Every finding on record at Regency Care of Arlington, LLC

Based on observation, interviews, and record review, review of facility policies, the facility failed to ensure food was stored, prepared, and maintained in accordance with professional standards for food service safety. a sanitary manner. This failure had the potential to affect 136 of 155 residents in the facility who consumed food from the kitchen. Findings include: Review of the facility's policy titled, Food Safety Requirements dated 2023 revealed . food should be labeled and dated. Foods should be used by its use-by date or discarded. Review of the facility's policy titled, Date Marking for Food Safety dated 2023 revealed . food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening the food shall be responsible for dating the food item when it is opened. Review of the facility's policy titled, Use and Storage of Food Brought in by Family and Visitors dated 2023 revealed . food items brought in by family or visitors must be labeled with content and dated. The facility will store the food in the nourishment refrigerator and food not consumed within three days will be thrown away. 1. Observation on 07/10/23 at 11:41 AM of the refrigerator in the fifth-floor kitchenette with the Dietary Manager (DM) revealed the following food items in the refrigerator were either not labeled, not dated, or were past the use-by date: A 12-ounce Styrofoam cup of a white substance A dinner plate of fruit that was loosely covered with plastic wrap and appeared to be half eaten. An open 8-ounce container of milk Two 1.5-quart containers of melted churned ice cream. The ice cream containers were in a plastic style grocery bag. A plastic container of what appeared to be Chinese food. A plastic container of rice. A brown substance wrapped in aluminum foil. A container of chicken rice and green beans which appeared to be partially eaten. An open container of [NAME] brand nectar thick water with a use-by date of 06/28/23. Three unopened containers of [NAME] brand nectar thick liquid with use-by date of 06/28/23. A half-gallon plastic container of tea. A plastic container of unidentified food. The DM was present and verified each of these findings. The DM stated that they should have been dated, labeled, and discarded within 72 hours of opening and/or placing them in the refrigerator. The DM also stated that the refrigerator was supposed to be used only for resident food items. 2. Observation on 07/10/23 at 12:00 PM, the fourth-floor refrigerator contained two 32-ounce containers of nectar thick water with a use by date of 04/02/23 and one 32 ounce-container of honey thick water with a use by date of 01/04/23. The DM verified the observation and stated that the items should have been discarded after the use by date. 3. Observation on 07/10/23 at 12:05 PM of the third-floor resident refrigerator/freezer located in the third-floor kitchenette contained the following undated, unlabeled food items: A plastic quart size container of an unidentified food item. The container had no name or date. There was a one-inch area of green furry mold on the top of the food item. A quart size bag of grapes. A container of rice and meat with R122's name written on it. The container was covered in foil and was not dated. Mold was growing on the top of the food. The bottom of the refrigerator was soiled with a brown substance. The freezer located over the refrigerator contained: A glass container of a red substance and two containers of food with no name or date. A 4-ounce container of yogurt with a use by date of 05/23/23. A paper on the front of the refrigerator directed staff to date and label all food items with resident's names and that all food would be discarded after 72 hours. The DM was present and verified each of these findings. The DM stated that the items should have been dated, labeled, and discarded within 72 hours of opening and/or placing them in the refrigerator. The DM again stated that the refrigerator was supposed to be used only for resident food items. 4. Observation on 07/10/23 at 11:30 AM and on 07/11/23 at 12:32 PM the following items were observed being stored on a shelf under the food preparation counter in the dietary department: A one-half full 32-ounce bottle of lemon juice. A one-half full 5-pound bottle of Teriyaki glaze. A gallon jug of [NAME] maple syrup. The jug had been opened; was three-fourths full; and had a best by date of 12/18/22. A gallon jug of [NAME] Choice soy sauce. The container only had about one cup of soy sauce left in it. None of the items were dated with the date they were opened. Review of the manufacturer's instructions on each of the products stated to Refrigerate after opening. On 07/11/23 at 12:32 PM, the DM and Cook 1 verified each of the products had been opened and partially used; none of the products were dated with the date they were opened; each of the products were supposed to be refrigerated after being opened; and the maple syrup was past its best by date. The DM and Cook1 stated they had never put the food products in the refrigerator after they were opened because they were not aware that they needed to be refrigerated. The DM stated the items should have been dated with the date they were opened.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure proper hand hygiene during meal service for 12 residents (R) from a sample of 35 residents. Staff failed to perform hand hygiene when passing meal trays to R63, R75, R86, R103, R122, R133, R409, R411, R412, R413, 414, and R415. Staff handled residents' food without wearing gloves. The facility also failed to post the correct signage for personal protective equipment (PPE) for two residents of six residents on transmission-based precautions. (R3 and R139). The facility also failed to ensure that the posted precautions were followed for one of six residents on transmission-based precautions (Resident #34). These combined failures have the potential to widely transmit infectious agents and increase the risk of facility-acquired infections. Finding include: 1. Staff failed to perform hand hygiene when passing meal trays. Review of the facility's undated policy titled Serving a Meal reads in part Perform hand hygiene prior to passing the first tray .Place the tray on the dining table or over bed table if the resident eats in their room .Avoid handling unwrapped food with bare hands .Perform additional hand hygiene after touching items in the resident's room or if hands become visibly soiled . Observation of breakfast on 07/11/23 at 07:39 AM on the fifth floor revealed the Assistant Director of Nursing (ADON) announcing the arrival of the breakfast cart on the unit. Certified Nursing Assistant (CNA)5 pulled out a tray and went R411's room and arranged the meal tray on the overbed table for the resident. CNA5 left the room and went to the meal cart without performing hand hygiene and pulled out another tray. CNA5 took this tray to R409's room and placed the tray on the overbed table. The CNA5 moved the overbed table so the resident could reach her food. CNA5 left the room without performing hand hygiene and went to the coffee cart to obtain coffee and condiments for R133. CNA 5 left the resident's room and made a phone call to the kitchen for a resident's request. Without performing hand hygiene, the CNA5 returned to the meal cart and pulled a tray for R415 and set up the tray on the resident's overbed table. CNA5 left the resident's room again without performing hand hygiene and removed a tray from the meal cart, added a cup of coffee, condiments, and entered R413's room. CNA5 arranged the resident's meal tray and bed covers. CNA 6 was observed in R414's room setting up the meal tray and came directly out of the room without performing hand hygiene. CNA5 requested CNA6's assistance in repositioning R412 in bed. Neither CNAs performed hand hygiene before or after assisting R412 in bed. Both CNAs walked past sanitizer wall units and bottles of hand sanitizer on the medication and treatment carts; and the coffee cart without utilizing any of the units. Both CNAs returned to the meal cart. CNA5 pulled a tray for R86, took it to her room, and set up the tray on the resident's overbed table. CNA5 left R86's room without performing hand hygiene. CNA6, without performing hand hygiene, removed a meal try for R63, took it to her room, and set it up to feed the resident. CNA6 was then observed tearing the breakfast bagel into small pieces with his bare hands. During an interview on 07/11/23 at 08:03 AM, CNA5 stated that she has been taught to perform hand hygiene after serving every two trays. When questioned further, CNA5 then changed her answer to performing hand hygiene after every tray. CNA admitted that she had not performed any hand hygiene during the meal service. Interview on 07/11/23 at 08:08 AM, CNA 6 stated that he sanitized his hands at the start of meal service and performed hand hygiene in the residents' rooms that he served trays. During an interview on 07/11/23 at 09:51 AM, the Assistant Director of Nursing (ADON)/Infection Control Preventionist stated that the issue of hand hygiene has been addressed in several meetings. The ADON stated that it is an expectation that staff will perform hand hygiene when passing each tray each. During an interview on 07/12/23 at 10:15 AM, with the ADON and the Infection Control Preventionist 7(in orientation), the ADON stated that she had observed CN6 and CNA5 not performing hand hygiene while passing trays. The ADON stated that she had reminded both employees that they should perform hand hygiene after passing each tray. The ADON stated that she instructed the two CNAs to pass this onto the other employees. The ADON also stated that even after reminding CNA 6 to perform hand hygiene, he failed to do so. 2. Staff failed to wear gloves before directly touching resident's food. Review of the facility's undated policy titled Serving a Meal reads in part Perform hand hygiene prior to passing the first tray .Place the tray on the dining table or over bed table if the resident eats in their room .Avoid handling unwrapped food with bare hands .Perform additional hand hygiene after touching items in the resident's room or if hands become visibly soiled . Observation on 07/11/23 at 8:04 AM, CNA4 was assisting R122 with setting up his food tray on the overbed table. At 8:06 AM, after assisting R122, CNA4 went over to R75's tray and picked up the resident's bagel with her bare hands, tearing the bagel into smaller pieces. At 8:15 AM, CNA4 picked up R103's bagel and tore it into smaller pieces with her bare hands. CNA4 was not observed to wash her hands between assisting any of the residents with their trays or before touching the bagels with her bare hands. At 8:16 AM, CNA4 was observed handling R122's straw with her bare hands. On 07/11/23 at 8:16 AM, when asked if she had washed her hands and/or wore gloves prior to touching the residents' food with her bare hands, CNA4 stated that she had not. On 07/11/23 at 4:45 PM, the observations were shared with the Director of Nursing (DON) who stated that CNA 4 should have used utensils to cut up the resident's food or should have worn gloves when she touched the food. 3. The facility failed to post the correct signage for isolation precautions. Review of the facility's policy titled Transmission Based Precautions' dated 07/25/18 reads in part Contact isolations precautions - healthcare personnel caring for resident wears gloves and gowns. Droplet Precautions - healthcare personnel must wear a mask for close contact with infectious resident . Observation during the initial tour on 07/11/23 at 11:41 revealed R3's signage on the door indicated that droplet and contact precautions were to be observed, directing that staff must wear gowns, gloves, mask, face shield/goggles. Observation on 07/11/23 at 10:30AM revealed CNA 6 and CNA8 in the R3's room wearing face mask, gown, and gloves. They were not wearing face shield/goggles as posted on R3's door. Review of R3's Physicians Orders for the month of July 2023 located under Orders tab revealed orders for contact isolation for multidrug resistant organisms. During an interview on 07/11/23 at 11:00 AM, CNA8 revealed that she had not looked at the sign posted on the door. CNA8 stated that she thought she needed just the mask, gown, and gloves. During the facility tour on 07/11/23 at 11:41AM, R139's door was observed to have signage posted for contact isolation precautions, directing staff to perform hand hygiene before entering and when leaving the room. The signage also directed that staff must put on gloves and gown before entering the room and discard before exiting the room, as well as stating, Do not wear the same gown and gloves for the care of more than one resident. Observation on 07/10/23 at 12:19 PM revealed a CNA8 entering R139's room without donning any PPE. The CNA wore an N95 face mask on her arm. CNA8 arranged R139's bed sheets, removed a pair of discarded gloves from the dresser and tossed them in the trash can. CNA8 exited R139's room and donned a pair of gloves, returned to the resident's room without donning any PPE, and removed the trash from R139's room. CNA8 emptied the trash can to the resident's room and removed her gloves. CNA8 failed to perform hand hygiene before going to the next resident's room. Review of R139's Physicians Orders for the month of July 2023 located in R139's EMR under the Orders revealed orders for contact isolation precautions: Staff to wear gown, gloves, and mask when in resident's room. During an interview on 07/10/23 at 1:30 PM, CNA 8 stated she was only pulling the trash from the resident's room and did not think she needed to wear the PPE when emptying the trash. Reminded CNA8 that she was observed at the R139's bedside adjusting his linen. CNA8 then acknowledged that she failed to perform hand hygiene before going to the next resident. Interview and tour on 07/11/23 at 12:30 PM with the Unit Manager Registered Nurse (RN)5 revealed that R3's isolation signage was incorrect. According to RN5, R3 should be on contact isolation precautions, not droplet precautions adding that staff should wear gowns and gloves. RN5 then stated that R139 was also on contact isolation precautions, adding that CNA8 should have worn PPE when entering R139's room. Interview on 07/12/23 at 10:30 AM with the Assistant Director of Nursing (ADON) and Infection Control Preventionist (ICP)7 revealed currently all the residents on the fifth floor were on contact isolation precautions. The ADON stated all the staff on the fifth floor had received training regarding the types of isolation precautions. The ADON stated the Unit Manager was responsible for ensuring the correct signage was posted on the resident's door and ensuring the staff was adhering to the directions. The ADON then stated that she did not realize the incorrect signage was posted for R3 and that staff were not following isolation precautions for R139. 28106 4. Facility staff failed to ensure infection control practices were followed while assisting a resident who was on contact isolation. On 7/11/23 at 8:10 AM a hospitality aide (Other Staff, OS #1) donned a gown and gloves and entered room [ROOM NUMBER]. A sign was posted on the door instructing staff and visitors of contact isolation and proper personal protective equipment needed. The sign also instructed to discard gown and gloves before exiting the room. The Resident in room [ROOM NUMBER], identified as Resident #34, was on contact isolation due to CRE (Carbapenem-resistant enterobacteriaceae), a bacterial infection. Approximately 5 minutes later, OS #1 came out of room [ROOM NUMBER] wearing the same gown, went across the hallway to room [ROOM NUMBER] to help another resident with a breakfast tray, then removed the gown, and put it into the trash can. On 7/11/23 at 8:27 AM, OS #1 was interviewed regarding wearing a gown from one room to another. OS #1 said that the gown is supposed to be removed prior to exiting the room, but had gotten in a hurry and did not take the gown off. On 7/11/23 at 4:29 PM, the above finding was presented to the administrator and director of nursing (DON). The DON verbalized that the facility has been doing a lot of education with infection control issues and OS #1 should have disposed of the gown before leaving the room. No other information was presented prior to exit conference on 7/12/23. 03115

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure a medication error rate of less than five percent. Medication pass observations revealed two errors out of thirty-four opportunities resulting in a 5.8% error rate. The findings include: 1. On 7/11/23 at 8:00 a.m., a medication pass observation was conducted with licensed practical nurse (LPN #2) administering medications to Resident #134 (R134). Included in the medications administered to R134 was Senna Plus 8.6/50 milligrams (mg). R134's clinical record documented a physician's order dated 6/19/23 for Senna 8.6 mg once per day for bowel management. R134 had no order for the Senna Plus 8.6/50 mg administered during the observed medication pass. On 7/11/23 at 9:25 a.m., LPN #2 was interviewed about the Senna Plus administered to R134. LPN #2 reviewed the orders and stated the order was for plain Senna and not Senna Plus, which included a stool softener. LPN #2 stated both senna products were from house stock and were available in the medication cart. This finding was reviewed with the administrator and director of nursing during a meeting on 7/11/23 at 4:30 p.m. with no further information provided about the medication error prior to the end of the survey. 28106 2. Resident #91 was given Vitamin C 500 milligrams (mg) instead of physician ordered combination medication of iron and Vitamin C medication. The Findings Include: On 09/27/22 at 9:00 AM a medication pass and pour observation was conducted. License practical nurse (LPN) #1 began pulling medications out of the medication cart for Resident #91 and handing the medications to this surveyor to document. One of the medications pulled from the medication cart was Vitamin C 500 MG. LPN #1 dispensed the Vitamin C into the medication cup and gave it to Resident #91. Physician's orders were then reviewed to verify accuracy of medications given. There was a physician's order to give Iron-Vitamin C Tablet 65-125 MG (a combination medication) for anemia. On 7/11/23 at 9:21 AM LPN #1 was interviewed regarding the discrepancy. LPN #1 reviewed the order and then looked in the medication cart for the proper medication but could not find it. LPN #1 verbalized that she thought she had given the correct medication and thought that it was only a Vitamin C tablet. On 7/11/23 at 4:29 PM the above information was presented to the director of nursing (DON) and administrator. No other information was presented prior to exit on 7/12/23.

Based on observation, interviews, record review, and review of facility policy, the facility failed to ensure that one resident (Resident #3) from a sampled 35 residents was properly positioned while receiving gastrostomy tube feeding. This failure has the potential for the resident to develop aspiration problems from the tube feeding. Finding include: Review of the facility's policy titled Care and Treatment of Feeding Tube dated October 2022 reads in part The resident's plan of care will direct staff regarding proper positioning of the resident consistent with the resident's individual needs. Review of the facility's policy titled Flushing a Feeding Tube dated October 2022 reads in part Prevent aspiration risk by keeping the head of bed elevated at a minimum of 30 degrees. Observation on 07/11/23 at 10:30AM of morning care revealed R3 in bed with the head of the bed (HOB) elevated less than 20 degrees, with the tube feeding infusing. While providing care the two Certified Nursing Assistants (CNA)6 and CNA 8 lowered the head of the R3's bed. R3's tube feeding continued to infuse while in this lower position. While in the lower position, R3 coughed a couple of times and the ventilator alarm sounded. The Respiratory Therapist entered the room and elevated R3s head to 35 degrees and suctioned the resident. Review of R3's Admission Record located in the electronic medical records (EMR) under Medical Diagnosis tab revealed R3 was admitted to the facility on [DATE] with the following diagnoses of sepsis, acute and chronic respiratory failure, ventilator dependent, and dysphagia. Review of R3's Admission Minimum Data Set (MDS) with an Assessment Reference Date of 05/12/23 located under the MDS tab revealed a Brief Interview for Mental Status score of zero out of 15, indicating severely impaired cognition. This MDS assessed R3 to be dependent on staff for all activities of daily living, as well as requiring enteral feeding through a gastrostomy to maintain his nutritional status. Review of R3's July 2023 Physicians Orders located under the Orders tab revealed .Always elevate HOB 30-45 degrees when in bed every shift. May interrupt tube feeding for medication administration and nursing care as needed. Review of R3's Care Plan with a revision date 6/2/23 located under the Care Plans tab revealed that the interventions for the tube feeding included to keep HOB elevated 30-45 degrees during tube feed administration. During an interview on 07/11/23 at 11:00 AM, CNA8 revealed that she was not sure of how many degrees the HOB should be when a resident is receiving tube feeding. When questioned further, CNA8 then stated she thought it should not be any lower than 35 degrees. Then she stated that she did not feel the HOB was that low. During an interview on 07/11/23 at 11:10 AM, CNA 6 revealed that he did not know what position the head of bed should be in for residents receiving tube feeding. During an interview on 07/11/23 at 11:27 AM, the Assistant Director of Nursing (DON) revealed that residents receiving tube feedings should have the HOB elevated at between 35 to 45 degrees. The DON also stated that when the CNA's were providing care to the residents on tube feeding, they are expected to notify the nurse so the tube feeding can be put on hold, until the care is completed. During an interview of 07/12/23 at 08:38 AM, the Unit Manager Registered Nurse (RN)5 revealed that any resident receiving tube feeding should have the HOB elevated at all times. RN 5 further stated that it is an expectation for the CNAs to notify the nurse when giving care, so the tube feeding can be held during the care.

