Every finding on record at Ridgecrest Manor Nursing & Rehabilitation

Based on observation and staff interview, the facility staff failed to prepare, distribute, and serve food in a manner that would prevent foodborne illnesses. The sanitizing cycle of the dishwashing machine was not working. The findings included: The sanitizing cycle of the dishwashing machine in the facility kitchen was not working. The test strips did not detect any sanitizing solution. On 02/20/24 at approximately 11:00 a.m., during the initial observation of the facility kitchen Dietary Employee #1 attempted to check the sanitizing solution of the dishwashing machine. Dietary Employee #1 used three different test strips to check the sanitizing solution. None of these test strips changed color. The sanitizing solution bucket was observed to be approximately 2/3 full of solution and the surveyor observed the system that pulled the sanitizer solution into the machine turning. Dietary Employee #1 stated they would call maintenance and would wash dishes by hand. 02/20/24 at 12:15 p.m., the Maintenance Director stated they had checked the dishwashing machine, the sanitizer line in the kitchen was leaking air and it had been replaced. 02/20/24 at 4:30 p.m., during a second observation of the kitchen Dietary Employee #1 stated maintenance had replaced the sanitizing solution line. Dietary Employee tested the solution with a test strip with no further problems being identified. On 02/20/24 at approximately 4:45 p.m., during an end of the day meeting with the Administrator and Director of Nursing the issue with the sanitizing solution was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents receive treatment and care in accordance with the comprehensive person-centered care plan and provider orders for 2 of 21 residents in the survey sample, Residents #34 and #56. The findings included: 1. For Resident #34, the facility staff failed to administer Hydroxychloroquine Sulfate (an oral medication prescribed to treat rheumatoid arthritis) as ordered by the provider on six (6) separate occasions. Resident #34's diagnosis list indicated diagnoses, which included, but not limited to Chronic Kidney Disease Stage 5, Rheumatoid Arthritis, Type 2 Diabetes Mellitus, and Essential Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 12/06/23 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. Resident #34's comprehensive person-centered care plan included a focus area stating the resident was at risk for pain and has RA (rheumatoid arthritis) with an intervention for medications as ordered and monitor for any side effects. Resident #34's current physician's orders included an order for Hydroxychloroquine Sulfate 100 mg by mouth two times a day. According to the resident's February 2024 Medication Administration Record (MAR) and nursing progress notes, Resident #34 did not receive the Hydroxychloroquine Sulfate at the following scheduled administration times: 2/02/24 8:00 AM Licensed Practical Nurse (LPN) #3 documented reason as awaiting arrival from the pharmacy 2/09/24 8:00 AM LPN #1 documented reason as held per nurse practitioner 2/11/24 8:00 AM LPN #1 documented reason as held per nurse practitioner 2/14/24 8:00 AM LPN #1 documented reason as held per nurse practitioner 2/16/24 8:00 AM LPN #5 documented reason as awaiting arrival from the pharmacy 2/19/24 8:00 AM LPN #1 documented reason as held per nurse practitioner On 2/21/24 at 10:39 AM, surveyor spoke with LPN #1 who stated there was a pharmacy issue with the Hydroxychloroquine Sulfate, insurance denied it and the facility had to pay for the medication and it came this past week. On 2/21/24 at 11:04 AM, surveyor spoke with a pharmacy staff member who stated the pharmacy sent a supply of Hydroxychloroquine Sulfate 60 tablets for Resident #34 on 12/15/23, 10 tablets on 2/02/24, and 60 tablets on 2/19/24. On 2/21/24 at 4:34 PM, surveyor spoke with LPN #3 who stated they did not remember if the medication was unavailable at any time and further stated sometimes there are extra medication supplies in the bottom drawer of the medication cart and nurses do not check and just re-order the medications. LPN #3 checked the medication cart in the presence of the surveyor and could only locate one card of Hydroxychloroquine Sulfate with 28 remaining tablets for Resident #34. The label on the card was dated 2/19/24 with a quantity of 60, however, LPN #3 was unable to locate the other card containing 30 tablets of the Hydroxychloroquine Sulfate. On 2/21/24 at 4:38 PM, the survey