-14 and 9-16-14, and were as follows: a) ordered 3-3-14 discontinued 9-16-14 (5 mg/0.25 ml) every 4 hours as needed. Dosage increased after left femur (leg) Fracture x-rayed 9-15-14. b) Increase ordered 9-16-14 (15 mg/0.75 ml) every three hours as needed, and was the current order through the date of survey. 3.) Tylenol Tab 650 mg (milligrams) by mouth every 4 hours as needed for pain ordered 2-24-14, and discontinued 10-27-14. Tylenol suppositories per rectum 650 mg every four hours as needed for pain was also ordered 2-24-14 and was the current order through the date of survey. Tylenol was administered on 9-8-14 once, on 9-9-14 twice, on 9-13-14 twice, on 9-14-14 once, and on 9-17-14 once. The Tylenol was ineffective on 9-8-14, and on 9-14-14. On 9-17-14 it was documented as reducing pain but not eradicating it. On none of these occasions was PRN [MEDICATION NAME] administered. 4.) As Needed (PRN) [MEDICATION NAME] ([MEDICATION NAME]) oral liquid 0.25 mg/0.125 ml every 6 hours as needed for anxiety was ordered 2-24-14 and discontinued 4-29-14. Then it was re-ordered on 9-2-14 as 0.20 mg/0.1 ml every 8 hours as needed for agitation which can be expressed by picking/scratching, and was the current order through the date of survey. No [MEDICATION NAME] was administered during the month of September 2014, and behavior monitoring had been discontinued 4-30-14. From 9-5-14 through 9-15-14 the Resident received routine [MEDICATION NAME] three times per day for pain at approximately 6:00 a.m., 12:00 noon, and 6:00 p.m. every day. On 9-16-14 the routine [MEDICATION NAME] was increased in dosage and timing to four times per day for pain at approximately 12:00 midnight, 6:00 a.m., 12:00 noon, and 6:00 p.m. every day, with the exception of 9-18-14, and 9-23-14 when the routine ordered medication was withheld and noted as the reason was that the Resident "was sleeping". From 9-5-14 through 9-16-14 the Resident received as needed (PRN) [MEDICATION NAME] only two times, once on 9-5-14, and once on 9-7-14. These were the only two times as needed pain medication was documented as being administered, even though the Resident received routine pain medication, it was insufficient as she complained daily of having pain. There was no evidence that the Resident received pain assessment or medication prior to care, which was documented almost daily by the staff as causing pain to the Resident. Further, the Resident was administered routine pain medication at approximately 6:00 a.m. and was bathed at between 9:00 a.m. and 11:00 a.m., according to CNA A staff statements. This was three to five hours after receiving the medication, and she had incontinence care approximately every two hours round the clock, which caused pain daily as documented by staff. Resident #1 was not administered pain medication before care previously, nor on the day that surveyor observations were made on 1-6-15, when the Resident was anxious and exhibiting signs of anxiety, and pain (Picking, slapping arms, biting linens, groaning, eyes shut tight with wrinkled forehead and facial grimacing upon repositioning and bathing). Observation of ADL care on 1-6-15 began at 11:00 a.m. The surveyor entered the room and found the Resident laying in bed on her left side, eyes closed and body covered with a blanket. Prior to the ADL care, the surveyor asked to observe the Resident's back, which was documented in the clinical record to have 2 wounds. CNA A removed the blanket that was covering the Resident and proceeded to pull the Resident over on the Residents right side, then the CNA stated you can see the back much better from the other side, and proceeded to roll the resident over again to return the Resident to the original left side on which the Resident had been laying. The Resident's face grimaced and she groaned becoming agitated repeatedly patting her upper arms. There were no positioning devices or pillows in the bed, other than one pillow under the Resident's head. The Resident's inner knees were reddened from pressing together in the side lying position. CNA A stated "we are getting ready to give her a bath, she usually gets cleaned up every morning between 9:00 a.m. and 11:00 a.m. after breakfast, and the hospice nurse is coming to bathe her." and the CNA A left the room as did the surveyor. At 11:30 a.m. on 1-6-14 a second observation occurred with the surveyor reentering the room of Resident #1, to find the hospice CNA (other F) in the Resident's room bathing the Resident. The Resident was not moaning at this time, however, facial grimacing with a wrinkled forehead and eyes squeezed shut during the entire cleansing procedure was noted. Resident #1 was laying on her back with towels covering her upper torso to the neck. Other F was busily attempting to bathe the Resident and speaking softly trying to soothe the Resident who was visibly agitated and resisting care, by guarding her body with her arms tightly crossed when touched, and then alternately pulling, biting, and picking at the towels covering her when Other F stopped touching her. Other F was asked if this was normal for Resident #1 and the response was "yes." Other F went on to say that the Resident was always anxious and agitated during care. Other F was asked if the Resident had received any medication for pain or agitation prior to the care, and her response was "I don't know, I don't give medications, the nurse does that." RN A was approached and asked if Resident #1 had received anything for pain or anxiety and her response was "yes, she is on a routine schedule for pain medication, and she got it at 6:00 a.m." No pillows or repositioning devices were used during care. After the ADL care was completed and approximately 12:00 noon the Resident was medicated with [MEDICATION NAME] pain medication according to the routine timing of pain medication. The Resident was not assessed for pain nor anxiety prior to the care, and no as needed (PRN) medications were administered. A review of the resident's care plan dated "7-16-14 to present", was conducted and revealed that Resident #1 had cognitive loss, behaviors, skin tears, [MEDICAL CONDITION] drug use, and pain listed as a problems. Interventions for