Based on observation, interview, record review, and review of facility policy, the facility failed to provide appropriate suprapubic catheter care and handling for one resident (Resident # 3) from a sample of 35 residents. This failure increases the potential for R3 to develop recurring urinary tract infections (UTIs) or other complications. Findings include: Review of the facility's policy titled Catheter Care-Suprapubic dated October 2022 reads in part .Ensure drainage bag is located below the level of the bladder to discourage backflow of urine .Suprapubic catheter care will be performed every shift and as needed by nursing personnel. Observation on 07/11/23 at 10:30AM revealed R3 receiving morning care. R3 was positioned on his back in bed. The catheter tubing was secured to R3's right thigh area with a leg strap. The catheter site did not have a dressing covering it. Certified Nursing Assistant (CNA) 6 and CNA8 were providing care to this resident. CNA 6 held the catheter drainage bag above the level of R3's bladder and then proceeded to empty the drainage bag, placing the drainage bag in the bed with the resident. However, there was still cloudy urine with sediment present in the tubing, which backed towards R3's bladder. After CNA8 wiped the suprapubic catheter, R3 was turned from side to side to clean his buttocks. While turning the resident, the drainage bag fell to the floor and remained there until the CNAs had completed R3's care and positioned him on his back again. Review of R3's Admission Record located in the electronic medical records (EMR) under Medical Diagnosis tab revealed R3 was admitted to the facility on [DATE] with the diagnosis of sepsis. Review of R3's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/12/23 located in the resident's EMR located under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated R3 was severely cognitively impaired. This MDS also assessed R3 as being dependent on the staff for all activities of daily living, as well as having a suprapubic catheter. Review of R3's Physicians Orders for the month of July located in the EMR under the Orders tab revealed orders to clean the suprapubic catheter site with wound cleanser and apply dry dressing daily on 11-7 shift. Review of R3's Urinalysis and Urine Culture Report located in the EMR under the Results tab revealed a urinalysis and urine culture report dated 06/28/23, which identified a urinary tract infection of proteus mirabilis - carbapenem resistant organism. This pathogen is common cause of cather-associated infections and can quickly progress into infections of the kidneys & blood stream.(1) During an interview on 07/11/23 at 11:00 AM, CNA 8 stated that she had been trained to empty the catheter drainage bag before placing it in the bed with the resident. CNA 8 stated that she was not aware there was still urine in the tubing, potentially backing into the resident's bladder. CNA8 stated the urine backing into the resident's bladder could lead to reoccurring UTIs. CNA8 stated she was aware the drainage bag had fallen to the floor and the resident should receive a new drainage bag. During an interview on 07/11/23 at 11:10 AM,CNA 6 stated that he knows to empty the drainage bag before placing it in the bed with the resident, but did not see the urine that remained in the tubing. Interview on 07/11/23 at 11:27 AM, the Assistant Director of Nursing (ADON) and Unit Manager Registered Nurse (RN)5 stated that staff should have ensured the urine was completely drained from the tubing and the bag before placing the bag in the bed with the resident while turning. Both agreed that the urine backing up into the resident's bladder can contribute to reoccurring UTIs. When questioned further, neither the ADON nor RN 5 were aware of the active physicians' order to clean R3's suprapubic catheter site with wound cleanser and apply dry dressing daily on 11-7 shift. 1. National Institutes of Health https://www.ncbi.nlm.gov>articles>PMC4638163

Based on observation, record review, interview, and review of facility policy, the facility failed to develop care plan interventions for one resident (Resident #3) from a sample of 35 residents. Resident #3 (R3) had physician's orders for care of his suprapubic catheter site but no interventions were care planned for this device. This failure has the potential for the resident not to receive the proper care of his catheter. Findings include: Review of the facility's policy titled Comprehensive Care Plans with an October 2022 revision date reads in part, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental psychosocial needs that are identified in the resident's comprehensive assessment. During an observation of morning care on 07/11/23 at 10:30AM, R3 was observed to have a suprapubic catheter draining cloudy urine with heavy sediment to a bedside bag. R3 did not have a dressing covering the suprapubic catheter site. Review of R3's Admission Record located in the electronic medical records (EMR) under Medical Diagnosis tab revealed R3 was admitted to the facility on [DATE]. Review of R3's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/12/23 located in R3's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated severe cognitive impairment. This MDS further assessed R3 to be dependent on the staff for all activities of daily living, as well as having a suprapubic catheter. Review R3's July 2023 Physicians Orders in the resident's EMR under the Orders tab revealed orders to clean the suprapubic catheter site with wound cleanser and apply dry dressing daily on 11-7 shift. Review of R3's Care Plan with a revision date of 06/02/23, located in the resident's EMR under the Care Plan, revealed the interventions for the resident's suprapubic catheter included the following: position catheter bag and tubing below the level of the bladder; check tubing for kinks each shift; monitor and document intake and output as per facility policy; monitor for signs and symptoms of discomfort on urination; monitor and document discomfort due to catheter; monitor and report any signs or symptoms of urinary tract infection. However, the interventions did not include the physician's order to clean the catheter site and cover it with a dressing. During an interview on 07/12/23 at 08:38 AM, the Unit Manager Registered Nurse (RN)5 revealed that all nurses were responsible for developing and updating the resident's care plans with interventions. RN 5 stated that she developed the care plan interventions for R3's suprapubic catheter. RN 5 further stated that interventions should have included the physicians' orders to cleanse the catheter site and cover it with dressing.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) for two of thirty-five residents in the survey sample (Residents #129 and #359). The findings include: 1. Resident #129's MDS dated [DATE] failed to accurately assess the resident's actual dental problems. Resident #129 (R129) was admitted to the facility with diagnoses that included quadriplegia, respiratory failure, neurogenic bladder, anemia, anxiety, history of pulmonary embolism, pressure ulcers and depression. The minimum data set (MDS) dated [DATE] assessed R129 as cognitively intact. On 7/10/23 at 3:15 p.m., R129 was interviewed about quality of care in the facility. R129 stated during this interview that she was missing all but her front upper teeth and that she had tooth decay. R129 then displayed her front teeth. The teeth were dark around the edges with broken, jagged surfaces. R129 was missing the upper back and lower teeth. Resident #129's clinical record documented an oral assessment dated [DATE] indicating that R129 had broken, decayed, and missing teeth. Section L0200 of R129's MDS dated [DATE] documented that the resident had no dental problems. The category to indicate obvious or likely cavities or broken natural teeth was not marked. Item Z. was erroneously marked indicating no oral/dental problems. On 7/12/23 at 8:00 a.m., the registered nurse MDS coordinator (RN #4) was interviewed about R129's MDS assessment indicating no dental problems. RN #4 reviewed the clinical record and stated the resident's oral assessment completed on 6/13/23 indicated broken, decayed teeth. RN #4 stated the 7/5/23 MDS should have indicated that R129's broken, decayed, and missing teeth. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual on pages L-1 and L-2 documents regarding oral/dental assessment, .This item is intended to record any dental problems present in the 7-day look-back period .Check L0200D, obvious or likely cavity or broken natural teeth: if any cavity or broken tooth is seen . (1) This finding was reviewed with the administrator and director of nursing during a meeting on 7/12/23 at 12:45 p.m. (1) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, Centers for Medicare & Medicaid Services, Revised October 2019. 03115 2. Review of R359's electronic medical record (EMR) discharge return not anticipated Minimum Data Set (MDS)with an Assessment Reference Date (ARD) of 01/13/23 in the MDS tab revealed the MDS was coded that R359 did not have any pressure ulcers at the time of discharge under section M. Review of R359's Specialty Physician Wound Evaluation and Management Summary dated 01/11/23 under the Miscellaneous tab of the EMR revealed R359 had an unstageable necrosis pressure wound measuring 5.7 centimeter (CM) by 6 cm by 0.1 cm. During an interview on 07/11/23 at 2:15 PM, the MDS was reviewed with the Assistant Director of Nursing (ADON), who verified R359 had the pressure ulcer on 01/13/13 when she was discharged from the facility. The ADON verified that the discharge MDS was inaccurately coded for pressure ulcers.

46592 Based on record review, interview, and review of facility policy, the facility failed to ensure three of three residents (Resident (R) 358, R84 and R135) reviewed for facility initiated emergent transfer to the hospital and/or their Resident Representative (RR) received a written bed hold notice that included all required information from a sample of 35 residents. This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization . Findings include: Review of the facility's policy titled, Transfer and Discharge (including AMA) dated 2022 provided by the Administrator, revealed that the facility will provide the facility's bed hold policy to the resident and representative as indicated. Review of the facility's policy titled, Bed Hold Notice Upon Transfer dated 2022 provided by the Administrator, revealed: 1. Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and /or the resident representative written information that specifies: a. The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility. b. The reserve bed payment policy in the state plan policy, if any. c. The facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed. d. Conditions upon which the resident would return to the facility: o the resident requires the services which the facility provides. o the resident is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. 2. In the event of an emergency transfer of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies, as stipulated in the State's plan. Review of a facility policy titled, Regency Care of Arlington - BED HOLD POLICY AND PROCEDURE provided by the Administrator revealed, Federal Law Requires that this statement be given to each resident upon discharge for a hospitalization or a therapeutic leave. 1. Review of R358's Diagnosis tab in the electronic medical record (EMR) revealed R358 was admitted on [DATE] with a non-operable fracture of the left humerus, fusion of the cervical spine, and a history of falling. Review R358's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/23/23 revealed R358 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating no cognitive impairment. Review of a nursing progress note dated 05/29/23 at 9:10 AM revealed R358 was sent to the hospital's emergency department (ED) due to an unwitnessed fall during the night. 2. Review of R135's Diagnosis tab of the EMR revealed that R135 was admitted on [DATE] with hypertensive chronic kidney disease, Type II Diabetes Mellitus, and generalized muscle weakness. Review of R135's Admission MDS with an ARD of 01/13/23 for R135 revealed he had a BIMS of 09 out of 15, indicating moderate cognitive impairment. Review of a nursing progress note dated 03/14/23 at 8:16 PM revealed R135 was sent to the hospital's ED due to an unwitnessed fall. Review of R135's EMR revealed no documentation of a written notice of bed hold being sent to the R135 and/or R135's responsible party. 3. Interview on 07/13/23 at 2:53 PM, R84 stated she was sent to the hospital not too long ago because her knee was swollen, and she was sick. When asked if she received a written bed hold notice, she stated not that she could remember. Review of R84's EMR under the medical diagnosis revealed her diagnosis included Methicillin Resistant Staphylococcus Aureus (MRSA) and inflammatory reaction due to internal left knee prosthesis. Review of R84's significant change MDS assessment with an ARD of 06/09/23 revealed R84 had a BIMS score of 13 out of 15 indicating she was cognitively intact. Review of a nursing progress note dated 05/14/29 at 11:48 PM stated R84 had coffee ground colored emesis. The doctor was notified, and R84 was sent to the hospital's ED for evaluation. Review of a nursing progress note dated 05/15/23 at 6:39 AM stated the resident was admitted to the hospital with a diagnosis of sepsis. Review of R84's EMR revealed no documentation that a written notice of bed hold was sent to R84 and/or R84's responsible party. During an interview on 07/12/23 at 10:50 AM, the Administrator revealed that the facility did not provide written bed hold notices to the residents and/or their representatives with emergent transfers to the hospital.

Based on record review, interview, and policy review, the facility failed to ensure three of three residents and their representatives (Resident (R) 358, R84 and R135) reviewed for facility initiated emergent hospital transfer were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. This failure had the potential to adversely affect the residents and their Resident Representatives (RR) by not having the knowledge of where and why a resident was being transferred, and/or how to appeal the transfer, if desired, as well as preventing the State LTC Ombudsman from identifying inappropriate discharges. Findings include: Review of the facility's policy titled, Transfer and Discharge (including AMA) dated 2022 provided by the Administrator, revealed the facility will provide a notice of transfer to the resident and representative as indicated. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman. 1. Review of R358's Diagnosis tab in the electronic medical record (EMR) revealed R358 was admitted on [DATE] with a non-operable fracture of the left humerus, fusion of the cervical spine, and a history of falling. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/23/23 revealed R358 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating no cognitive impairment. Review of a nursing progress note dated 05/29/23 at 9:10 AM revealed R358 was sent to the hospital's emergency department (ED) due to an unwitnessed fall during the night. Review of R358's EMR revealed no documentation that a written notice of transfer/discharge was sent to R358, R358's responsible party, or the Ombudsman. 2. Review of R135's Diagnosis tab in the EMR revealed R135 was admitted [DATE] with diagnoses of hypertensive chronic kidney disease, Type II Diabetes Mellitus, and generalized muscle weakness. Review of R135's admission MDS with an ARD of 01/13/23 revealed a BIMS of 09, indicating moderate cognitive impairment. Review of a nursing progress note dated 03/14/23 at 8:16 PM revealed R135 was sent to the hospital's ED due to an unwitnessed fall with head injury. Review of R135's EMR revealed no documentation that a written notice of transfer/discharge was sent to R135, R135's responsible party, or the Ombudsman. 3. Interview on 07/13/23 at 2:53 PM, R84 stated that she was sent to the hospital not too long ago because her knee was swollen, and she was sick. When asked if she received a written transfer notice, she stated that she could not remember. Review of R84's EMR Diagnosis tab revealed diagnoses of Methicillin Resistant Staphylococcus Aureus (MRSA) and inflammatory reaction due to internal left knee prosthesis. Review of R84's significant change MDS with an ARD of 06/09/23 revealed a BIMS score of 13 out of 15 indicating R84 was cognitively intact. Review of a nursing progress note dated 05/14/29 at 11:48 PM, indicated resident had emesis with coffee ground color. The doctor was notified, and the resident was sent to the hospital ED for evaluation. Review of a nursing progress note dated 05/15/23 at 6:39 AM indicated the resident was admitted to the hospital with a diagnosis of sepsis. Review of R84's EMR revealed no documentation that a written notice of transfer/discharge was sent to R84, R84's responsible party, or the Ombudsman. During an interview on 07/12/23 at 10:50 AM, the Administrator revealed that the facility did not provide written transfer notices or contact the Ombudsman concerning emergent transfers of the residents to the hospital. 46592

Based on interviews, record review, and policy review, the facility failed to ensure an allegation of abuse was reported to the Administrator and to the State Agency within two hours of the allegation being reported to facility staff. This involved one resident (R)84) in the sample of 35 residents. Findings include: During an interview on 07/10/23 at 12:30 PM, R84 stated that a male aide was rough with her during perineal care and had cursed at her. When asked if he hurt her, R84 stated he hurt her bottom. R84 stated it had occurred on the 3:00 PM to 11:00 PM shift and it has been ongoing. At 12:32 PM, the Unit Manager/Registered Nurse (RN)3 entered R84's room. R84 told the Unit Manager that the male aide on the evening shift was rough with her, that she did not want him caring for her, and that she preferred to have a female aide. On 07/10/23 at 3:22 PM, the resident was asked by the surveyor if she knew who was assigned to care for her on the 3:00 PM to 11:00 PM shift that evening. R84 answered that the same male aide had been assigned to her, and she was not happy about it. At 3:23 PM, Licensed Practical Nurse (LPN)2 was queried about which nursing assistants were assigned on the second shift. LPN2 stated that certified nursing assistant (CNA) 2 and CNA 3. CNA 2 met the description provided by R84 earlier. At 3:25 PM, CNA 2 and CNA 3 were both asked what residents they were assigned to, and both stated CNA 2 was assigned to care for R84. CNA 2 stated R84 was on his routine assignment. On 07/10/23 at 3:28 PM, the Unit Manager/RN 3 was asked what R84 had reported when she entered R84's room. RN 3 stated that R84 had reported that a male aide on the evening shift was rough during perineal care, she did not want him caring for her, and that she requested a female care giver. RN 3 stated that she was going to make sure R84 had a female CNA, however she had not yet gotten around to it. When questioned further, RN 3 stated that she had not told the Administrator what R84 had reported to her. During an interview on 07/10/23 at 4:06 PM, the Director of Nursing (DON) and the Administrator stated they had just been informed at 3:30 PM by RN 3 of R84's allegation that a male nursing assistant had been rough during peri care. The Administrator stated that RN3 told her she was looking into it and trying to figure out which male nursing assistant, since there were two male nurse aides working the 3:00 PM to the 11:00 PM shift. The Administrator stated that a resident stating an aide was rough during perineal care would be considered as abuse. The Administrator stated she had not been told about it until 3:30 PM after the surveyor queried RN 3 about it. Interview on 07/10/23 at 4:33 PM, the RN 3 was interviewed with the Administrator present. RN 3 stated that at 12:30 PM, R84 told her CNA 2 was rough and she wanted a female aide. RN 3 stated that she did not report it to the Administrator because she did not consider it to be abuse and she was attempting to figure out which male nursing assistant R84 was talking about. Review of R84's electronic medical record (EMR) under the Minimum Data Set (MDS) tab revealed R84's significant change MDS with an Assessment Reference Date (ARD) of 06/09/23 indicated R84 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating she was cognitively intact and required extensive assistance of one person for toilet use and personal hygiene. Review of a progress note under the progress note tab of the EMR written by Unit Manager/RN3 dated 07/10/23 at 5:10 PM revealed, Resident reports that the assigned male 3-11 CNA [certified nurse aide] is rough when providing peri care, causing soreness to her perineum, head to toe assessment performed no redness or excoriation noted to perineum no discoloration or bruises observed, denies discomfort at time of assessment. Review of the facility's policy titled, Regency Care of Arlington Resident Abuse dated 05/03/17 revealed the facility's definition of abuse included .causing physical pain or injury. The policy stated, . reported allegations or suspected abuse must be reported to the Administrator, other officials in accordance with State law, and the State Survey and Certification agency within 2 hours after the allegation is made.

Based on observation, staff interviews, and chart review, the facility failed to maintain a clean, home-like environment for one resident, Resident #49, out of thirty-five residents in the survey sample, as well as for one of four units (300 unit) in the facility. The findings include: 1. Resident #49 (R49) did not have her personal items and clothing returned after a room change. R49 was admitted to the facility with diagnoses that included paraplegia, hypertension, gastroesophageal reflux disease, gastric ulcer, diabetes, COPD (chronic obstructive pulmonary disease), polyneuropathy, major depression disorder and anemia. The minimum data set (MDS) dated [DATE] assessed R49 as cognitively intact and to require the extensive assistance of two people for bed mobility, transfers, dressing and hygiene. On 7/10/23 at 12:00 p.m., R49 was interviewed about quality of life/care in the facility. R49 stated during this interview that she moved rooms a couple of months ago and many of her personal items were missing and had not been brought to her new room. R49 stated, They lost all my personal items. R49 stated missing items included clothing, shoes, cosmetics, facial creams, family pictures and a purse. R49 stated the social worker was aware that she was missing the items and she had received no follow up about when the items would be returned. Resident #49 stated she did not want to lose her items, especially her family pictures, and that she wanted to wear some of her summer clothes. On 7/11/12 at 1:35 p.m., the certified nurses' aide (CNA #1) caring for R49 was interviewed. CNA #1 stated the resident moved from another floor and her personal items were packed in storage. CNA #1 stated the resident preferred to wear a gown in bed but wanted clothes on when she went to activities and/or appointments. CNA #1 was not sure if the resident was missing clothing or other personal items. On 7/11/23 at 1:37 p.m., accompanied by the registered nurse unit manager (RN #3) and with R49's permission, the resident's room, dresser and closet were inspected. Several plastic containers beside the bed stored crafts and paper/pens but no clothing or pictures. There was one pair of sweatpants, a shirt, socks and a pair of shoes on top of the plastic containers. There were two fleece sweatsuits in the dresser. There were no other clothing or personal items in the dresser or in the resident's closet. The resident's cosmetics, creams and pictures were not located in the room. No summer clothing items were found other than the set on top of the plastic container. RN #3 was interviewed at this time about R49's belongings. RN #3 stated that R49's move from another floor was initially planned to be temporary because the room required maintenance/repair. RN #3 stated that R49's items and clothing were packed and placed in storage. RN #3 stated that R49 decided to stay in the new room. When questioned regarding R49's personal items not being returned, RN #3 stated Somebody has dropped the ball. On 7/11/23 at 3:45 p.m., the maintenance director (other staff #2) was interviewed about R49's belongings. The maintenance director stated that the resident moved floors due to renovations of the previous room. The maintenance director stated that R49 .had too much stuff and that most of the items were packed and placed in storage. The maintenance director stated that R49 was told when she moved that only the things she needed would be brought to the new room to reduce the clutter. The maintenance director stated R49's items were not lost but were packed in the storage room. The maintenance director stated the social worker was aware and he thought the family was going to assist the resident with selecting items for the new room. On 7/12/23 at 9:53 a.m., the social worker (other staff #5) was interviewed about R49's clothing and personal items. The social worker stated the resident had lots of items. The social worker stated prior to the room change, she had a conversation with R49 about not taking all the items to the new room. The social worker stated R49 had about .ten boxes of stuff. The social worker stated that R49 had some of her things in the new room and the problem was going through the boxes with her to get out what she wanted and/or needed. Resident #49's clinical record documented the resident moved to the current floor on 5/2/23. This finding was reviewed with the administrator and director of nursing during a meeting on 7/11/23 at 4:30 p.m. 03115 2. The 300 unit was observed to have several areas of persistant concern. Findings include: Observation on 07/10/23 at 2:37 PM, on 07/11/23 at 4:17 PM, and 07/12/23 at 10:33 AM revealed that the plastic base board was loose and fell off the wall in a 5-foot area in room [ROOM NUMBER]A's bathroom. The wall behind the base board was disintegrating. Observation on 07/10/23 at 2:28 PM, 07/11/23 at 7:50 AM and 4:17 PM and on 07/12/23 at 10:33 AM revealed that the upholstered seats on five of five wooden chairs in the TV lounge on the 3rd floor were soiled with white and brown substances. Three of the chair seats were soiled with what appeared to be a large, dried spot in the center of the seats. Observation on 07/10/23 at 2:28 PM, 07/11/23 at 7:50 AM and 4:17 PM and on 07/12/23 at 10:33 AM revealed a build up of brown substance on the floor around the base of the toilet in room [ROOM NUMBER]'s bathroom. On 07/12/23 at 10:33 AM, the Administrator, Maintenance Director and Housekeeping Director were present during each of the observations, and verified the findings. They stated that they were not aware of the environmental issues. Review of the undated facility policy titled Maintenance and Housekeeping stated, .the facility's maintenance and housekeeping departments will work to provide a safe, clean, comfortable, and homelike environment