team met with the Administrator, Director of Nursing (DON), Assistant Director of Nursing and discussed the concerns with Resident #34's prescribed Hydroxychloroquine Sulfate. On 2/22/24 at 9:05 AM, the DON provided a pharmacy delivery receipt indicating the facility also received a delivery of 60 tablets of Hydroxychloroquine Sulfate on 1/10/24 and stated there was an overstock of the medication at one time. On 2/22/24 at 9:11 AM, the DON stated there was an overstock of the Hydroxychloroquine Sulfate for Resident #34 in the facility and the medication was present and available at the times when it was not administered. The DON stated when the medication was not administered it was because the nurses could not find the tablets in the medication cart, but they were there. The DON further stated that the nurse practitioner held the doses when the nurses could not locate the medication until it arrived from the pharmacy. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/22/24. 2. For Resident #56, the facility staff failed to administer Coal Tar Extract Lotion as ordered by the provider. Resident #56's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Generalized Osteoarthritis, and Severe Protein-Calorie Malnutrition. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/26/24 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. Resident #56's comprehensive person-centered care plan included a focus area stating (Resident #56) has Psoriasis on back with an intervention stating, Treatment as ordered. According to Resident #56's clinical record, the resident was seen by the nurse practitioner (NP) on 2/14/24. The progress note read in part .(He/she) is seen today per nurse request for evaluation of 'rash'. Dermatitis to back has been present long-term however appears to be spreading, today on examination (he/she) appears to have scaly, patchy appearance similar to psoriasis .start coal tar to back/site daily x 14 days . An order for Coal Tar Extract Lotion 1% apply to back topically one time a day for rash for 14 days was provided on 2/14/24 to start on 2/15/24. According to Resident #56's February 2024 Medication Administration Record (MAR), the Coal Tar was not administered on 2/15/24, 2/19/24, or 2/20/24, on each date, Licensed Practical Nurse (LPN) #1 documented the reason for not administering the medication as held per NP. The Coal Tar was initialed on the MAR by LPN #3 as being administered on 2/16/24 through 2/18/24. On 2/21/24 at 10:40 AM, surveyor spoke with LPN #1 who stated the facility could not get the Coal Tar 1% over the counter, but the pharmacy could get Coal Tar 2% and the order was changed yesterday. LPN #1 stated the medication was not at the facility prior to the order being changed yesterday and was not sure if the medication had been delivered since the reorder. On 2/21/24 at 11:06 AM, surveyor spoke with a pharmacy staff member who stated the Coal Tar 1% was not filled because they were unable to get the medication and now the order had been discontinued. On 2/21/24 at 1:42 PM, surveyor spoke with the Director of Nursing (DON) who stated the pharmacy did not have Coal Tar 1% and Resident #56 had not received any and Coal Tar 2% had been ordered. On 2/21/24 at 2:28 PM, surveyor spoke with LPN #3 who stated they did not actually apply Coal Tar on 2/16/24, 2/17/24 and 2/18/24 but applied A&D ointment and thought it was the same as Coal Tar. On 2/21/24 at 2:38 PM, with the assistance of LPN #3, surveyor observed Resident #56's upper left to mid back, extensive redness with no open areas visualized. On 2/21/24 at 2:44 PM, surveyor spoke with the NP who stated Resident #56's rash was on-going, and the Coal Tar 1% was not available from the pharmacy, and they changed the order to 2% yesterday. The NP stated yesterday was the first-time staff had talked with them about changing the order but also stated they share coverage with another NP. On 2/21/24 at 4:38 PM, the survey team met with the Administrator, DON, and Assistant DON, and discussed the concern of Resident #56 not receiving treatment as ordered to their back since 2/15/24 and LPN #3 signing the MAR for the administration of Coal Tar 1% in error on 2/16/24 through 2/18/24. According to Resident #56's clinical record, the resident received the first administration of Coal Tar to their back on 2/21/24 at 10:15 PM. On 2/22/24 at 9:10 AM, surveyor spoke with the DON who stated they had no additional information regarding Resident #56's Coal Tar. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/22/24.