those problems included the following; Assess for pain if she is combative, observe facial gestures, body language and behaviors to determine if she is having pain or discomfort. She will bite clothes or linens if she is in pain., utilize draw sheet when repositioning her in bed, when turning resident keep pillow between legs, encourage her to hold a stuffed animal when repositioning, Place a pillow for comfort against her body when turning to reduce the risk of injury, Two staff assist at least to reduce risk of injury, support extremities as needed, and Administer pain medication prior to ADL (Activities of daily living) care. The care plan for skin tears and [MEDICAL CONDITION] drug use related to anxiety and related behaviors further included the following interventions; Administer antianxiety medication as ordered for which can be expressed by picking/scratching, she will be kept comfortable and pain free. The care plan was not followed as the Resident was not medicated for pain before ADL care. The resident exhibited signs of pain during the ADL care, and no medications were administered until care was completed. The Resident was biting and picking during ADL care, and no antianxiety medication was administered. No draw sheet, pillow, or stuffed animal were used during either observation. Only one staff member rolled and repositioned the Resident during the first observation. Nursing staff stated "Mosby's" and "Lippincott" as the reference used for nursing practice at the facility. Mosby's Nursing fundamentals estimates: "In nursing homes, 70-80% of residents have persistent, untreated pain." The consequences of persistent pain include depression, sleep difficulties, changes in gait and mobility and decreased socialization. Many factors influence the management of pain, including cultural influences, fear related to the use of [MEDICATION NAME] medications, and the problem of pain assessment with cognitively impaired older adults. Nurses caring for older adults have to advocate for appropriate and effective pain management. The goal of nursing management of pain with older adults is to maximize function and improve quality of life." On 1-6-14 at the end of day debrief the Director of Nursing and Administrator were made aware of concerns, and the DON stated "Yes, I am aware it was reported late to the state agency" (the fracture & bruises), and when asked if the x-ray should have been done sooner, since the Resident's complaints were daily and the physician had ordered on 9-5-14 if the pain continued to get an x-ray the DON nodded her head yes, in agreement, and went on to say that the Resident does get routine med's to control her pain. The DON was asked why PRN pain medication was not used, as the routine medication and Tylenol were ineffective, and there was no response. Review of the facility's policy on "Pain" stated that the nurse would assess for pain and administer pain medication's as ordered. On 1-6-15, and 1-7-15 at end of day debrief the DON and Administrator were made aware of, and notified of, harm level findings.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to report injuries of unknown origin timely to the state office for one resident, (Resident #1), in a survey sample of 14 residents. 1. For Resident #1 eight bruises and a swollen left leg reported by staff on 9-9-14, was not initially reported to the state agency until 9/11/14, and a fracture of unknown origin diagnosed by x-ray on 9-15-14 was not initially reported to the state agency until 9-17-14. The findings included: 1. Resident #1 was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1's most recent MDS (minimum data set) with an ARD (assessment reference date) of 10-30-14 was coded as an significant change full assessment. Resident #1 was coded as severely impaired cognitively. Resident #1 was coded as requiring extensive to total assistance of one to two staff persons for physical assistance with all activities of daily living (ADL's) such as transferring, bed mobility, eating, incontinence care, and bathing. Resident #1 was coded as always incontinent of bladder and of bowel, and had no toileting program. The Resident was coded as having indicators of pain, including facial expressions and protective body movements or postures. Review of the nursing notes revealed that beginning on 9-5-14 Resident #1 was yelling out and guarding her left leg, stating "it hurts". The Resident was given as needed pain medication and the doctor was made aware of the Resident's complaints at 11:43 a.m. That same day the Resident's doctor told staff at approximately 1:45 p.m. to monitor the Resident's pain and if it continued, to order a mobile imaging x-ray of the left hip and leg, as the resident had a history of [REDACTED]. Further review of the nursing notes revealed an injury causing 8 Bruises on the arms and ankle of Resident #1 of an unknown origin were reported by staff on 9-9-14, as well as the Left knee was swollen and painful when moved. Pain in the left leg was noted and reported originally on 9-5-14. These injuries were significant in number and not reported to the state agency until 9-11-14. The Femur fracture of unknown origin was diagnosed by x-ray on 9-15-14 at 6:29 p.m., however the Resident's doctor was not made aware of the results until 9-16-14 at 4:19 p.m. and during the doctor's visit to the Resident. The fracture of unknown origin found 9-15-14 was not reported to the state agency until 9-17-14. The Resident had complained of pain in the left leg since 9-5-14, and had symptoms from 9-5-14 through 9-15-14 which included; daily complaints of pain, multiple notes of swelling, warmth, and discoloration. Review of the facility's policy and procedures on abuse, stated: The facility will investigate and report injuries of unknown source to other officials in accordance with established guidelines as dictated by Virginia state law. Federal regulations are not mentioned. The DON (who is the abuse coordinator) was questioned as to the delay in reporting. She stated, "yes, we know it was late." On 1-6-15, and 1-7-15 at end of day debrief the DON and Administrator were made aware of findings. No further information was provided.