Based on facility document review, clinical records review and staff interview, the facility staff failed to ensure the infection prevention and control program (IPCP) antibiotic stewardship included antibiotic use protocols and an accurate system for monitoring antibiotic use. Findings include: On 08/31/22, the facility's antibiotic stewardship book/program was reviewed. The book/program did not consistently identify the type of infection, the antibiotic used, did not identify the specific organism, did not include the date of infection, specific symptoms and/or means of confirming infection prior to the prescribing and/or administering antibiotics. There was not a way to confirm the antibiotic prescribed was for the correct indication, dose, and duration to appropriately treat the resident. The antibiotic stewardship program for antibiotic use protocol(s) did not address antibiotic prescribing practices (i.e., documentation of the indication, dose, and duration of the antibiotic; review of laboratory reports to determine if the antibiotic is indicated or needs to be adjusted; an infection assessment tool or management algorithm is used when prescribing) and a system to monitor antibiotic use (i.e., antibiotic use reports, antibiotic resistance reports) were not found in the information provided by the administrator. The administrator stated that they do not currently have an IPCP preventionist at this time and stated that she has been gone since June 24th and that they recently hired someone for that role, but the person has not actually worked and was supposed to start on Monday (August 29th), but had not started yet. The administrator stated that the previous DON (director of nursing) had left approximately 2-3 weeks and that the new/current DON has been at the facility for approximately 2 weeks. The administrator stated that she knew the program was lacking as the information was not being input into the system. The administrator was asked for a policy on antibiotic stewardship. The policy was presented and reviewed and documented, .Antibiotic Stewardship Program .implement an Antibiotic Stewardship Program .optimize treatment of infections while reducing the adverse events associated with antibiotic use .includes antibiotic protocols and a system to monitor antibiotic use .complete an SBAR .lab testing .uses the (CDC's NHSN surveillance definitions) to define infections .Loeb minimum criteria are used to determine whether or not to treat an infection with antibiotics .monitoring .shall be reviewed for appropriateness .random audits .antibiotic use shall be measured by .monthly prevalence, antibiotic starts . The administrator was made aware that the policy provided does not match the antibiotic stewardship program, that there no evidence of SBAR, lab testing, surveillance, and/or any criteria/algorithm for indications of use/necessity. No further information and/or documentation was provided prior to the exit conference on 08/31/22 to evidence that the facility had an effective and accurate antibiotic stewardship program in place.

Based on staff interview and facility document review, the facility staff failed to ensure at least one staff member was designated as the infection preventionist who is responsible for the facility's IPCP (infection prevention and control program). Findings include: On 08/31/22 at approximately 7:30 AM, the facility's IPCP/antibiotic stewardship program was reviewed. The program presented did not consistently identify the type of infection, did not identify the specific organism, did not identify the antibiotic used/prescribed, did not include the date of infection, specific symptoms and/or means of confirming infection prior to the prescribing and/or administering antibiotics to residents. On 08/31/22 at approximately 9:30 AM, the administrator stated that they do not currently have an IPCP preventionist at this time and stated that she (infection preventionist) has been gone since June 24th and that they have not had anyone in that role, but did recently hire someone for that role. The administrator stated that the person has not actually worked yet and was supposed to start on Monday (August 29th), but had not started yet. The administrator stated that the previous DON (director of nursing) had left approximately 2-3 weeks ago and that the new/current DON has been at the facility for approximately 2 weeks. The administrator stated that she knew the program was lacking as the information was not being input into the system for the infection control program. The administrator was asked for a policy on antibiotic stewardship. The policy was presented and reviewed and documented, .Antibiotic Stewardship Program .implement an Antibiotic Stewardship Program .the infection preventionist, with oversight from the DON, serves as the leader of the .program .DON serves backup . The administrator stated that the current DON had pretty much, just got here to the facility and has not been in that role. No further information and/or documentation was provided prior to the exit conference on 08/31/22 to evidence that the facility had a designated infection control preventionist.

Based on staff interview, clinical record review and facility document review, the facility staff failed to review and revise the CCP (comprehensive care plan) for six of 29 residents in the survey sample, Resident #47, #97, #118, #131, #107 and #8. 1.) The facility staff failed to update Resident #47's care plan related to snacks and an AV (arteriovenous) fistula (no longer in use). 2.) The facility failed to update Resident #97's care plan related to trach care interventions for dislodgement of a tracheotomy tube. 3.) Resident #118's care plan was not reviewed and revised to remove the focus area, Resident is a smoker. 4.) Resident #131's care plan was not reviewed and revised to include his repositioning of his tracheotomy tube, nor was the care plan revised to delete the use of hemostats to open up the stoma in the event the tube was coughed out. 5). Resident #107's CCP was not reviewed & revised for code status change. 6.) Resident #8's CCP was not reviewed & revised for discontinuation of anticoagulant medication. Findings include: 1.) Resident #47's diagnoses included, but were not limited to: end stage renal disease (recent kidney transplant), metabolic encephalopathy, cardiovascular and coagulation disease, high blood pressure, enlarged prostate, constipation, reflux disease, dementia without behaviors, insomnia, major depression, and arteriovenous fistula (no longer used). The resident's most recent full MDS (minimum data set) was a significant change assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15, indicating the resident was intact for daily decision making skills. The resident triggered in the CAAS (care area assessment summary) section of this MDS for nutrition. On [DATE] at approximately 9:30 AM, the resident was interviewed and stated that he has lost weight, but has a good appetite. The resident was eating corn flakes and stated that he likes to 'indulge' in eating them, he really enjoyed them. The resident stated that staff do not bring him snacks and that he wants to eat. The resident stated that his brother had brought the corn flakes to him. The resident also stated that he had just had a kidney transplant, which may have contributed to some of the weight loss that he was in the hospital for 2 weeks. The resident stated that he was happy and doing well, was no longer receiving dialysis, and was hoping to be able to get rid of his fistula (AV fistula located in the resident's left arm) and eventually go home. The resident's physician's orders were reviewed and documented, SNACKS TID [three times a day] three times a day @ 10AM, 2PM, & 8PM Active [DATE] . The physician orders did not document any information regarding the AV fistula. The resident's CCP was then reviewed and the physician ordered TID snacks (intervention for weight loss) was not located on the care plan. The resident's CCP did not mention and/or address the resident's AV fistula that was still in place, but no longer in use. The resident's TARS (treatment administration records) were reviewed, it was documented by staff initials that the resident was getting the snacks TID. There was no information on the resident's MARs/TARs (medication/treatment administration records) regarding the resident's AV fistula. On [DATE] at 8:47 AM, the MDS coordinator/care planner (MDSCC) was interviewed regarding the above information. The MDSCC stated that the RD (registered dietitian) is supposed to update the care plans regarding nutrition. The MDSCC did not have an answer regarding the resident's AV fistula. On [DATE] at approximately 9:00 AM, the RD was interviewed and stated that she will include interventions, but that is typically added by the MDSCC and stated that the snacks should have been included on the resident's care plan. On [DATE] at approximately 11:45 AM, the DON (director of nursing) and the administrator were made aware of above regarding Resident #47's CCP. The administrator stated that 'it doesn't work that way' as far as the RD updating the care plan, that is actually done by the MDSCC. The concern regarding the resident not having a care plan for the AV fistula was also shared. The DON stated that the resident should have a care plan for the fistula that was no longer in use (since the kidney transplant). No further information and/or documentation was provided prior to the exit conference on [DATE]. 2.) Resident #97's diagnoses included, but were not limited to: atrial fibrillation, diabetes mellitus, and sudden cardiac arrest now with tracheotomy and ventilator dependent. The most recent full MDS was a significant change assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15 indicating the resident was intact for daily decision making skills. The resident was assessed as having a trach and ventilator on this MDS. The resident was observed on [DATE] and [DATE]. The resident was not interviewable. The resident's trach care was observed on [DATE] at approximately 10:00 AM with RT (respiratory therapist) #2. RT #2 explained the procedure during the observation of Resident #97's care for suctioning, inner canula change and total care of the tracheotomy tube and what should happen if the resident's tube is dislodged. There was no mention of hemostats and no hemostats were observed at the bedside. The resident's physician orders and CCP were then reviewed. The resident's physician's orders did not have any information regarding hemostats. The resident's CCP was reviewed for trach/ventilator care and documented, .TUBE OUT PROCEDURES: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. Obtain medical help IMMEDIATELY . On [DATE] at approximately 5:30 PM RT #2 was interviewed with the survey team. RT #2 explained that they do not use hemostats and wasn't sure why that information was on the resident's care plan. On [DATE] at approximately 8:45 AM, the MDSCC was interviewed regarding Resident # 97's care plan for trach/vent care. The MDSCC could not provide an answer to where that particular intervention came from and then stated that he has a library to pick interventions from for trach/vent care and that must have been selected for this resident (even though hemostats are not used at this facility and did not apply to this resident). The MDSCC was made aware that the care plan was not specific to this resident and was generalized, not customized for this particular resident. On [DATE] at approximately 11:45 AM, the DON and administrator were made aware of the above information and findings. The DON and administrator both stated that they are aware they have a problems with MDS and care plans. No further information and/or documentation was provided prior to the exit conference on [DATE]. 29123 3. Resident #118 was admitted to the facility with the following diagnoses, including but not limited to: Unspecified convulsions, chronic pain, left above knee amputation, peripheral vascular disease and COPD (chronic obstructive pulmonary disease) A quarterly MDS (minimum data set) with an ARD (assessment reference date) of [DATE], assessed Resident #118 as cognitively intact with a summary score of 15. Resident #118's clinical record was reviewed on [DATE] at approximately 10:00 a.m. A focus area, Resident is a smoker was observed with interventions that included, but were not limited to: Instruct resident about smoking risks, Instruct resident about facility policy on smoking, observe clothing and skin for signs of cigarette burns. At approximately 10:30 a.m., the administrator was asked if any residents in the facility were allowed to smoke. She stated, No, we do not allow smoking here. She was informed that Resident #118's care plan listed him as a smoker. She stated, That is incorrect. Resident #118 was interviewed on [DATE] at approximately 10:45 a.m. He was asked about smoking. He stated, I don't smoke anymore, I have COPD and had to quit. I did the patch .smoking is a hard habit to break. The above information was discussed during a meeting with the DON (director of nursing) and the administrator on [DATE] at approximately 12:15 p.m. They were asked who updates the care plans. The administrator stated, (Name of MDS) we meet every morning for an IDT (interdisciplinary team) meeting we discuss everything, that is the time for MDS to update the care plan. She was asked if the nurses also updated the care plans. She stated, No, it should be done in real time by MDS in the morning meeting. She was told about the interventions for smoking on Resident #118's care plan. She stated, We know we have a problem with care plans .that should have been updated. No further information was obtained prior to the exit conference on [DATE]. 4. Resident #131 was admitted to the facility with the following diagnoses including but not limited to: Chronic respiratory failure, heart failure, diabetes mellitus, gastrostomy, tracheostomy, dependence on ventilator, mediastinal b-cell lymphoma, heart failure, rib fractures and COPD. The admission MDS with an ARD of [DATE], assessed Resident #131 as cognitively intact with a summary score of 13. The clinical record was reviewed on [DATE] at approximately 3:00 p.m. The following note was written [DATE]: [DATE] 01:22 (a.m.) Respiratory Therapy Progress Not .Called to pt's room at approximately 2310 (11:10 p.m.) by CNA (certified nursing assistant) who said pt was requesting to see respiratory. Pt indicated that he was having trouble breathing. Airway assessed, and trach noted to be partially out of stoma. Before I could advance the trach tube further into place, the resident reached up and pulled his trach tube out. Attempted several times unsuccessfully to reinsert trach using obturator and correct position. [DATE] was immediately called after several unsuccessful attempts of reinsertion of trach tube. Trachea appeared to have blockage which would not allow for insertion. Began bagging pt with stoma mask. Additional attempts made to pass tracheostomy tube, but again unsuccessfully. Began bagging pt with stoma mask again. Pt became unresponsive during this process, and CPR (cardio pulmonary resuscitation) was initiated. CPR was continued until the EMTs (emergency medical transports) arrived and took over the resuscitation process. The care plan was reviewed. A focus area: The resident has a tracheostomy r/t (related to) respiratory failure. One of the interventions listed was: TUBE OUT PROCEDURES: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. The director of respiratory services was interviewed on [DATE] at 5:30 p.m. He was asked about the incident. He stated, (Name of resident) had mobility in his hands he would reposition the vent and the trach. OS (other staff) #3 a respiratory therapist that had worked with Resident #131 earlier in the shift of the night his trach tube cam out was interviewed at 6:20 p.m. She stated that Resident #131 Messed with is trach .he moved it to the right and to the left .we told him the importance of leaving it alone. She was asked if hemostats were used to reopen the stoma if a trach came out as the care plan directed. She stated, No, we don't do that. On [DATE] at 07:40 a.m., OS #2 the therapist who attempted to reinsert the trach was interviewed. She stated, When I got in there he had his hands on his trach .I got his hands down and tried to get it back in but I couldn't get it in, it was blocked .I bagged him and suctioned him, and still couldn't get it in. She was asked if she had used hemostats per the care plan to try to reopen the stoma. She stated, We don't do that. She was asked if Resident #131 moved his trach around. She stated, Yes, he was constantly, moving and fiddling with it .we tried to explain to him that it was his lifeline. She was asked what was normally done if residents moved their trachs around or touched them frequently. She stated, We talk to the nurses, they may need a PRN (as needed) to relax them. sometimes a psych consult. She was asked if she had spoken with any of the nurses, she stated, No. On [DATE] at approximately 8:20 a.m., the MDS nurse who created Resident #131's care plan was interviewed. He was asked about the intervention for the use of hemostats to reopen the stoma in the event the trach tube came out. He explained that he had a library of interventions in the computer system to choose from when doing care plans. He stated, that respiratory therapy should review the care plans to make sure they were okay. He was asked why there were no interventions regarding Resident #131 moving his trach around. He stated, I was unaware of that. He was asked if he had been aware would that have been care planned. He stated, Yes. The director of respiratory services was interviewed at approximately 9:00 a.m. and was asked if he had reviewed the care plan. He stated, Yes. He was asked if hemostats were used to reopen the stoma if the tube was coughed out as the care plan directed. He looked at the intervention and stated, No, we don't do that. I missed that on the care plan. That part should have been marked out. Concerns were voiced to him that the intervention regarding the use of hemostats had not been reviewed and revised/removed from the care plan, nor had the respiratory therapists communicated to the MDS nurse or documented in the clinical record, that Resident #131 was moving his trach tube around so interventions could be put into place. The policy on care plans was requested and contained the following: An interdisciplinary plan of care will be established for every resident and updated in accordance with stated and federal regulatory requirements and on an as needed basis . The above information was discussed with the DON and the administrator in a meeting on [DATE] at approximately 12:15 p.m. The administrator stated the care plan should have been updated. No further information was obtained prior to the exit conference on [DATE]. 40027 5. Resident #107 was admitted to the facility with diagnoses that included: hyperlipidemia, presence of pacemaker, anemia, stage 5 chronic kidney disease - requiring dialysis, muscle weakness, urinary tract infection, and afib. The most recent minimum data set (MDS) dated [DATE] was the 5-day admission assessment and assessed Resident #107 as moderately impaired for daily decision making with a score of 12 out of 15. Resident #107's clinical record was reviewed. Observed on the order summary report was the following order: DNR (do not resuscitate). Order Date [DATE]. Resident #107's clinical record included a copy of a DNR form signed on [DATE]. Resident #107's care plans included the following focus area with goals and interventions: Resident identified Advanced Directives are Full Code. Date Initiated: [DATE]. On [DATE] at 6:10 p.m., the MDS Coordinator (RN #2) was interviewed regarding Resident #107's care plans. RN #2 reviewed Resident #107's clinical record and stated the advance directive/code status care plan should have been reviewed and revised to reflect the change from Full Code to DNR. On [DATE] at 12:14 p.m., the above findings were reviewed during a meeting with the administrator & DON. 6. Resident #8 was admitted to the facility with diagnoses that included: dependence on renal dialysis, anxiety disorder, dysphagia, long-term use of anticoagulant, dysphagia, anemia, hypercalcemia, depression, hypertensive heart, and acute embolism and thrombosis of right internal jugular vein. The most recent readmission assessment dated [DATE] assessed Resident #8 as alert and oriented times 4. On [DATE], Resident #8 clinical record was reviewed. Observed on the care plans was the following focus area with goals and interventions, The resident is on anticoagulant therapy r/t (related to) Right internal jugular vein thrombosis (RIJ DVT) and right basilic vein thrombosis. Date Initiated: [DATE]. Revised: [DATE]. Resident #8's orders were reviewed and documented the following order: Heparin Sodium (Porcine) Solution 5000 Unit/ML Inject 5000 unit subcutaneously every 12 hours for clotting prevention for 1 week. Start Date: [DATE]. End Date: [DATE]. Resident #8's medication administration record (MAR) was reviewed for the period of [DATE] through [DATE]. The MARS documented Resident #8 received the Heparin as ordered for one week, ending on [DATE]. On [DATE] at 8:26 a.m., the MDS Coordinator (RN #2) was interviewed regarding Resident #8's care plans. RN #2 reviewed Resident #8's clinical record and stated the anticoagulant care plan should have been resolved since the Heparin order was completed in June. On [DATE] at 12:14 p.m., the above findings were reviewed during a meeting with the administrator & DON. On [DATE] at 12:14 p.m., during a meeting with the administrator and DON concerns with care plans was discussed. The administrator stated, the IDT (interdisciplinary team) meets daily and discusses any changes with the residents. The care plans are pulled up at that time and should be reviewed and revised daily at that time instead of waiting until the care plan meeting. This keeps everyone updated on the plan of care .

Based on staff interview and clinical record review, the facility failed to ensure an accurate MDS (minimum data set) assessment for three of 18 resident's in the survey sample. 1. Resident #82's MDS section B (vision) and section H (Bladder and Bowel) was coded incorrectly. 2. Resident #133's MDS section A (discharge) was coded incorrectly. 3. Resident #131's MDS section A (discharge) was coded incorrectly. The Findings Include: 1. Diagnoses for Resident #82 included: Malignant neoplasm of bladder, anxiety, adult failure to thrive, and unspecified dementia. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of [DATE]. Resident #82's cognitive score was a 13 indicating cognitively intact. On [DATE] at 10:06 AM an interview was conducted with Resident #82. During the conversation Resident #82 verbalized she liked reading but her glasses were broke and said no one has done anything about it (glasses were sitting on Resident #82's dresser, the ear pieces were broken off). Also during the interview Resident #82 was asked if she had a catheter in place (as documentation indicated Resident #82 had a catheter). Resident #82 verbalized that she has never had a catheter. On [DATE] Resident #82's clinical record was reviewed. Section B1000 (Vision) of Resident #82's most recent MDS documented Resident #82's vision was adequate and no corrective lenses were needed. Also, section H0100 (Bladder and Bowel documented Resident #82 had an indwelling catheter. On [DATE] at 2:16 PM the MDS coordinator (registered nurse, RN #2) was asked about the concerns regarding vision and catheter that were listed on the MDS. RN #2 verbalized that he filled out the sections and gets information from the chart and interviews with family and Resident's, but would look into it. On [DATE] at 8:16 AM, RN #2 verbalized after reviewing Resident #82's admission MDS he realized a mistake had been made on the MDS regarding vision and catheter. RN #2 went onto say Resident #82 does need glasses and Resident #82 never had a catheter. On [DATE] at 12:15 PM the above information was presented to the administrator and director of nursing (DON). No other information was presented prior to exit conference on [DATE]. 40027 2. Resident #133 was admitted to the facility with diagnoses that included long-term use of insulin, insomnia, osteoarthritis, GERD, stage 5 chronic kidney disease requiring dialysis, hyperlipidemia, anemia, and muscle weakness. The discharge minimum data set (MDS) dated [DATE] documented Under Section A that Resident #133 discharge to an acute hospital. On [DATE], Resident #133's closed clinical record was reviewed. Observed in the clinical record was the Discharge Summary and Discharge Plan/Instructions dated [DATE], both documented that Resident #133 discharged to home on [DATE]. A progress note dated [DATE] documented Resident #133 discharged to home on [DATE] at 11:15 a.m. Resident #133's discharge MDS was reviewed and documented that the resident discharged on [DATE]. The MDS documented the discharged was planned and the resident's return was not anticipated. The discharge MDS documented that the resident discharge to an acute care hospital. On [DATE] at 6:10 p.m., the MDS Coordinator (RN #2) was interviewed regarding Resident #133's discharge location. RN #2 stated the resident discharged to home. RN #2 was asked to review the MDS for accuracy of the resident's discharge location. RN #2 reviewed the discharge MDS and stated it was coded in error, that Resident #133 did not discharge to the hospital, and the resident was planned discharge to home. On [DATE] at 12:14 p.m., the above findings were reviewed during a meeting with the administrator & DON. 29123 3. Resident #131 was admitted to the facility with the following diagnoses including but not limited to: Chronic respiratory failure, heart failure, diabetes mellitus, gastrostomy, tracheostomy, dependence on ventilator, mediastinal b-cell lymphoma, heart failure, rib fractures and COPD. The admission MDS with an ARD of [DATE], assessed Resident #131 as cognitively intact with a summary score of 13. Resident #131 was added to the survey sample a closed record with a discharge disposition of Death in Facility. The clinical record was reviewed on [DATE] at approximately 3:00 p.m. The following note was written [DATE]: [DATE] 01:22 (a.m.) Respiratory Therapy Progress Not .Called to pt's room at approximately 2310 (11:10 p.m.) by CNA (certified nursing assistant) who said pt was requesting to see respiratory. Pt indicated that he was having trouble breathing. Airway assessed, and trach noted to be partially out of stoma. Before I could advance the trach tube further into place, the resident reached up and pulled his trach tube out. Attempted several times unsuccessfully to reinsert trach using obturator and correct position. [DATE] was immediately called after several unsuccessful attempts of reinsertion of trach tube. Trachea appeared to have blockage which would not allow for insertion. Began bagging pt with stoma mask. Additional attempts made to pass tracheostomy tube, but again unsuccessfully. Began bagging pt with stoma mask again. Pt became unresponsive during this process, and CPR (cardio pulmonary resuscitation) was initiated. CPR was continued until the EMTs (emergency medical transports) arrived and took over the resuscitation process. During a meeting with the DON (director of nursing) and the administrator on [DATE] at approximately 12:15 p.m. Resident #131's death in the facility was discussed. The administrator stated, He didn't die here .he died at the hospital. The administrator was informed that since the patient was transferred out to the hospital his MDS discharge status should have been, Acute hospital, not deceased . She agreed. The discharge documentation from the hospital was presented at approximately 1:00 p.m. and included: .Patient presented in cardiac arrest .bedside ultrasound showed no organized cardiac activity. Patient was declared dead at 12:42 (a.m.) No further information was obtained prior to the exit conference on [DATE].

Based on Resident interview, staff interview and clinical record review, the facility failed to develop a care plan for one of 29 resident's. Resident #82 did not have a care plan for vision. The Findings Include: Diagnoses for Resident #82 included: Malignant neoplasm of bladder, anxiety, adult failure to thrive, and unspecified dementia. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 7/26/22. Resident #82's cognitive score was a 13 indicating cognitively intact. On 8/30/22 at 10:06 AM an interview was conducted with Resident #82. During the conversation Resident #82 verbalized she liked reading but her glasses were broke and said no one has done anything about it (glasses were sitting on Resident #82's dresser, the ear pieces were broken off). On 8/30/22 Resident #82's clinical record was reviewed. Section B1000 (Vision) of Resident #82's most recent MDS documented Resident #82's vision was adequate and no corrective lenses were needed. Resident #82's care plan was also reviewed and revealed no documentation of a care plan for vision. On 8/30/22 at 2:16 PM the MDS coordinator (registered nurse, RN #2) was asked about the concern regarding vision listed on the MDS as not needing glasses and vision was adequate. RN #2 verbalized that he filled out the sections and gets information from the chart and interviews with family and Resident's, but would look into it. On 8/31/22 at 8:16 AM, RN #2 verbalized after reviewing Resident #82's admission MDS he realized a mistake had been made on the MDS regarding vision and that resident #82 needed glasses. RN #2 was asked, if vision would have been triggered on the MDS as needing glasses and vision was inadequate, should a care plan be developed. RN #2 verbalized a care plan would have been put in place for a resident needing glasses. On 8/31/22 at 12:15 PM the above information was presented to the administrator and director of nursing (DON). No other information was presented prior to exit conference on 8/31/22.

Based on clinical record review, staff interview and in the course of a complaint investigation, the facility staff failed to ensure a discharge summary/recapitulation of stay was completed and documented by the physician for one of 4 residents in the survey sample, Resident #4. Findings include: Resident #4 was admitted to the facility on [DATE] and discharged on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was a significant change assessment dated [DATE]. This MDS assessed the resident with severe impairment in long and short term memory. The resident was also assessed as requiring extensive to total assistance from one to two staff member for all ADL's (activities of daily living). During the clinical record review, it was documented that the resident was discharged from the facility on 10/25/20 to the hospital for declining status. The resident did not return to the facility. There was no physician discharge summary was found in the Resident #4's clinical records. A nursing discharge summary was found. This discharge summary was dated 10/26/21 and timed 2:30 PM. The discharge summary was a fill in the blank/check the box type of document and was completed by an RN (Registered Nurse). The summary was not completely filled out, it did not document where Resident #4 was being discharged to, did not describe the mode of discharge, the reason for the discharge was described as, other. A section of the discharge summary documented, Nursing Recap .Course of treatment while in facility included complications. The form did not include pertinent information regarding Resident #4's stay and was not completed by the resident's physician. On 12/14/21 at 9:00 AM, the DON (director of nursing) was asked for the physician discharge summary for Resident #4. At approximately 9:15 AM, the DON stated that there was a discharge summary (referring to the one mentioned above). The DON was made aware that the above discharge summary was completed by an RN, not the physician and was incomplete. The DON stated that it should have been scanned into the electronic medical record and would look in the resident's closed paper chart. At 10:20 AM, the DON stated that she could not find a discharge summary from the physician and presented the resident's closed paper chart. No discharge summary was found. No further information and/or documentation was presented prior to the exit conference on 12/14/21 at 11:00 AM to evidence that the physician completed a discharge summary for Resident #4.

Based on staff interview, clinical record review, and in the course of complaint investigation, the facility failed to develop a care plan for the care and safeguard of dentures for one of 4 residents, Resident #3 The findings include: Resident #3 was admitted to the facility on [DATE] with the most recent admission on 8/13/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 8/20/21. Resident #3 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was discharged on [DATE]. On 12/13/21 Resident #3's medical record was reviewed. Documentation in the nursing notes and MDS assessments indicated Resident #3 was discharged to the hospital on 6/10/21 and returned to the facility on [DATE]. A registered dietitian (RD) progress note dated 6/29/21 Documented the following, Resident dentures have been misplaced. RD met with the resident to discuss possible downgrade in food texture . A nursing note dated 6/29/21 documented: During initial admission upon assessment writer asked resident if she used dentures resident said 'yes', writer asked resident where is it resident said 'I lost them in the hospital.' A social workers (SW) progress note dated 7/1/21 documented, Spoke to resident sister .Sister is also upset about the missing dentures. Writer informed sister that writer will address her concern . Resident #3's care plan was reviewed and did not evidence a care plan for the care and safeguard of Resident #3's dentures. On 12/14/21 at 9:00 AM, the director of nursing (DON) was interviewed regarding care planning of dentures. The DON stated that a care plan should have been completed for dentures, and information should be on the Treatment Administration Record (TAR) so the nurses can sign off that dentures were in place. On 12/14/21 at 9:45 AM, the DON stated the TARs had been reviewed and did not include dentures for the nurses to sign off. On 12/14/21 at 10:30 AM the above information was discussed with the DON and the administrator. No other information was presented prior to exit conference. This is a complaint deficiency.

Based on staff interview and facility document review, the facility staff failed to perform facility wide testing for staff and residents based their outbreak status. The findings include: On 12/21/2020 at approximately 10:30 a.m., an interview was conducted with the facility administrator regarding testing frequency. The administrator stated, we are waiting on testing kits to arrive to complete our testing. The administrator was asked the dates of the most recent facility testing. The administrator stated, our last testing was completed on 12/11/2020. The administrator was asked if the facility had completed testing the week of 12/13/2020 through 12/19/2020. The administrator stated, no, we did not receive our test kits and missed last week. The administrator stated, we were having problems with the lab, so I have implemented another contract with a new lab to make sure we are able to receive our kits and results in a timely manner. The local health department visits us weekly. They were here on last Tuesday 12/15/2020 and were aware of the problem with a delay in receiving the test kits and stated it was okay for us to test later in the week because the kits were suppose to arrive on Friday, 12/18/2020. I have a chain of emails to show communication with the lab regarding the testing kits. The administrator was asked when did the facility place the order for the test kits. The administrator stated, (DON) sent an email on 12/11/2020. The administrator was asked if this was enough turn around time for the lab to send the test kits and the facility to begin testing. The administrator stated, yes, we would have started testing on 12/15/2020, so that was 4 days to receive the tests. The administrator was asked if the local health department was aware that the facility did not receive the tests kits on Friday, 12/18/2020 and if any efforts to get assistance for test kits were obtained from the local health department. The administrator stated, no I was going to contact them this morning . The administrator was asked when did the facility enter outbreak status and what was the testing frequency. The administrator stated, we started outbreak on 11/09/2020 and the local health department told us we are supposed to test weekly, every 3-7 days until there are zero positive results. I have a copy of the outbreak letter they sent me when I notified them that we had new positive cases. The administrator was asked about the county positivity rate. The administrator stated, we are sent the rate, but I also check the information personally on the VDH (Virginia Department of Health) website. I will get you all of the information. The administrator was asked what guidelines they use for testing frequency. The administrator stated, we use the CDC (Centers for Disease Control) guidelines. The administrator was asked if the facility had received a COVID -19 rapid POC (point of care) testing machine. The administrator stated, yes, we have one machine. I have ordered additional machines; however, they are on back order. It would take us a long time to administer testing using the rapid machine because this is such a large facility and the frequency of testing required. On 12/21/2020 at approximately 11:30 a.m., the director of nursing (DON) was interviewed regarding the testing frequency. The DON stated, we test on Tuesday, Wednesday, Thursday, and Friday to meet the requirement of every 3-7 days because we are still in outbreak status. We have to email the lab weekly to request our test kits because we require about 600 kits a week to meet the current testing requirements. I emailed the lab on 12/11/2020 requesting the test kits for the following week. The contact person at the lab told (Administrator) the kits had been shipped to the facility; however, we never received them, so finally the lab sent (Administrator) another email and the kits were going to arrive on Friday, 12/18/2020. However, we did not receive those, so now they are scheduled to come tomorrow (12/22/2020). The DON was asked why the facility did not use the rapid POC machine. The DON stated, me and my staff complete all of our testing for the residents and staff. We don't have an outside lab or contract with anyone to come in to do this for us. We only have one rapid POC machine at the time and it would be very time consuming if we had to use the one POC machine to test this large facility. The DON stated, we did complete some tests last week using the POC machine. I will get you the number of tests completed. We used the rapid POC machine to tests some residents to move them from the warm unit to the cold unit and for new staff. On 12/21/2020, the administrator provided the following percentages for county positivity rates obtained from the VDH website: 11/10/2020: 4.9% 11/16/2020: 5.6% 11/20/2020: 7.8% 11/23/2020: 8.0% 11/30/2020: 8.0% 12/14/2020: 9.0% The administrator and DON provided the following testing information: 11/08/2020: 129 residents tested , 2 positive residents: 111 staff tested , 3 positive staff 11/15/2020: 126 residents tested , 2 positive residents: 111 staff tested , 0 positive staff 11/22/2020: 119 residents tested , 0 positive residents: 139 staff tested , 0 positive staff 11/29/2020: 113 residents tested , 2 positive residents; 128 staff tested , 0 positive staff 12/06/2020: 125 residents tested , 0 positive residents; 107 staff tested , 2 positive staff The facility completed 6 rapid POC tests between 12/14/2020 - 12/20/2020, consisting of four residents and two staff. All tests were negative. A review of the outbreak letter sent from the local health department documented the following: .Testing: Plan for facility-wide (all residents and team members) COVID-19 testing on a weekly basis. Continue repeat testing of all previously negative residents and team members (e.g. every 3 to 7 days until testing identifies no new cases of COVID-19 among residents or team members over at least 14 days since the most recent positive result. Do not test those who previously had an initial COVID-19 positive test within the last 90 days . A review of the facility's Coronavirus Testing policy documented the following: Policy Explanation and Compliance Guidelines: 1. The facility will conduct testing through the use of rapid point-of-care (POC) diagnostic testing devices or through an arrangement with an offsite laboratory .Testing of Staff and Residents in Response to an Outbreak: 1. All staff and residents will be tested upon identification of a single new case of COVID-19 infection in any staff or residents. 2. All staff and residents that test negative will be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result On 12/21/2020 at approximately 3:15 p.m., the administrator and DON were interviewed regarding the above findings. They were both asked if the facility had the POC test kits to use with the rapid POC machine. The administrator stated, yes, we have the tests. I ordered additional rapid POC machines about two weeks ago, but they are on back order. It would take a lot of time to use one machine to test this large building but I understand that we should have used the POC machine for testing since we did not receive the test kits from the lab. The DON stated, we understand we can't make excuses for not testing when we did have the rapid POC machine available. No additional information was presented to the survey team prior to exit on 12/21/2020 at 4:00 p.m.

Based on clinical record review, observations, and staff interview, the facility staff failed for one of 37 residents in the survey sample, Resident # 36, to implement the plan of care. Resident # 36, who had a [DIAGNOSES REDACTED]. The findings were: Resident # 36 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]., [MEDICAL CONDITION] disorder, anxiety disorder, depression, [MEDICAL CONDITIONS], and mood disorder. According to the most recent MDS, Quarterly review, with an ARD of 12/7/19, the resident was assessed under Section C (Cognitive Patterns) as being severely cognitively impaired, with a Summary Score of 00 out of 15. During the orientation tour at 8:30 a.m. on 2/25/2020, the resident's room was noted to have two twin size mattresses, both covered with sheets, placed side-by-side on the floor. There was a pillow on one of the mattresses, and the call bell was laying on the other mattress. Resident # 36's care plan included the following problem, The resident is at risk for falls r/t (related to) impaired mobility, unsteady gait and Dx (diagnosis) [MEDICAL CONDITION] and increased chorea. The goal for the problem was, The resident will be free of fall related injury through next review date. Included as an intervention to the stated problem was the following, Place mattress on the floor as needed and pad walls for safety and prevent injury from chorea activity. The date the intervention was added to the care plan was listed as 8/25/19. Following review of the resident's care plan, a second observation of the room was made. There was no padding on the walls of the resident's room. During observation of the noon meal in the third floor Dining Room on 2/26/2020, LPN # 3 (Licensed Practical Nurse), the Unit Manager on the third floor, was asked about the wall padding in Resident # 36's room. There is none, LPN # 3 said. They (administration) have been talking about it. The findings were discussed at an end of day meeting held at 5:00 p.m. on 2/26/2020, that included the Administrator, Director of Nursing, and the survey team. The Administrator, who has only been in the position for approximately six months, was unaware of the care plan intervention for wall padding. The Director of Nursing offered no explanation as to why padding had not been added to the walls of Resident # 36's room.

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility failed to provide supervision and prevent accidents/falls for 1 of thirty-nine residents (Resident #146) in the survey sample and failed to ensure a safe room environment for 1 of thirty-nine residents (Resident #48) in the survey sample. 1. The facility staff failed to provide supervision to prevent accidents and falls for Resident #146. Resident #146 who had a history of [REDACTED]. 2. A portable oxygen tank was stored unsecured next to Resident #48's bed. The half-full oxygen tank was positioned in the floor between Resident #48's bed and the bed table. The tank was not in a storage rack or cart to prevent tipping over or accidental damage. The findings include: 1. Resident #146 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent minimum data set ((MDS) dated [DATE] assessed Resident #146 as being severely cognitively impaired, with inattention continuously present and disorganized thinking fluctuating in severity. Resident #146 was also assessed on this MDS as requiring extensive assistance for ambulation, with one person physical assistance. The MDS assessed Resident #146 balance as not steady, only able to stabilize with human assistance. Resident #146's closed clinical record was reviewed on 10/31/18 at 9:25 a.m. A nursing note dated 08/29/18 at 2:14 p.m. documented the following: Patient was observed in floor in the therapy room, head to toe assessment done no injury sustained. Assisted patient back in his wheelchair. Spouse with patient during therapy. Neuro check initiated. A nursing noted dated 08/30/18 at 3:20 p.m. documented the following: Per follow-up with therapist who were at the scene when the incident occurred, he (Therapist) went to set up a patient bike, when he turned around resident on the floor on his left side. Per PT (physical therapist), resident wife (name) told him (PT) that resident reached forward for a stool and slid out of his WC (wheelchair). Assisted patient back in his wheelchair by assigned nurse with the help of PT, patient refused vital signs to be done, per nurse. Head to toe assessment was done, able to stand with three people assist. Surgical site intact with staples, no sign of infection noted. Patient is being seen by PT. MD (medical director) aware. The resident needs activities that minimize the potential for falls while providing diversion and distraction. MD aware, will continue to monitor. A review of Resident #146's care plans documented the following focus area created on 08/27/18: The resident is at high risk for falls r/t confusion, gait/balance problems and remains at risk for further falls due to hx (history) of fall. The care plan goal was documented as: The resident will be free of minor injury through the review date. The interentions/tasks were documented as the following: Anticipate and meet the resident's needs .Be sure the resident's call ligt is within reach and encourage the resident to use it. CNA for assistance as needed. The resident needs prompt response to all requests for assistance .Educate the resident/family/caregivers about the safety reminders and what to do if a fall occurs. On 10/31/18, the director of nursing (DON) was asked for the facility's fall investigation report regarding Resident #146's fall on 8/29/18. The DON presented the a folder including the fall investigation report and a statement from the director of rehab. The DON stated there is not much information included in the investigation report. A review of the facility's fall investigation documented the following under the incident description/nursing description section: Nurse was called to the therapy room to assess patient on the floor before getting patient off the floor. Upon getting to the therapy room, patient observed on the floor, lying on left side hold head up. All therapy staff was not able to tell how patient gets on floor. Patient unable to express himself due to medical diagnosis. Documented under the immediate action taken section was the following: Assisted patient back in his wheelchair, patient refused vital signs to be done. Head to toe assessment was done, able to stand with three people assist. Surgical site intact with staples, no sign of infection noted. On 10/31/18 at 2:45 p.m., the director of rehab (DOR) was interviewed regarding Resident #146's fall incident. The rehab director stated he was out the facility at the time of the incident and the PRN (as needed) occupational therapist (OT) who was assigned to work with Resident #146 on the date of the incident was no longer employed with the company. He stated another therapist who was in the therapy room at the time of the incident could possibly give information on what happened. The rehab director provided copies of the therapy department's evaluations and progress notes for Resident #146. On 10/31/18 at 2:50 p.m., the Physical Therapist (PT) who was present in the room on the day of the fall incident was interviewed. Present during this interview was the rehab director. The PT said he was not working directly with Resident #146, but was in the therapy room. He stated the occupational therapist (OT) had turned away and the resident's wife had gotten up to take a phone call. He said the resident's wife told him the resident was reaching for a stool and slid out of his wheelchair, which was locked at the time. He said he observed the resident laying on his left side and the nurse was called to assess him for possible injuries. The rehab director stated Resident #146 had therapy on 8/30/18 and when it was observed that he appeared to be favoring his left leg, he (rehab director) suggested x-rays should be ordered. The rehab director stated the x-ray results were received on 8/31/18 which documented a left [MEDICAL CONDITION]. On 10/31/18 at 3:30 p.m., the therapy department's evaluations and progress notes were reviewed. An occupational therapy note dated 08/29/18 at 12:52 p.m. documented the following: Resident easily distracted and needs constant redirection. Therapist asked the PT to watch over the resident while this therapist walked out of the rehab gym for 40 seconds to get something. When this therapist came back resident was on the floor on the left side. Wheelchair breaks (sic) were both lock. According to the wife resident leans forward to reach for a stool and slid on the floor. The other therapist watching over just turned around for a second to set up somebody on the bike. A physical therapy note dated 08/29/18 at 04:46 p.m. documented the following: Pt (patient) easily distracted and daughter w/ patient as therapist went to set up a patient on stationary bike then turned around and saw Pt (patient) on the floor on the left side. According to the wife, Pt (patient) reached forward for a stool and slid out of the wc (wheelchair). At the time wc (wheelchair) had the breaks (sic) on. Nurse in charge was called to assess Pt (patient) for possible injuries. Pt (patient) was assisted back to wc (wheelchair) with max assist of 4 people. On 10/31/18 at 4:25 p.m., the rehab director was interviewed regarding the OT's note documenting she had asked the PT to watch the resident while she stepped away. The rehab director said from his understanding the PT was standing in the room working on the stationary bike near the resident when he fell . The rehab director stated he believed the PT stepped away to move another resident who was near the therapy doorway, but he was not 100% sure. The rehab director was asked if the therapy department had a policy on resident safety and supervision. He stated he would contact the corporate office for a copy of the policy. On 10/31/18 at 4:41 p.m., the rehab director said he contacted the corporate office for the resident safety and supervision policy; however, they did not have an actual written policy. He stated resident safety and supervision is basically understood and that any therapist should know they are never to leave a resident unattended. He was asked what was the expectation regarding resident safety and supervision. He stated it is a professional standard and best practice for the residents to be monitored and supervised while in therapy. A review of the director of rehab's written statement documented the following: In reference to the incident regarding (resident's name) on Wednesday (MONTH) 29. Though this therapist was not present when he slipped out of his chair the incident was reported to me as soon as I returned to the therapy room. I was notified of the incident and informed who was present and that the nursing staff had been notified and they checked the patient per protocol. I personally checked on the patient in his room later the same day. The following day, (August 30th) with wife present for therapy, three attempts were made to ambulate the patient after standing from wheelchair. The patient was not performing as well as previous sessions. It appeared he was tentative with taking steps though some of the same tentativeness had been exhibited in previous sessions as well, though the patient had been ambulatory at times as documented in previous therapy progress notes. This was discussed with the patient's spouse as she was still present and had been present in previous attempts. Palpation to the left lower extremity was performed with no visible discomfort. It was discussed at this point with the patient's wife that if the same performance was exhibited the following day (August 31st) that x-rays would be ordered. The patient was brought to therapy (MONTH) 31st. The wife was not present on this day. The patient was once again helped from sit to stand but showed avoidance of ambulating and it appeared to this therapist it may be due to the patient's left lower extremity weight bearing avoidance. At this time therapy was discontinued and patient was returned to room and nursing was notified to order x-rays. This therapist spoke with the patient's wife later that evening regarding having x-rays done with results at the time. The statement was dated and signed by the rehab director on (MONTH) 4, (YEAR). Resident #146's clinical record documented a telephone order dated 08/31/18 at 1:18 p.m. for X-ray (L) Leg Hip and Femur one time only for pain. A copy of the x-ray results documented the following: Left femur, four views. Again, a basocervical [MEDICAL CONDITION] hip was seen. The fracture was acute. The remainder of the femur was intact. A mild effusion was seen in the suprapatellar bursa. The results were signed and dated on 8/31/18 at 6:35 p.m. A nursing note dated 08/31/18 at 10:26 p.m. documented: (MD's name) made aware of the x-ray results. New order received to transport resident to ER (emergency room ) via Non-emergency transport further evaluation; RP (responsible party, wife's name) made aware of the x-ray results and also of new order received. A nursing note dated 08/31/18 at 10:30 p.m. documented: Resident picked up by (name of transport company) and transported to (name of hospital), left in stable condition. This above information was reviewed with the administrator, director of nursing and assistant director of nursing during a meeting on 10/31/18 at 05:13 p.m. No further information was provided to the survey team prior to the exit conference on 11/01/18 at 1:00 p.m. This is a complaint deficiency. 2. Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #48 as cognitively intact. The resident's clinical record documented a physician's orders [REDACTED]. On 10/30/18 at 10:41 a.m., Resident #48 was observed in bed. A half-full portable oxygen tank was positioned in the floor between the resident's bed and bed table. The oxygen cylinder was unsecured and not in a rack or cart to ensure upright positioning. The portable oxygen tank was still in the floor without a rack/cart on 10/30/18 at 11:53 a.m. On 10/30/18 at 10:58 a.m., the registered nurse (RN #5) caring for Resident #48 was interviewed about the oxygen tank stored in the resident's room. RN #5 removed the portable tank from Resident #48's room and stated the tanks were supposed to be in a rack. RN #5 stated the portable tanks were used with Resident #48 when she went to [MEDICAL TREATMENT] or out of the facility. RN #5 stated the resident had been out earlier in the morning (10/30/18) for a physician appointment. RN #5 carried the portable tank by hand to a storage rack in a room behind the nursing station. When asked how they stored and/or transported the portable oxygen cylinders, RN #5 stated sometimes they have a rolling cart but if no cart was available, she transported the tanks manually. On 10/30/18 at 12:10 p.m., the director of nursing (DON) was interviewed about the unsecured oxygen tank in Resident #48's room. The DON stated oxygen cylinders were supposed to be stored in racks and/or carts. The facility's policy titled Oxygen Safety (revised 12/2017) stated, It is the policy of this facility to provide a safe environment for residents, staff, and the public. This policy addresses the use and storage of oxygen and oxygen equipment .When small-size (A, B, D, or E) cylinders are in use, they shall be attached to a cylinder stand or to medical equipment designed to receive and hold compressed gas cylinders .Protect cylinders from damage by not storing in locations where heavy objects may strike them or fall on them, or where they can be tipped over by foot traffic or door movement . These findings were reviewed with the administrator and director of nursing during a meeting on 10/31/18 at 5:15 p.m.

Based on resident interview, staff interview, clinical record review, facility document review and during the course of a complaint investigation the facility staff failed to ensure skin assessments for the prevention of a Stage III pressure ulcer for one of 18 residents, (Resident # 112) resulting in actual harm. The facility staff failed to complete a weekly, full body skin assessment on Resident # 112 for over 6 weeks, as a result a Stage III pressure ulcer was found on the resident on 08/29/16. Findings include: Resident # 112 was admitted to the facility on originally on 03/11/16, with the most current readmission on 07/05/16. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a significant change assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15, indicating the resident was cognitively intact. The resident was also assessed as requiring extensive assistance with dressing, toileting, hygiene and bathing, with assistance of at least one staff member physical assist. During an interview with Resident # 112 on 09/19/16 at 4:00 p.m., the resident stated that there is a absence of care on the night shift as far as changing briefs. The resident stated that if he needs to be changed on the night shift, he will use the call bell to tell them (staff) and that staff will tell me (resident) that we (staff) have changed you already, you will have to wait. The resident stated that it is consistently on the night shift. The resident was asked, how this made him feel. The resident stated, Pissed off! The resident was then asked if he had a bruise on his bottom and was informed of a complaint that alleged the resident had a large bruised area over his bottom. The resident stated, that he could not see it, but there had been discoloration. The resident stated that he felt like the staff not changing him on night shift had contributed to the condition of his bottom. The resident was asked to clarify, and was asked if he (resident) thought the bruised area was from staff not changing him on the night shift. The resident stated, Yes. The resident was then asked if he had any open areas on his bottom. The resident stated, Yes. Resident # 112's clinical records were reviewed. Nursing notes were reviewed and documented the following: 08/29/16 (2:53 p.m.) Resident is alert and verbally responsive. Able to make needs known. Routine nursing care provided .Resident left for [MEDICAL TREATMENT] this after noon around 1415 (2:15 p.m.) in stable condition. No acute distress noted upon departure . 08/29/16 (3:09 p.m.) Assigned CNA (certified nursing assistant) reported to the wound nurse that the resident has an open area. Resident was assessed by the wound nurse and the writer. Circular shape open area 1 cm (centimeters) in length and 0.8 cm in width noted on resident's right upper buttock. No drainage, nor bleeding, slight slough noted. Resident c/o (complained of) mild pain. Dr. (name of physician) was notified .frequent turning and positioning was through out this shift . 08/29/16 (5:55 p.m.) new skin area observed on a (sic) resident Rt (right) upper buttock (stage 3) MD (medical doctor) .new order give . Resident # 112's wound records were then reviewed. A Skin Observation Tool-Licensed Nurse was reviewed dated 07/12/16 and timed 6:30 p.m. This form had a picture of a human body, with numbers corresponding to 52 different areas over the body to accurately identify the location of concern on the body. The form also had a description area to the right of the body image that described skin conditions in detail, which documented: Suspected Deep Tissue Injury-Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage I-Intact skin with no-blanchable redness of a localized area usually over a bony prominence .Stage II-Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough .Stage III-Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV (4)-Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present .Unstageable-Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the wound bed . Below this area on the form was an area to document the site (area on the body with number), the type (type of wound/area), length, width, depth, and stage. This form (dated 07/12/16) above described area was blank, section 2 under Notes documented the following: Wound care treatment continues as ordered. The skin observation tool form dated 08/29/16 was then reviewed and documented, Site: 31 Right buttock Type: Pressure Length: 2 (cm) Width: 1.5 Depth: (no depth was documented) Stage: III .Notes: new skin area observed on a (sic) resident Rt upper buttock (stage 3) MD .notified new order given. 50% G (granulation tissue) 50 % S (slough) . LPN (Licensed Practical Nurse) # 1, also known as the wound nurse was interviewed on 09/21/16 at 8:10 a.m. LPN # 1 was asked if weekly skin assessments are done. LPN # 1 stated, yes and they are completed by the floor nurses and are called Skin Observation Tool-Licensed Nurse. The LPN stated that she does an initial assessment on admission and whenever there is a brand new area found. LPN # 1 stated that once an area is found, she will take care of the wound, by notifying the physician, rounding with the wound clinic if that is ordered for a resident, completing measurements regarding progress and dressing changes for that particular wound, per the physician's orders [REDACTED].# 1 stated that the floor nurses are responsible for the full body weekly skin assessment. The LPN was asked to look at Resident # 112's full body skin assessments. LPN # 1 pulled up the Skin Observation Tool forms located in the electronic clinical record. The LPN was made aware that the last one done prior to the stage III was completed on 07/12/16. The LPN was made aware that over 6 weeks had passed since the last assessment was completed and now the resident had a stage III. The LPN again verbalized that these are done by the floor nurses. LPN # 1 was asked about Resident # 112's stage III pressure ulcer and how this was found. LPN # 1 stated that it was reported on 08/29/16 by CNA # 2 and there was slough and necrotic tissue. LPN # 1 stated that she and the floor nurse went into assess it and notified the physician. LPN # 1 was asked how this went from nothing to a stage III. LPN # 1 stated that she wondered the same thing and stated that she started to investigate herself and went into the computer to see if anything could be found. LPN # 1 stated that she had found where CNA # 3 documented in the computer on 08/18/16 that the resident's bottom was red, but she did not report it to anyone. LPN # 5, also known as the Unit manager was interviewed and was asked who is responsible for the resident's weekly full body skin assessments. LPN # 5 stated, the floor nurses. The LPN was asked where those would be. The LPN voiced in the computer and pulled up the skin observation tool form; the LPN was made aware that the last one completed before finding the stage III was on 07/12/16. Both LPN's were reviewed the electronic clinical record and became aware that no full body skin assessments could be located for Resident # 112 after 07/12/16. Both LPN's agreed that the last one completed prior to finding the stage III on Resident # 112, was dated 07/12/16. LPN # 5 stated that the weekly full body assessments should be done weekly and that it should documented in the POC (plan of care). LPN # 5 was asked to clarify what she meant by POC. The LPN stated that it is in the computer and it triggers for the nurses to complete, but she didn't know why they were not completed. LPN # 1 stated that the resident was offered a low air mattress prior to the stage III and that the resident refused. LPN # 1 was asked for dates regarding the mattress refusal. Nursing notes were again reviewed and did not document anything regarding Resident # 112's buttock skin condition, in the days leading up to the discovery of the stage III, on 08/29/16. A weekly wound evaluation form was reviewed dated 07/28/16. This form documented an area on the resident's right second toe. A weekly wound evaluation form dated 08/18/16 was reviewed. This form documented an area on the left first toe. A weekly wound evaluation form dated 08/25/16 was reviewed. This form documented an area on the left shin. A weekly wound evaluation form dated 09/02/16 was reviewed. This form documented the area on the right upper buttock, as acquired pressure of stage III and that granulation tissue and necrotic tissue was present. The resident's CCP (comprehensive care plan) was reviewed and documented, .Bathing and Showering: (03/12/16) Avoid scrubbing and pat dry sensitive skin .provide sponge bath when a full bath or shower cannot be tolerated .Bed mobility: The resident requires limited assistance by (1) staff to turn and reposition in every two hours and as necessary .Resident is totally dependent on (1) staff for dressing requires extensive assistance by (1) staff for personal hygiene .totally dependent on (1) staff for toilet use .Anticipate and meet the resident's needs .The resident needs prompt response to all request for assistance .monitor wound healing progress .encourage good nutrition and hydration in order to promote healthier skin .keep skin clean and dry . No further information was located on the resident's CCP regarding pressure ulcer prevention interventions. A Documentation survey report for August 2016 was reviewed for CNA documentation. In the Skin observation it was documented on 08/01/16 and 08/02/16 that the resident had a discoloration to the skin (no location specified). On 08/11/16 it was documented the resident had a red area (no location). On 08/18/16 it was documented that the resident had a red area (no location). On 08/24/16 it was documented that the resident had discoloration (no location). On 08/26/16 it was documented that the resident had a red area (no location). On 08/29/16 it was documented that the resident had an open area (no location). Resident # 112 was interviewed again on 09/21/16 at 8:50 a.m., the resident stated that he did not like the air mattress and specifically named the bed an air maxx. The resident stated that staff had ordered one and put on his bed back in March, when he was first admitted . The resident stated that the mattress would get air pockets in it and it was extremely difficult for him to move at all. The resident stated that he felt like he was in a hole and he did not feel like that was good for him. The resident was asked if he could move and turn himself. The resident stated that he needed assistance from staff because of his [MEDICAL TREATMENT] graft in his left arm, he was not suppose to put a lot of pressure or weight on that arm and that he has weakness and can't really turn himself very well. The resident stated that he felt like a new, regular type of mattress would be better for him. Resident # 112's nutrition/dietary information was then reviewed. A nutritional risk assessment, completed by the RD (Registered Dietitian) was reviewed dated 07/10/16. This assessment documented that the resident has a significant weight loss over the last 30, 90, and 180 days and that the resident typically consumes an average of 50%. The assessment additionally documented that the resident required extensive assistance from staff for walking and did not have any problems feeding himself. No [MEDICATION NAME] information was listed and the assessment documented that the resident had wounds on his right 2nd and 5th toes. This assessment documented that the resident was high risk. A nutritional risk assessment completed by the RN (Registered Nurse) # 4, dated 09/02/16 documented that the resident had intake of 76-100% and had a stage III/VI pressure ulcers or multiple impaired areas, suspected deep tissue injury. This form did not include any additional information and assessed the resident as a moderate risk. The RD wrote a dietary note on 09/01/16 at 6:11 p.m.,which documented: Visited with (name of Resident # 112) to discuss recommendations to support wound healing .protein bars available to him at all times and he was encouraged to eat at least one daily to support wound healing . The RD was interviewed on 09/21/16 at 10:15 a.m. regarding Resident # 112. The RD was asked how often are residents seen the RD stated that is based on their risk. The RD was made aware that Resident # 112 was assessed as a high risk on 07/10/16, five days after his readmission on 07/05/16. The RD was asked if an [MEDICATION NAME] had been obtained for Resident # 112. The RD stated that an [MEDICATION NAME], is really not a useful determination of nutritional status, as it once was. The RD was asked, she would order something like an [MEDICATION NAME]. The RD stated, no and went on to say the physician would normally order that. The RD was asked if she collaborates with the resident's physician in regards to wound healing strategies. The RD stated, Not really. No specific nutritional recommendations were found for Resident # 112 on the 07/10/16 nutritional assessment. The resident's CCP was reviewed and documented to monitor the resident's intake, liberalize diet, and to monitor for decreased appetite. No other nutritional interventions were found for Resident # 112. On 09/21/16 at approximately 10:40 a.m., the ADON (assistant director of nursing) was interviewed and was asked how do you know who which residents are to receive weekly skin assessments. The ADON stated that on admission, MDS does their assessment and then enters it into the computer. The ADON stated that it doesn't matter if a resident had a current skin problem or not upon admission, skin assessment information is put into the system by MDS for assessments to be completed on each resident. The ADON was asked why, full body skin assessments were not completed on Resident # 112 from 07/12/16 through 08/29/16, when the stage III pressure area was found on his buttocks. The ADON stated that she would look into it and get back to this surveyor. On 09/21/16 at approximately 11:25 a.m. the ADON stated, Even though it (weekly skin assessments) wasn't completed, we have a comprehensive assessment that was completed. The comprehensive weekly nursing assessment evaluation forms were reviewed. This form reviews and touches on 12 different systems from vital signs to bladder to skin. The following were reviewed: 08/14/16 (4:36 p.m.) .skin assessment-assessment will include skin color, skin temperature, skin integrity, turgor and condition .Normal findings indicate: skin color good/within norm; turgor is good; skin is warm/dry/intact; no skin problems .1A. Normal findings 1B. Abnormal findings from skin assessment (this was blank) 1C. New changes to the resident's skin integrity noted in the last 24 hours .No new areas .1D. New changes in skin integrity (this area was blank) . This form additionally describes wound care and dressing, the entire area was blank, no preventative measures were marked, the entire area was blank. 08/21/16 (7:36 p.m.) .skin assessment-assessment will include skin color, skin temperature, skin integrity, turgor and condition .Normal findings indicate: skin color good/within norm; turgor is good; skin is warm/dry/intact; no skin problems .1A. (area was blank-no information documented) 1B. Abnormal findings from skin assessment (this was blank) 1C. New changes to the resident's skin integrity noted in the last 24 hours .No new areas .1D. New changes in skin integrity (this area was blank) . This form additionally describes wound care and dressing, the only information documented was, treatment on right foot continues as ordered. No other information was documented in the wound care/dressing, preventative measures section. 08/27/16 (2:19 p.m.) .skin assessment-assessment will include skin color, skin temperature, skin integrity, turgor and condition .Normal findings indicate: skin color good/within norm; turgor is good; skin is warm/dry/intact; no skin problems .1A. (area was blank-no information documented) 1B. Abnormal findings from skin assessment (this was blank) 1C. New changes to the resident's skin integrity noted in the last 24 hours .No new areas .1D. New changes in skin integrity (this area was blank) . This form additionally describes wound care and dressing, the only information documented was, treatment on right foot continues as ordered and encourage frequent turning and repositioning. No other information was documented in the wound care/dressing, preventative measures section. 08/28/16 (10:30 p.m.) .skin assessment-assessment will include skin color, skin temperature, skin integrity, turgor and condition .Normal findings indicate: skin color good/within norm; turgor is good; skin is warm/dry/intact; no skin problems .1A. Normal findings 1B. Abnormal findings from skin assessment (this was blank) 1C. New changes to the resident's skin integrity noted in the last 24 hours .No new areas .1D. New changes in skin integrity (this area was blank) . This form additionally describes wound care and dressing, the only information documented was, treatable wounds present-treatment completed as ordered. No other information was documented in the wound care/dressing, preventative measures section. The ADON stated that the wound physician could be reached if the survey team would like to speak with him. An interview was conducted with wound physician on 09/21/16 at 3:35 p.m., via telephone with the survey team. The physician was asked Resident # 112 and the stage III pressure area that found. The physician stated that screening is done by nursing staff and bring any issue up to initiate treatment early, when they brought it to me it was a stage III. The physician stated that he was not sure who is doing the assessment and what they are reporting, which nurse. The physician was told about the lack of assessments and was made aware that a CNA documented redness on 08/18/16, but did not report it. The physician stated that a stage III could develop in 11 days. The physician stated that he was not sure of the facility's policy on skin assessments. The administrator, DON (director of nursing) and ADON were made aware of concerns regarding Resident # 112 being found with a stage III and the lack of weekly skin assessments, in a meeting with the survey team on 09/21/16 at 3:50 p.m. The facility policy and procedure was requested on skin assessment completion. The Skin Checks policy and procedure was presented and reviewed on 09/22/16. The policy documented: .The nursing facility is committed to identifying and implementing timely treatments to all skin conditions .Comprehensive skin checks will conducted on all residents at admission, readmission, weekly and as needed .abnormalities will be identified and documented in the clinical chart .CNAs will monitor for skin changes throughout their shift .area of abnormality found by the aide will be reported to a licensed nurse who will assess .additional preventative interventions to prevent recurrence .detailed documentation .chart will be updated as needed to reflect the status of the skin condition .ADON or designee will review the documentation and monitor . On 09/22/16 the DON presented an email from the wound physician, which documented: .To whom at (sic) may concern, .several weeks ago he was noted to have a small buttock pressure injury about 1 cm (centimeter) .PI (pressure injury) is not clear however it is within the realm of possibility for it to develop at any time given surrounding environment PI develop in short duration from 1 to 4 hours as is well noted in the literature . On 09/22/16 at approximately 8:30 a.m., the literature the physician was referring to was requested by the survey team. At approximately 9:50 a.m., the information was presented and reviewed. The How much time does it take to get a pressure Ulcer? Integrated evidence from human, animal, and in vitro studies Volume 54-Issue 10 -October, 2008 was reviewed and documented: .Surprisingly, information regarding the timeframe for pressure onset, particularly for deep tissue injury onset, is scant . The provided literature did not indicate or specify any information regarding a stage III pressure ulcer. No further information or documentation was presented to evidence that Resident # 112 had weekly full body skin assessments completed for the prevention of a stage III pressure ulcer; no further information and/or documentation was presented to evidence that Resident # 112's stage III pressure ulcer was unavoidable.

Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to provide supervision for accidents resulting in harm for two of 27 residents, Resident #1, and 4. In addition, the facility staff failed to provide safety interventions for two of 27 residents in the survey sample, Resident #3 and 7. 1. Resident #1 was not provided supervision in the dining room, which resulted in a fall with facial lacerations requiring twelve sutures resulting in harm. 2. Resident #4 was not provided supervision and safety interventions while in bed, which resulted in a fall with lacerations requiring sutures which constitutes harm. Resident #4 was found by his bedside with a laceration to his left ear and abrasions to his buttocks. He was sent to the emergency and returned with sutures in his ear. During the survey Resident #4 was observed without physician ordered alarms in place, the incorrect alarms in place, and not wearing physician ordered hipsters to prevent hip injuries in the event of a fall. 3. The facility staff failed to ensure appropriate supervision and/or safety devices for the prevention of falls for Resident # 3; Resident # 3 was identified by the facility as being at high risk for falls, and as having a history of falls. 4. Resident #7 was not provided safety interventions for accident prevention. Resident, # 7, did not have a fall mat by the bedside, and did not have the hipsters on to prevent hip injury from a fall. The findings include: 1. Resident #1 was not provided supervision in the dining room, which resulted in a fall with facial lacerations requiring twelve sutures resulting in harm. Resident # 1 was admitted to the facility on [DATE], with but not limited to the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/9/16 was a quarterly assessment. The resident was assessed as being having short and long-term memory impairments and moderately impaired in decision-making skills. Section G for transfers assessed the resident as 3/3, extensive assistance with two person physical assist. Ambulation the resident was assessed as 4/2, total dependence with the assist of one person. On 8/2/16 at approximately 3:00 p.m., Resident #1's clinical record was reviewed. A nursing note was documented to include the following: 7/20/16 Note Text: At 4:36pm writer was called by another nurse saying that resident in (room #) fell . Observed resident on the floor face down with laceration on her forehead. Site was cleaned .Resi was sent to ER (emergency room ) via 911 per MD (doctor/physician's) orders . 7/20/16 22:43 (10:23 p.m.) Resident returned from ER via stretcher .she returned with twelve stitches on her left forehead and with order sutures out 5-7 days .(sic). A fall assessment dated [DATE], 2/18/16 and 5/20/16 assessed the resident as being a 55 (High Risk 45 and higher) for falls. A Fall Care plan initiated and revised on 4/25/16 was documented to include the following: Focus: The resident had an actual fall /at risk for further falls R/T (related to) Gait/balance problems and unaware of safety needs .Intervention/Tasks: Staff will close dining room when not in use by resident .Staff to frequently check on resident . On 8/3/16 at approximately 7:47 a.m., the director of nursing was interviewed regarding an investigation related to the fall. The director of nursing presented to this Surveyor a copy of the Fall Investigation. Upon review of the Fall Investigation, the following was documented: 7/20/16 .Description of Current Fall Date 7/20/16: 4:36 p.m. Location: D-Dining room .Fall within the past (3 months was marked) Conditions: Unsteady Gait, Incontinence, Short-term memory loss .Environmental /Situational Conditions .Attempts to walk without assistance .Impact from Fall .Laceration to her left side forehead .Staff interviews (CNA, certified nursing assistant caring for Resident #1) Per staff she stated I took another resident to the bathroom and left the other resident in the dining room. Resident was sitting in her wheelchair .Care Plan Review: Current Plan is effective to prevent recurrent falls/injury .Frequent staff check. The staff, who was involved in the incident, provided Witness Statements, which were attached to the Fall Investigation Report. The Witness Statements were reviewed to include the following: A. I was coming up I saw the nurse runing (sic) towards the dining room. I following the nurse I saw a Resident on the Floor B. I was in the Dinning Room I told (CNA named) I going to get something in my car I will be back C. Writer was called by another nurse to the dinning say resident in (room number) fell . Observed resident on the floor face down with laceration on her forehead. Assign CNA told me that another CNA was in the dinning room who left without telling somebody else to sit with residents On 8/3/16 at approximately 7:47 a.m., the director of nursing (DON) was interviewed regarding the above incident and investigation. The DON was interviewed and asked if the Resident was left unattended in the dining room. The DON stated, Yes. When interviewed and asked if the resident should have been left unattended, the DON stated, No. This Surveyor requested to speak with the CNAs involved in the incident; the CNAs were not available for interview during the time of the Survey. No further information was provided during the course of the survey as to why the resident was left unattended in the dining room. 2. Resident #4 was not provided supervision and safety interventions while in bed, which resulted in a fall with lacerations requiring sutures which constituted harm. Resident #4 was found by his bedside with a laceration to his left ear and abrasions to his buttocks. He was sent to the emergency and returned with sutures in his ear. During the survey Resident #4 was observed without physician ordered alarms in place, the incorrect alarms in place, and not wearing physician ordered hipsters to prevent hip injuries in the event of a fall. Findings were: Resident #4 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: Unspecified mood disorder, hypertension (high blood pressure), depressive disorder, chronic ischemic heart disease (heart problems), history of falling and a traumatic brain injury. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 06/25/2016. Resident #4 was assessed as having difficulty with both long and short term memory, as well as being moderately impaired with daily decision making skills. The paper/hard chart and electronic medical record were reviewed on 08/02/2016. The following orders were present on the current physician order [REDACTED]. The care plan was reviewed. A problem area listed was: Resident have (sic) had actual falls with no injury/potential for further falls R/T (related to) unsteady gait and being non compliance (sic) (intentionally transferring himself on the floor) and confusion. Interventions included but were not limited to: Bed alarm to alert staff; Hipster to minimize fall related injury; Wheel chair alarm to alert nurse (utilize pressure pad). On 08/02/2016 at approximately 3:00 p.m., Resident #4 was observed sitting up in his wheelchair eating a snack. His private sitter was in the room. There were no alarms visible on his wheelchair. The sitter was asked if the resident had any alarms in use. She stated, He has one, I will put it on now. She then went to a chest of drawers in the room and located a tab alarm lying on the top. The cord for the alarm was wrapped around the alarm box. The sitter was asked if she normally used the alarm. She stated, No, but I will put it on him now. The sitter was asked if Resident #4 was wearing his physician ordered hipsters. She stated, No .they were soiled with poopie and I sent them to laundry. The sitter was asked when they were sent to be cleaned. She stated, Yesterday. She was asked if he had more than one pair. She stated. No, just the one. On 08/03/2016 at approximately 8:30 a.m., Resident #4 was observed in the dining room. He was sitting in the middle of the room, dressed in shorts and a t-shirt. There was a tab alarm on his chair and hooked to the back of his shirt. A CNA (certified nursing assistant) in the dining room was asked if he was wearing his hipsters. She stated, I'm not his aid today but I will take him to his room and we can check .breakfast isn't here yet. She then took Resident #4 to his room. Once in his room the CNA stated, I don't feel them on him. The private sitter was in his room. She had a pair of hipsters in her hand. They were new and still in the wrapper. She stated, I just got them (hipsters) .his wife does his laundry and his are at home .I will put the new ones on now. The progress note section of the clinical record was reviewed on 08/03/2016. Observed was a note dated 10/19/2015 which read: resident sustained [REDACTED].Was noted to have gotten up from wheelchair and fell on to buttocks. Hipsters were on, resident had a wheelchair alarm that appeared to have had the string removed (where it was attached to resident). Resident switched to pressure alarm as intervention to prevent tampering. Also observed in the progress notes were the following entries: 12/3/2015 07:57 (7:57 a.m.) This writer assessed pt (patient). Pt observed with laceration to the left ear (pinna) measuring 5 X (by) 1 cm (centimeter). Pressure applied to site and wrapped with bandaid. Multiple abrasion noted on pt buttocks. Supervisor made aware. On call MD (medical doctor) notified. Pt alert and verbally responsive, hand grasp are strong bilaterally. Pt transferred to (name of hospital) via 911. 12/03/2016 14:00 (2:00 p.m.) .Resident had a fall this morning, was found in his room by his bedside, sustain laceration to Lt (left) ear and abrasions to buttocks. Resident was D/C (discharged ) to the hospital for evaluation. Resident return back from Hospital .New orders for Keflex prophylaxis, to remove dressing from Lt ear laceration in 1 wk (week), treatment to abrasion on buttocks. Bed and W/C (wheelchair) alarm MD and RP (responsible party) notified. The review showed no evidence that interventions were in place to prevent Resident #4 from falling. Also observed in the clinical record were discharge instructions from the hospital which included the following information: Laceration was not repaired completely because pt was combative. Dressings, applied, will need to stay in place for 1 week. Discharge Prewritten Instructions: Laceration Care, Sutured Wound Care. On 08/03/2016 a fall investigation was requested for the fall on 12/03/2016. At 2:45 p.m., the ADON (assistant director of nursing) stated, We cannot find the fall investigation for the fall in December .I am pretty sure we did one, I was the unit manager at the time .the DON (director of nursing) that was here then is gone now. The ADON was asked if Resident #4 had sutures placed in his ear at the time of the fall. She stated, I don't think so. The wound care specialist notes were reviewed. The note dated 12/16/2015 contained the following information: Assessment and Plan: WOUND OF THE LEFT EAR FACE-NO CHANGE .REMOVED SUTURES The above note was shown to the ADON. The ADON was asked if she knew how many sutures Resident #4 had in his ear. She looked through the clinical record and reported that she had been unable to locate that information. On 08/04/2016 at approximately 1:15 p.m., this surveyor went to Resident #4's room with the unit manager to determine what type of alarm Resident #4 had in place. The care plan entry for the pad alarm was shown to the unit manager. She accompanied this surveyor to the room. Resident #4 was lying on his bed. The unit manager lifted up the edge of the fitted sheet, revealing a green pressure alarm on the bed. The unit manager was asked where the alarm box was as this surveyor had observed the private sitter transfer the resident from his bed to his wheelchair earlier in the day and had not heard an alarm sound. The private sitter and the unit manager located the cord coming from the pad alarm and pulled it out from under the bed. The cord was not attached to anything. The private sitter was asked if the alarm ever sounded when she transferred the resident. She stated, No, it is not attached to anything. The unit manager was asked if the alarm box had fallen under the bed. She stated, No. She then looked in the drawer of the bedside table. She located an alarm box in the back of the drawer and a small pad alarm still in the wrapper and not previously used. The wheelchair was sitting at the bedside. There was not a pad alarm in the seat of the wheelchair. This surveyor pointed to the seat and asked if the pad alarm located in the drawer was supposed to be the one on the wheelchair. The unit manager stated, Yes. The unit manager was asked why the pad alarm on the bed was not attached to an alarm box and why the pad alarm in the drawer had not been used on the chair. She stated, We need to educate. She was asked who was checking the placement and function of the alarms every shift as ordered by the physician. She again stated, We need to educate. The ADON came to the conference room at approximately 1:30 p.m. and stated, I just went up to (name of Resident #4) .he has the alarms in place now. The above information was shared with the DON (director of nursing), the ADON and the administrator during a meeting on 08/04/2016 at approximately 2:30 p.m. Concerns were voiced that Resident #4 did not have physician ordered safety devices in place: hipsters, and alarms. Also discussed was the identification of possible harm due to his fall in December with resulting suture placement. No further information was obtained prior to the exit conference on 08/04/2016. 3. The facility staff failed to ensure appropriate supervision and/or safety devices for the prevention of falls for Resident # 3; Resident # 3 was identified by the facility as being at high risk for falls, and as having a history of falls. Findings include: Resident # 3 was admitted to the facility on [DATE] originally, with the most current readmission on 07/06/16. [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) was a significant change assessment dated [DATE], which assessed the resident as having a cognitive score of 7, indicating the resident had severe impairment in daily decision making skills. The resident was also assessed on this MDS as having 2 or more falls with injury (except major) and as having 1 fall with major injury. The resident was additionally assessed as not ambulating during the look back period and as requiring extensive to total dependence on staff for all ADL's (activities of daily living). The resident additionally triggered for cognition, communication, vision and falls in the CAAS (care area assessment summary) section of this MDS. In section G0300. Balance During Transitions and Walking of this MDS, the resident was coded as 'Activity did not occur' for moving from seated to standing position, walking, turning around and facing the opposite direction while walking, and as 'Not steady, only able to stabilize with human assistance' for moving on and off the toilet and surface to surface transfers. The most recent quarterly MDS assessment was reviewed for comparison. This MDS assessment dated [DATE] (just prior to the fall with injury on 07/03/16) documented Resident # 3 as having a cognitive score of 7, again indicating the resident had severe impairment in daily decision making skills. This MDS additionally assessed the resident as requiring limited assistance for transfers (bed mobility/transfers) and ambulation (in room/corridor), with at least one staff for guided maneuvering and physical assistance. The resident was coded on this MDS as requiring extensive assistance from at least one staff person for dressing/toileting/hygiene and bathing. In section G0300. Balance During Transitions and Walking of this MDS, the resident was coded as 'Not steady; only able to stabilize with human assistance' for moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet and surface to surface transfers. During clinical record review on 08/02/16 through 08/04/16, Resident # 3's nursing notes were reviewed. The following was revealed. 12/12/15 timed 11:03 a.m. .observed on floor on buttocks . 01/02/16 timed 2:14 p.m. .sitting on the hallway (sic) with legs bend (sic) and his cane with him . 02/14/16 timed 8:27 a.m. .observed in his room sitting in his buttock (sic) close to his bed .floor clean and dry noted wearing plastic sandal with one pair on and the other off (sic) . 04/01/16 timed 5:02 p.m. .sitting in bathroom at 11:00 am .legs got weak .helped back to his feet . 05/06/16 timed 1:34 p.m. .always in room occasionally takes a walk to dining room or nursing station when needed assistance (sic) . 05/21/16 timed 10:37 p.m. .at 7:00 pm heard a big sound .found him (resident) lying on his right lateral side on floor between his bed and his roommate .no injury . 05/23/16 timed 9:49 p.m. .Resident found on floor .no injury . 06/03/16 timed 11:54 p.m. .denies any post fall pain, gait remains unsteady with ambulation care provided with assist including accompanying resident to and from bathroom fall precautions maintained . 06/06/16 timed 4:18 p.m. .Resident is forgetful, needs constant encouragement and reminders to call for assist (sic) with needs . 06/08/16 timed 12:27 a.m. .resident has unsteady gain .continues on monitoring for falls . 06/09/16 timed 10:02 p.m. .confused .encourage resident to push the call for help to get out of bed . 06/21/16 timed 2:22 p.m. Resident has a history of not wearing proper shoes/socks when ambulating. During this review period there were not reports of resident being non-compliant. Will continue to monitor . No other information or documentation could be located throughout the resident's clinical record regarding the resident not wearing appropriate shoes and/or socks. 06/21/16 timed 2:23 p.m. .resident continues to exhibit cognitive impairment r/t (related to) dx (diagnoses) of dementia .A&O (alert and oriented) to name but presents with confusion, resident has two certifications stating that he is unable to make medical decisions . A nursing note dated 07/03/16 was created at 5:31 p.m. and had an 'effective' time as 2:30 p.m. documented: Resident complained of pain on his left knee and left leg .no swelling noted but bruises noted on his right inner thigh and upper back. Resident able to acknowledge that he fell , but unable to verbalized (sic) how the incident occurred .medicated with Tylenol 650 mg (milligrams) .MD (medical doctor) notified of the incident .order for an x-ray to the femur, left knee, and tibia and fibula . 07/03/16 timed 4:30 p.m. PRN (as needed) Tylenol given at 10 Am (sic) . 07/03/16 timed 5:48 p.m. RP (responsible party) .made aware . 07/03/16 timed 7:45 p.m. PRN administration was effective . 07/04/16 timed 1:13 a.m. Res (resident) alert and verbally responsive. C/O (complained of) left hip pain, medicated with PRN Tylenol, help (sic) X-ray done in the AM. Result came with the impression on no (L) (left) femoral shaft fracture but appear (sic) to be fracture involving the (L) femoral neck. MD made aware .order for x-ray of the hip to R/O (rule out) FX (fracture) of femoral neck. X-ray done and result came back with impression of acute fracture of the left femoral neck. MD made aware of new x-ray report, order given by MD to transfer res to ER (emergency room ). Res transferred to (initials of hospital) ER via 911. RP made aware . 07/04/16 timed 8:19 a.m. Resident transferred to hospital . 07/06/16 timed 2:06 a.m. .returned from hospital via stretcher this evening .able to move (R) (right) leg but can slightly move (L) (left) injured (FX) (fractured) leg .Assessment by this writer reviled (sic) large (R) inner thigh bruise, and bruise on the buttock, abrasion on (L) upper back and redness on the sacral area .remains in bed . On 08/02/16 at 4:10 p.m., in a meeting with the survey team, the DON (director of nursing) and administrator were asked for the resident's care plan and investigation regarding the fall with injury. Resident # 3's fall assessments were then reviewed. A fall assessment dated [DATE] documented: HISTORY OF FALLING- yes .AMBULATORY AID- uses crutches, cane or walker .GAIT-WEAK (stooped but able to lift head without losing balance-steps are short, resident may shuffle .MENTAL STATUS-Overestimates or forgets limits .SCORING-Click Save. The score and category will appear in the header of the assessment. Morse Fall Scoring: High Risk 45 and higher Moderate Risk 25-44 Low Risk 0-24 . Resident # 3's fall risk category on this fall assessment was documented as High Risk for Falling and as having a fall risk score of 80. A fall assessment dated [DATE] (just prior to the fall on 07/03/16) documented: HISTORY OF FALLING- yes .AMBULATORY AID- uses crutches, cane or walker .GAIT-IMPAIRED (difficulty rising from chair, uses chair arms to get up, bounces to rise, keeps head down when walking, watches the ground, grasps furniture, person or aid when ambulating. Cannot walk unassisted) .MENTAL STATUS-Overestimates or forgets limits .SCORING-Click Save. The score and category will appear in the header of the assessment. Morse Fall Scoring: High Risk 45 and higher Moderate Risk 25-44 Low Risk 0-24 . Resident # 3's fall risk category on this fall assessment was documented as High Risk for Falling and as having a fall risk score of 90. A vision consult dated 10/5/15 was reviewed for Resident # 3. The vision consult documented: .bilateral wet AMD (age related macular degeneration) .poor prognosis .symptoms (for) 2-3 years . The resident's CCP (Comprehensive Care Plan) was presented and reviewed. The CCP documented: .09/09/15 (date initiated) Resident is dependent on staff .The resident needs assistance/escort to activity functions .09/09/15 (date initiated) The resident has an ADL self-care performance deficit r/t dementia .Encourage the resident to use bell to call for assistance .09/09/15 (date initiated) The resident has impaired cognitive function/dementia or impaired thought processes r/t dementia, difficulty making decisions .Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion .09/09/15 (date initiated) The resident has a communication problem r/t hearing deficit .Communication: .Do not rush .use simple, brief, consistent words .Monitor for/record .decline in cognitive status, mood, decline in ADL .09/09/15 (date initiated) Resident had a fall and he is at risk for further falls r/t confusion, deconditioning, vision complications .Anticipate and meet resident's needs, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed, 04/01/16 (date initiated) Frequent cueing/supervision and monitoring by the staff due to resident's deconditioning status .12/23/15 (date initiated) Remind resident to use call light when attempting to ambulate, transfer or toilet use .05/27/16 (date initiated) Staff will encourage resident to have proper and safe foot wear on at all times when OOB (out of bed) .09/09/15 (date initiated) The resident has impaired visual function r/t blurred vision .Arrange consultation with eye care practitioner as required, monitor /document /report PRN any s/sx (signs or symptoms) of acute eye problems: Change in ability to perform ADLs, decline in mobility . On 08/03/16 at 10:30 a.m., the survey team again met with the DON and administrator and they were made aware of concerns regarding the above information. The fall investigation for Resident # 3's fall on July 3 was again requested. Resident # 3's fall investigation was presented on 08/03/16 at approximately 2:00 p.m. The fall investigation documented: FALL INVESTIGATION 07/03/16 Diagnoses: [REDACTED].Description of current fall: 07/03/16 2:56 p.m. Location: resident room History-has resident had a fall within the past month, 3 months, 6 months (3 months was marked for Resident # 3) Conditions: Unaware of safety hazards, history of falls within past 6 months .environmental/situations conditions: ambulating without needed help .Impact from fall: bruise (only result marked) .describe what the resident was doing before the fall; describe the resident's behavior prior to the fall. (write in box below) Resident reported to staff that he fell (no other information was documented) .CARE PLAN REVIEW: Recommendations to minimize recurrent falls (write in box): Resident was transported to the hospital for treatment due to s/p (status [REDACTED]. No other information was included in this investigation. X-ray documents were then reviewed for Resident # 3. An x-ray dated 07/03/16 and timed 3:19 p.m. documented: .no evidence of left femoral shaft fracture. There does, however appear to be an acute fracture involving the left femoral neck . An x-ray dated 07/03/16 and timed 4:25 p.m. documented: .left knee show no fracture or dislocation . An x-ray dated 07/03/16 and timed 4:25 p.m. documented: .left tibia and fibula reveal no fracture . An x-ray dated 07/03/16 and timed 8:03 p.m. documented: .left hip show an acute .left femoral neck fracture. The intertrochanteric area and femoral shaft are displaced superiorly and laterally . At approximately 1:30 p.m., the DON, ADON (assistant director of nursing), and administrator were made aware of concerns regarding the above. The DON was asked if there was any additional information/documentation regarding Resident # 3's fall with significant injury. The DON voiced, only what was in the nursing notes and the fall investigation presented. The DON was made aware of multiple concerns with lack of information/documentation in the investigation. The investigation did not provide any details regarding the fall, specifically how the resident was found and by whom, what the actual time of the fall was, what were the circumstances surrounding the fall, and that there were no employee/witness statements of any kind from anyone. The facility staff were also made aware that this resident had been identified as a high fall risk by the facility with no new or updated interventions were put in place in an attempt to decrease the probability of the resident falling again after the resident had multiple falls in the past without injury. The DON, ADON and administrator were made aware that the interventions in place for Resident # 3 may not have been appropriate, such as encouraging the resident to call for assistance when the resident had been assessed with [REDACTED]. The DON was asked what 'fall precautions' meant. The DON voiced that it means to have the call bell in reach, the bed in low position, items the resident uses frequently close and in reach and further voiced that those should be in place all the time. The DON voiced that she would look for additional information regarding the above. A policy was requested on falls, unwitnessed falls, falls with injury. A fall policy was presented on 08/04/16 at approximately 1:00 p.m. The policy documented: Policy and Procedure Fall prevention and risk assessment .to provide an environment that is safe and that minimizes the potential for resident injury due to falls .Falls are a common source of injury and death among the elderly. Early identification of risk factors and staff intervention can reduce the risk of falls; investigation and analytics post fall can identify other risk factors and provide information that may serve in planning interventions to prevent recurrence .internal risk factors .resident's physical and cognitive health, as well as functional status .external factors .medication side effects, the use of assistive devices or appliances and restraints .Fall: any event in which the resident comes to rest unintentionally upon the ground, floor or other lower level .rolls from a bed, the resident is considered to have fallen even if the event is not witnessed .SPECIFIC PROCEDURE/REQUIREMENTS: All residents will be assessed for fall risk, upon admission, quarterly and upon any significant change .the results of the fall risk assessment will be used in identifying immediate measures to be instituted to prevent the resident from falling .providing a low bed with bedside mats .bed or chair alarms .perimeter definers .adaptive call bell .non skid slippers or shoes during transfer .medication regimen review .rearranging the resident's room to reduce trip hazards and obstacles .providing specific toileting schedule or bedside commode .Risk factors and fall prevention measures for individual residents will be documented on the residents comprehensive care plan and communicated to the direct care staff for implementation .Any resident who falls will be immediately assessed for potential injury, and treated as necessary; the nurse responsible for the resident will document the circumstances surrounding the fall in the medical record. The nurse will take any immediate measures necessary to prevent a recurrence of a fall .will be investigated to identify internal and external factors .circumstances within or beyond the facility's control in preventing the fall .the result of the investigation will used .in identifying and care planning additional interventions . Resident # 3 was observed in his room on 08/03/16 at 7:50 a.m., the resident was laying flat in his bed, two 1/2 siderails in the up position were observed with the call bell in reach. No fall mats were observed, no alarm of any kind was observed. The resident had a cane located in one corner of his room and a rolling walker located in other. Again on 08/04/16 at 2:30 p.m., the administrator, DON and ADON were made aware of multiple concerns in a meeting with the survey team. The DON voiced that the facility had no additional information or documentation regarding Resident # 3's fall with injury. No further information or documentation was presented prior to the exit conference on 08/04/16 at 3:30 p.m. 4. Resident # 7 did not have a fall mat at the bedside while in bed, and did not have hipsters (a padded shield worn to protect the hip area) on for the prevention of an injury in case of a fall. Findings include: Resident # 7 was admitted to the facility with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly review dated 7/28/16 and had Resident # 7 coded with se

Based on resident interview, staff interview, clinical record review, facility document review and during the course of a complaint investigation the facility staff failed to ensure skin assessments for the prevention of a Stage III pressure ulcer for one of 18 residents, (Resident # 112) resulting in actual harm. The facility staff failed to complete a weekly, full body skin assessment on Resident # 112 for over 6 weeks, as a result a Stage III pressure ulcer was found on the resident on 08/29/16. Findings include: Resident # 112 was admitted to the facility on originally on 03/11/16, with the most current readmission on 07/05/16. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a significant change assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15, indicating the resident was cognitively intact. The resident was also assessed as requiring extensive assistance with dressing, toileting, hygiene and bathing, with assistance of at least one staff member physical assist. During an interview with Resident # 112 on 09/19/16 at 4:00 p.m., the resident stated that there is a absence of care on the night shift as far as changing briefs. The resident stated that if he needs to be changed on the night shift, he will use the call bell to tell them (staff) and that staff will tell me (resident) that we (staff) have changed you already, you will have to wait. The resident stated that it is consistently on the night shift. The resident was asked, how this made him feel. The resident stated, Pissed off! The resident was then asked if he had a bruise on his bottom and was informed of a complaint that alleged the resident had a large bruised area over his bottom. The resident stated, that he could not see it, but there had been discoloration. The resident stated that he felt like the staff not changing him on night shift had contributed to the condition of his bottom. The resident was asked to clarify, and was asked if he (resident) thought the bruised area was from staff not changing him on the night shift. The resident stated, Yes. The resident was then asked if he had any open areas on his bottom. The resident stated, Yes. Resident # 112's clinical records were reviewed. Nursing notes were reviewed and documented the following: 08/29/16 (2:53 p.m.) Resident is alert and verbally responsive. Able to make needs known. Routine nursing care provided .Resident left for [MEDICAL TREATMENT] this after noon around 1415 (2:15 p.m.) in stable condition. No acute distress noted upon departure . 08/29/16 (3:09 p.m.) Assigned CNA (certified nursing assistant) reported to the wound nurse that the resident has an open area. Resident was assessed by the wound nurse and the writer. Circular shape open area 1 cm (centimeters) in length and 0.8 cm in width noted on resident's right upper buttock. No drainage, nor bleeding, slight slough noted. Resident c/o (complained of) mild pain. Dr. (name of physician) was notified .frequent turning and positioning was through out this shift . 08/29/16 (5:55 p.m.) new skin area observed on a (sic) resident Rt (right) upper buttock (stage 3) MD (medical doctor) .new order give . Resident # 112's wound records were then reviewed. A Skin Observation Tool-Licensed Nurse was reviewed dated 07/12/16 and timed 6:30 p.m. This form had a picture of a human body, with numbers corresponding to 52 different areas over the body to accurately identify the location of concern on the body. The form also had a description area to the right of the body image that described skin conditions in detail, which documented: Suspected Deep Tissue Injury-Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage I-Intact skin with no-blanchable redness of a localized area usually over a bony prominence .Stage II-Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough .Stage III-Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV (4)-Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present .Unstageable-Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the wound bed . Below this area on the form was an area to document the site (area on the body with number), the type (type of wound/area), length, width, depth, and stage. This form (dated 07/12/16) above described area was blank, section 2 under Notes documented the following: Wound care treatment continues as ordered. The skin observation tool form dated 08/29/16 was then reviewed and documented, Site: 31 Right buttock Type: Pressure Length: 2 (cm) Width: 1.5 Depth: (no depth was documented) Stage: III .Notes: new skin area observed on a (sic) resident Rt upper buttock (stage 3) MD .notified new order given. 50% G (granulation tissue) 50 % S (slough) . LPN (Licensed Practical Nurse) # 1, also known as the wound nurse was interviewed on 09/21/16 at 8:10 a.m. LPN # 1 was asked if weekly skin assessments are done. LPN # 1 stated, yes and they are completed by the floor nurses and are called Skin Observation Tool-Licensed Nurse. The LPN stated that she does an initial assessment on admission and whenever there is a brand new area found. LPN # 1 stated that once an area is found, she will take care of the wound, by notifying the physician, rounding with the wound clinic if that is ordered for a resident, completing measurements regarding progress and dressing changes for that particular wound, per the physician's orders [REDACTED].# 1 stated that the floor nurses are responsible for the full body weekly skin assessment. The LPN was asked to look at Resident # 112's full body skin assessments. LPN # 1 pulled up the Skin Observation Tool forms located in the electronic clinical record. The LPN was made aware that the last one done prior to the stage III was completed on 07/12/16. The LPN was made aware that over 6 weeks had passed since the last assessment was completed and now the resident had a stage III. The LPN again verbalized that these are done by the floor nurses. LPN # 1 was asked about Resident # 112's stage III pressure ulcer and how this was found. LPN # 1 stated that it was reported on 08/29/16 by CNA # 2 and there was slough and necrotic tissue. LPN # 1 stated that she and the floor nurse went into assess it and notified the physician. LPN # 1 was asked how this went from nothing to a stage III. LPN # 1 stated that she wondered the same thing and stated that she started to investigate herself and went into the computer to see if anything could be found. LPN # 1 stated that she had found where CNA # 3 documented in the computer on 08/18/16 that the resident's bottom was red, but she did not report it to anyone. LPN # 5, also known as the Unit manager was interviewed and was asked who is responsible for the resident's weekly full body skin assessments. LPN # 5 stated, the floor nurses. The LPN was asked where those would be. The LPN voiced in the computer and pulled up the skin observation tool form; the LPN was made aware that the last one completed before finding the stage III was on 07/12/16. Both LPN's were reviewed the electronic clinical record and became aware that no full body skin assessments could be located for Resident # 112 after 07/12/16. Both LPN's agreed that the last one completed prior to finding the stage III on Resident # 112, was dated 07/12/16. LPN # 5 stated that the weekly full body assessments should be done weekly and that it should documented in the POC (plan of care). LPN # 5 was asked to clarify what she meant by POC. The LPN stated that it is in the computer and it triggers for the nurses to complete, but she didn't know why they were not completed. LPN # 1 stated that the resident was offered a low air mattress prior to the stage III and that the resident refused. LPN # 1 was asked for dates regarding the mattress refusal. Nursing notes were again reviewed and did not document anything regarding Resident # 112's buttock skin condition, in the days leading up to the discovery of the stage III, on 08/29/16. A weekly wound evaluation form was reviewed dated 07/28/16. This form documented an area on the resident's right second toe. A weekly wound evaluation form dated 08/18/16 was reviewed. This form documented an area on the left first toe. A weekly wound evaluation form dated 08/25/16 was reviewed. This form documented an area on the left shin. A weekly wound evaluation form dated 09/02/16 was reviewed. This form documented the area on the right upper buttock, as acquired pressure of stage III and that granulation tissue and necrotic tissue was present. The resident's CCP (comprehensive care plan) was reviewed and documented, .Bathing and Showering: (03/12/16) Avoid scrubbing and pat dry sensitive skin .provide sponge bath when a full bath or shower cannot be tolerated .Bed mobility: The resident requires limited assistance by (1) staff to turn and reposition in every two hours and as necessary .Resident is totally dependent on (1) staff for dressing requires extensive assistance by (1) staff for personal hygiene .totally dependent on (1) staff for toilet use .Anticipate and meet the resident's needs .The resident needs prompt response to all request for assistance .monitor wound healing progress .encourage good nutrition and hydration in order to promote healthier skin .keep skin clean and dry . No further information was located on the resident's CCP regarding pressure ulcer prevention interventions. A Documentation survey report for August 2016 was reviewed for CNA documentation. In the Skin observation it was documented on 08/01/16 and 08/02/16 that the resident had a discoloration to the skin (no location specified). On 08/11/16 it was documented the resident had a red area (no location). On 08/18/16 it was documented that the resident had a red area (no location). On 08/24/16 it was documented that the resident had discoloration (no location). On 08/26/16 it was documented that the resident had a red area (no location). On 08/29/16 it was documented that the resident had an open area (no location). Resident # 112 was interviewed again on 09/21/16 at 8:50 a.m., the resident stated that he did not like the air mattress and specifically named the bed an air maxx. The resident stated that staff had ordered one and put on his bed back in March, when he was first admitted . The resident stated that the mattress would get air pockets in it and it was extremely difficult for him to move at all. The resident stated that he felt like he was in a hole and he did not feel like that was good for him. The resident was asked if he could move and turn himself. The resident stated that he needed assistance from staff because of his [MEDICAL TREATMENT] graft in his left arm, he was not suppose to put a lot of pressure or weight on that arm and that he has weakness and can't really turn himself very well. The resident stated that he felt like a new, regular type of mattress would be better for him. Resident # 112's nutrition/dietary information was then reviewed. A nutritional risk assessment, completed by the RD (Registered Dietitian) was reviewed dated 07/10/16. This assessment documented that the resident has a significant weight loss over the last 30, 90, and 180 days and that the resident typically consumes an average of 50%. The assessment additionally documented that the resident required extensive assistance from staff for walking and did not have any problems feeding himself. No [MEDICATION NAME] information was listed and the assessment documented that the resident had wounds on his right 2nd and 5th toes. This assessment documented that the resident was high risk. A nutritional risk assessment completed by the RN (Registered Nurse) # 4, dated 09/02/16 documented that the resident had intake of 76-100% and had a stage III/VI pressure ulcers or multiple impaired areas, suspected deep tissue injury. This form did not include any additional information and assessed the resident as a moderate risk. The RD wrote a dietary note on 09/01/16 at 6:11 p.m.,which documented: Visited with (name of Resident # 112) to discuss recommendations to support wound healing .protein bars available to him at all times and he was encouraged to eat at least one daily to support wound healing . The RD was interviewed on 09/21/16 at 10:15 a.m. regarding Resident # 112. The RD was asked how often are residents seen the RD stated that is based on their risk. The RD was made aware that Resident # 112 was assessed as a high risk on 07/10/16, five days after his readmission on 07/05/16. The RD was asked if an [MEDICATION NAME] had been obtained for Resident # 112. The RD stated that an [MEDICATION NAME], is really not a useful determination of nutritional status, as it once was. The RD was asked, she would order something like an [MEDICATION NAME]. The RD stated, no and went on to say the physician would normally order that. The RD was asked if she collaborates with the resident's physician in regards to wound healing strategies. The RD stated, Not really. No specific nutritional recommendations were found for Resident # 112 on the 07/10/16 nutritional assessment. The resident's CCP was reviewed and documented to monitor the resident's intake, liberalize diet, and to monitor for decreased appetite. No other nutritional interventions were found for Resident # 112. On 09/21/16 at approximately 10:40 a.m., the ADON (assistant director of nursing) was interviewed and was asked how do you know who which residents are to receive weekly skin assessments. The ADON stated that on admission, MDS does their assessment and then enters it into the computer. The ADON stated that it doesn't matter if a resident had a current skin problem or not upon admission, skin assessment information is put into the system by MDS for assessments to be completed on each resident. The ADON was asked why, full body skin assessments were not completed on Resident # 112 from 07/12/16 through 08/29/16, when the stage III pressure area was found on his buttocks. The ADON stated that she would look into it and get back to this surveyor. On 09/21/16 at approximately 11:25 a.m. the ADON stated, Even though it (weekly skin assessments) wasn't completed, we have a comprehensive assessment that was completed. The comprehensive weekly nursing assessment evaluation forms were reviewed. This form reviews and touches on 12 different systems from vital signs to bladder to skin. The following were reviewed: 08/14/16 (4:36 p.m.) .skin assessment-assessment will include skin color, skin temperature, skin integrity, turgor and condition .Normal findings indicate: skin color good/within norm; turgor is good; skin is warm/dry/intact; no skin problems .1A. Normal findings 1B. Abnormal findings from skin assessment (this was blank) 1C. New changes to the resident's skin integrity noted in the last 24 hours .No new areas .1D. New changes in skin integrity (this area was blank) . This form additionally describes wound care and dressing, the entire area was blank, no preventative measures were marked, the entire area was blank. 08/21/16 (7:36 p.m.) .skin assessment-assessment will include skin color, skin temperature, skin integrity, turgor and condition .Normal findings indicate: skin color good/within norm; turgor is good; skin is warm/dry/intact; no skin problems .1A. (area was blank-no information documented) 1B. Abnormal findings from skin assessment (this was blank) 1C. New changes to the resident's skin integrity noted in the last 24 hours .No new areas .1D. New changes in skin integrity (this area was blank) . This form additionally describes wound care and dressing, the only information documented was, treatment on right foot continues as ordered. No other information was documented in the wound care/dressing, preventative measures section. 08/27/16 (2:19 p.m.) .skin assessment-assessment will include skin color, skin temperature, skin integrity, turgor and condition .Normal findings indicate: skin color good/within norm; turgor is good; skin is warm/dry/intact; no skin problems .1A. (area was blank-no information documented) 1B. Abnormal findings from skin assessment (this was blank) 1C. New changes to the resident's skin integrity noted in the last 24 hours .No new areas .1D. New changes in skin integrity (this area was blank) . This form additionally describes wound care and dressing, the only information documented was, treatment on right foot continues as ordered and encourage frequent turning and repositioning. No other information was documented in the wound care/dressing, preventative measures section. 08/28/16 (10:30 p.m.) .skin assessment-assessment will include skin color, skin temperature, skin integrity, turgor and condition .Normal findings indicate: skin color good/within norm; turgor is good; skin is warm/dry/intact; no skin problems .1A. Normal findings 1B. Abnormal findings from skin assessment (this was blank) 1C. New changes to the resident's skin integrity noted in the last 24 hours .No new areas .1D. New changes in skin integrity (this area was blank) . This form additionally describes wound care and dressing, the only information documented was, treatable wounds present-treatment completed as ordered. No other information was documented in the wound care/dressing, preventative measures section. The ADON stated that the wound physician could be reached if the survey team would like to speak with him. An interview was conducted with wound physician on 09/21/16 at 3:35 p.m., via telephone with the survey team. The physician was asked Resident # 112 and the stage III pressure area that found. The physician stated that screening is done by nursing staff and bring any issue up to initiate treatment early, when they brought it to me it was a stage III. The physician stated that he was not sure who is doing the assessment and what they are reporting, which nurse. The physician was told about the lack of assessments and was made aware that a CNA documented redness on 08/18/16, but did not report it. The physician stated that a stage III could develop in 11 days. The physician stated that he was not sure of the facility's policy on skin assessments. The administrator, DON (director of nursing) and ADON were made aware of concerns regarding Resident # 112 being found with a stage III and the lack of weekly skin assessments, in a meeting with the survey team on 09/21/16 at 3:50 p.m. The facility policy and procedure was requested on skin assessment completion. The Skin Checks policy and procedure was presented and reviewed on 09/22/16. The policy documented: .The nursing facility is committed to identifying and implementing timely treatments to all skin conditions .Comprehensive skin checks will conducted on all residents at admission, readmission, weekly and as needed .abnormalities will be identified and documented in the clinical chart .CNAs will monitor for skin changes throughout their shift .area of abnormality found by the aide will be reported to a licensed nurse who will assess .additional preventative interventions to prevent recurrence .detailed documentation .chart will be updated as needed to reflect the status of the skin condition .ADON or designee will review the documentation and monitor . On 09/22/16 the DON presented an email from the wound physician, which documented: .To whom at (sic) may concern, .several weeks ago he was noted to have a small buttock pressure injury about 1 cm (centimeter) .PI (pressure injury) is not clear however it is within the realm of possibility for it to develop at any time given surrounding environment PI develop in short duration from 1 to 4 hours as is well noted in the literature . On 09/22/16 at approximately 8:30 a.m., the literature the physician was referring to was requested by the survey team. At approximately 9:50 a.m., the information was presented and reviewed. The How much time does it take to get a pressure Ulcer? Integrated evidence from human, animal, and in vitro studies Volume 54-Issue 10 -October, 2008 was reviewed and documented: .Surprisingly, information regarding the timeframe for pressure onset, particularly for deep tissue injury onset, is scant . The provided literature did not indicate or specify any information regarding a stage III pressure ulcer. No further information or documentation was presented to evidence that Resident # 112 had weekly full body skin assessments completed for the prevention of a stage III pressure ulcer; no further information and/or documentation was presented to evidence that Resident # 112's stage III pressure ulcer was unavoidable.

Based on staff interview and clinical record review, the facility staff failed to ensure adequate supervision to prevent accidents for one of 25 residents in the survey sample, Resident # 11. The facility staff failed to provide adequate supervision to Resident # 11, and as a result Resident # 11 incurred significant injury on two separate occasions. Resident # 11 sustained a laceration to the left forehead area which required sutures on 02/26/14, and sustained a comminuted impacted fracture to the right humeral head and neck on 03/06/14. Findings include: Resident # 11 was admitted to the facility originally 12/02/11, with the most current readmission on 03/07/14. [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) with CAAS (care area assessment summary) was a significant change assessment dated [DATE]. This assessment coded the resident with short and long term memory impairment and moderate impairment in daily decision making skills. This MDS also assessed the resident as requiring extensive assistance from staff with assistance of at least one person physical assistance for most all ADL's (activities of daily living) including transfers, ambulating in the corridor, dressing, toileting, hygiene and bathing. The resident triggered for falls, ADL's and psych drug use on this MDS. An annual MDS dated [DATE] was reviewed for comparison. This MDS assessed the resident with a cognitive score of "3", indicating the resident had severe impairment in daily decision making skills. The resident was also assessed to require supervision with at least one staff physical assistance for all ADL's. The resident triggered for behaviors, falls, and psych drug use on the CAAS section of this MDS. On 08/19/14 at 7:30 a.m., Resident # 11 was observed in her room, in her bed. The resident was in a low bed with a fall mat down on each side of the bed. The resident also had 1/4 side rails on each side of the bed in the up position. The resident was covered, lying supine. The resident was observed again at 9:50 a.m., in the same manner as described above. On 08/19/14 at approximately 10:30 a.m., Resident # 11's clinical record was reviewed and revealed the following: A psychiatric progress note dated 02/20/14 documented: "...psychiatric followup...for evaluation and management of agitation, behavioral dyscontrol with bizarre behavior...This patient has had a recent increase in bizarre behavior. She has become more agitated. This morning, she wandered into another resident's room, took his comb, dipped it in peanut butter and began to eat the peanut butter off the comb. She also attempts to leave the unit and remains an elopement risk. Her condition is worse compared to when I last saw her on 12/16/13...thought processes were rambling and confused...severe deficits in recent memory and significant deficits in remote memory...current general knowledge was nonexistent...insight and judgment were poor...Alzheimer's dementia with behavioral disturbance...This patient has a hospice consult pending. If she becomes a hospice patient, I will no longer be able to follow her..." Nursing notes revealed the following: 02/24/14: "Resident wandered into room (number) while the resident in (room number) was using the bathroom. Resident was asked to leave room. She refused and the resident in (room number) chased her out of the room to the west hall way and punch (sic) her on the chest..." 02/25/14: "...Resident was observed in front of room (number) with face down with another resident in room (number) close to her side. Resident had a deep cut on the left forehead. Pressure was applied...to stop bleeding...Resident was transferred out. Resident is hospice care. Resident wander (sic) around..." 03/01/14: 11:08 p.m. "...continue to ambulates (sic) around unit. Resident sutures to left forehead is intact..." 03/03/14: 3:24 p.m. "...Resident was observed by staff rushing out of room (number). Resident stated that the resident in room (number) hit her left upper thigh with her cane. Left upper thigh assessed noted a bruised area measuring 15 X 12 centimeters complained of pain...Wandering in and out of other resident room..." 03/06/14: 12:46 p.m. "...Increased agitation and combativeness noted this week. Last night she hoisted herself over the door to the nurse's station and threw a computer and charts to the floor. She threw hot coffee on a nurse...unable to be redirected...Ativan 0.5 mg IM (intramuscularly) at 4 am effective for 4 hours. At 8 am was attacking another patient in the hallway...redirected...At 10 am...combative and abusive to staff. Screaming and singing (sic)! ...Ativan 0.5 mg IM..." 03/06/14: 10:00 p.m. "...called to assess patient after an incident...resident trying to enter room (number) to use bathroom...(room number) tried to escort her out of room. Pt. was found on the floor...exchange of words and resident told this writer that resident fell down while present with her...right shoulder pain, swollen area noted, decrease range of motion observed...xray to be done to ruled (sic) our fracture..." 03/06/14: 11:50 p.m. "...Resident observed going to room (number). Resident in room (number) told her 'that is not where your bathroom is'...(room number) gentle guide her out of her room...X-ray results received. Resident has fracture...right humerus...transfer to hospital in AM due to FX of humeral (sic)..." 03/07/14: 2:34 a.m. "...resident was up at 2:00 a.m. agitated, trying to strip off her clothing, prn Ativan 1 ml given IM..." 03/07/14: 10:34 a.m. "...transferred to (initials of) hospital...further eval due to right shoulder fracture..." 03/11/14: 11:14 p.m. "Resident is alert and confuse (sic). Resident observed with some swallow (sic) on right arm...PRN ativan...for agitation..." 03/13/14: 12:43 "Resident discussed at interdisciplinary...meeting...fall on 3/6 with fx...declined since then...lethargic due to pain meds. However continues to complain of pain...hospice patient." 03/17/14: 7:41 a.m. "Careplan reviewed resident requires extensive assistance, dependent on staff for bathing, grooming, dressing, transfer, toileting, and incontinent care. Resident is unable to assist due to fractured right arm..." 03/17/14: 7:54 a.m. "...staff continue to monitor resident frequently due to poor safety awareness and redirecting resident from wandering into other resident rooms..." 03/17/14: 8:06 a.m. "...Ativan increased by hospice due to resident restlessness and increased agitation. No complications related to psychotropic drugs..." 04/15/14: 2:30 p.m. "...CNA assigned...informed (nurse) that she was walking...and she heard screams from room (number)...went into room...observed resident of room (number) and resident of (room number) (resident # 11) with a laceration on her nose...laceration measured 6 centimeters in length...she stated she was hit in the nose by someone..." 04/16/14: 12:30 p.m. "...keep resident away from east end of hall..." 04/16/14: 8:30 p.m. "...continued to redirect away from other's rooms. Ativan given at 5:00 p.m. for anxiety/pacing/agitation..." 04/17/14: 12:30 p.m. "...resident continues to wander into other resident's rooms..." 04/30/14: 7:52 p.m. "...Pt was standing in the hallway when another resident tried to get her to walk more quickly down the hall and come to the other resident's room...grabbed (name of resident's) right arm...lost her balance and fell down on her knees...confused...experiencing pain...Dr...present in facility at time of altercation..." 05/01/14: 11:52 a.m. "...continue to complain right shoulder pain...x-ray...result pending..." 05/01/14: 7:52 p.m. "...X-ray result...revealed healed impacted fracture..." 05/15/14: 7:33 p.m. "...increased agitation...seeking exit door..." 05/17/14: 1:52 p.m. "...wandering in the unit..." 05/23/14: 8:23 p.m. "...Ativan 1 mg IM at 4:00 p.m...attempts to touch/be physically combative with another resident, resisting care and refusing po (by mouth) mediation and generally resistant to redirection...pacing and entering other resident rooms...second dose of IM Ativan 1 mg at that time..." 06/01/14: 11:01 p.m. "Ativan 0.5 ml given today at 3:30 pm...increase agitation. Combative to staff, resisting care..." 06/02/14: 12:30 p.m. "...agitated...resisting care combative to staff. Ativan 0.5 ml IM given at 7:30 am... 06/03/14: 2:58 p.m. "...agitated...resisting care combative to staff. Ativan 1 mg po at 9am..." 06/04/14: 3:29 p.m. "...agitated after lunch resisting care combative to staff, wandering room to room Ativan po at 3 pm was given..." 06/05/14: 5:23 p.m. "...agitated after lunch resisting care combative to staff, wandering room to room Ativan IM 1 mg at 3:30 pm was given..." 06/06/14: 8:42 p.m. "...agitated this evening. Combative to staff, wandering from room to room. Ativan 1 mg po given..." Further review of nursing notes from 06/0/14 to present documented that the resident had continued wandering tendencies with aggression, resistance to care and combativeness, several falls. The resident had a fall without injury on 06/13/14 per nursing notes. On 06/16/14 a nursing note documented that the resident had "different spot bruise on different parts of the body." No further explanation of this information was found. On 06/18/14 a nursing note documented that the resident had increased agitation, wandering in and out of other resident's room, disrupted activities and disrobed self on the hallways and that the resident was unable to rest; it was documented that hospice would be contacted. The resident had another fall on 06/26/14 without injury per nurse's notes. The resident had a fall on 07/01/14, which resulted in a bruise to the left foot. On 07/04/14 it's documented that the resident is up in a "geri-chair." On 07/05/15 a nursing note documented that the resident attempted to get out of the geri-chair and Ativan 1 mg IM was given. On 07/06/14 a nursing note documented that resident was non compliant in geri-chair trying to get out of chair and PRN IM Ativan was given. On 07/08/14 a nursing note, again documented that the resident was non compliant in geri-chair and prn Ativan was administered. On 07/20/14 a nursing note documented: "...Resident get up by her self to the floor (sic). Staff left the room to get her geri-chair, when she returned she found her on the floor...observed blood to right side of her head...cleanse site and apply steri strips..." Resident # 11's current POS (physician's orders [REDACTED]. The resident's CCP (comprehensive care plan) was reviewed from admission to present and documented the following: A care plan with the problem start date of 09/07/12 for: "Behavior/agitation" documented interventions dated 10/08/12, which included: "allow resident to vent feelings/needs, listen to resident's needs and adjust plan as appropriate, listen to the resident and try to calm, remove the resident from environment...12/06/11-elopement related to dementia/cognitive loss:...If unable to redirect resident, stay with resident and provide support and supervision until able to redirect...12/04/11-Falls...Provide verbal cues, place call light within reach, maintain a clutter-free environment in the resident's room...03/13/13-Risk for complications related to the use of psychotropic drugs...monitor changes in mental and functional level and report to MD as indicated, monitor side effects and consult physician and/or pharmacist..." The current CCP was reviewed and documented the above interventions. New interventions added to the CCP included: "...monitor resident while out of room for close proximity to other residents (04/30/14), floor mat x 2 while resident is in bed (07/20/14)..." On 08/20/14 at 8:55 a.m., the DON (director of nursing) was interviewed with the survey team. The DON was made aware of the concerns with Resident # 11, specifically the behaviors which had resulted in injury to the resident. The DON was made aware of the lack of interventions regarding safety and supervision for Resident # 11. The DON was asked about the correlation of care between the facility and hospice for the resident. The DON stated the hospice nurse comes one time per week and an aide may come three times per week, depending on the individual case and she was not exactly sure for Resident # 11. The DON was asked about a hospice care plan. When asked if hospice had a care plan for the resident, the DON stated, "I think". The DON stated, "I don't think it's in our chart, they (hospice) are invited to (our) care plan meetings; not sure if they come." The DON stated that the hospice nurse communicates verbally with our nurses and that hospice or the facility nurses will not necessarily make a note of the communication. The DON stated that if hospice makes changes for the resident, as far as orders or interventions it goes in our orders (physician's orders [REDACTED]. plan) for the resident. The DON was asked about the psychiatrist note dated 02/20/14 that documented the resident would no longer be seen by psych if she became a hospice patient. The DON stated that the resident would not be seen because of "contracts" and further explained that once the resident is on hospice, they (hospice) becomes the payer source and if they (hospice) feels psych is needed then they take care of that. The DON was then made aware that the resident is here at the facility all the time and facility staff have the majority of observations/knowledge of the resident. The DON stated, "We can ask for that (psych consult) from hospice." On 08/20/14 at 11:15 a.m., the administrator, DON, and corporate nurse were made aware of the serious concerns regarding Resident # 11 and the lack of supervision/safety interventions. The DON was asked if the resident had been regularly seen by psych and if the she was aware of the above findings. The DON stated that the resident had been regularly seen by psych services. The DON stated that the resident's behaviors have been "so bizarre" and that "medically, we (staff) saw that before...definitely needs to be evaluated." The DON was asked if she was aware of the above findings regarding Resident # 11. The DON stated, "Not all of this, recently have been told that she was getting better..." On 08/20/14 at 12:10 p.m., the DON and RN (Registered Nurse) # 8, also known as the hospice nurse were interviewed with the survey team. RN # 8 stated that she had been Resident # 11's nurse since "around March." RN # 8 stated that last month the resident became very agitated and July had recurrent falls. RN # 8 stated that the resident "peed in the nurse's station" and scheduled ativan was ordered for history of alcoholism and that the geri-chair came last month per the unit manager's request because of comfort. The RN stated she comes two times per week and had witnessed some behaviors and that she wasn't sure if the resident needed a psych consult. The RN was asked about other interventions for Resident # 11. The RN stated that the Ativan was given for the agitation, not following commands, pulling down her "pull-up" (brief)... RN # 8 stated, "She would be very agitated so she get ativan (sic)." No further information or documentation was provided prior to the exit conference on 08/20/14 to evidence appropriate supervision was provided for Resident # 11 to prevent injuries.