Based on resident interview, staff interview, clinical record review and facility document review the facility staff failed to assess a resident's ability to safely smoke for 1 of 21 residents, Resident #64. Facility staff failed to complete a smoking assessment for Resident #64 when resident began smoking after admission. The findings included: For Resident #64 the facility staff failed to complete a safe smoking assessment once the resident began smoking. During entrance conference, surveyor was provided with a list of residents that smoke. Resident #64's name was on this list. Resident #64's face sheet listed diagnoses which included but not limited to bipolar disorder, severe, with psychotic features, chronic obstructive pulmonary disease, and generalized anxiety disorder. Resident #64's most recent minimum data set with an assessment reference date of 12/12/23 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #64's comprehensive care plan was reviewed and contained a care plan for at risk for injury due to smoking-Date initiated 01/01/2024. Interventions for this care plan included Will be assessed for smoking safety. Resident #64's clinical record was reviewed and contained a Safe Smoking Assessment form dated 11/06/23 which read in part, 1. A. Type of Assessment: Admission. 2. History. 1. Does the Resident Currently Smoke, Use Vape/e-Cig, Use Chewing Tobacco, Use Snuff, or any Other 'Smoking' Device. B. No. 1 A. Resident's Intentions Related to 'Smoking.' A. Intends to remain non-smoking. 5. Summary of Evaluation.1K. Resident non-smoker or intends not to smoke. Resident #64's clinical record contained nurse's notes which read in part, 11/07/2023 Chief Complaint/Nature of Presenting Problem: s/p (status post) hospital stay for pancreatitis. History of Present Illness: . admitted to the facility for skilled services. PMH (past medical history) includes but is not limited to Anxiety disorder, Bipolar 1 disorder, CHF (congestive heart failure), .tobacco use. Social History: reports she has been smoking cigarettes. She has been smoking an average of .5 packs per day ., 11/07/2023 09:00 Note Text: Resident confused and refused medications thus far this shift. Resident refused to let staff obtain vital signs. Risks explained to resident. Resident would not engage in conversation about medications and only asked about smoking. NP (nurse practitioner) made aware., and 11/14/2023 10:51 Note Text: Resident sitting up in wheelchair in dayroom. Requests to go smoke at next smoke break . Surveyor spoke with the family nurse practitioner on 02/21/24 at 3:10 PM. Surveyor asked nurse practitioner if Resident #64 is a smoker, and nurse practitioner stated they are. Surveyor spoke with licensed practical nurse (LPN) #3 on 02/21/24 at 3:40 PM. Surveyor asked LPN #3 if they had completed the initial smoking assessment for Resident #64, and LPN #3 stated they had. Surveyor asked LPN #3 why they had coded the resident as a non-smoker, and LPN #3 stated, She didn't smoke when she first came in, but then decided to. Surveyor asked LPN #3 if a safe smoking assessment should have been completed when the resident decided to smoke, and LPN #3 stated, Honestly, it should have. and Activities usually does those, or therapy. Surveyor asked LPN #3 how long after being admitted did Resident #3 start smoking, and LPN #3 stated, Maybe a week or so before she started back smoking. Surveyor spoke with the activities director on 02/21/24 at 3:50 PM. Surveyor asked activities director if they do the smoking assessments for residents, and activities director stated, I do the contract, not the assessments. Surveyor asked activities director if they look at the smoking assessments prior to having a resident sign the smoking contract, and activities director stated, I'm sure I wouldn't have had her sign a contract without a safe assessment. She's been here over a year now. Activities director provided the surveyor with a copy of the resident's Resident Smoking Contract dated 12/11/23 and signed by the resident and activities director. Surveyor spoke with the administrator on 02/21/24 at 4:10 PM regarding Resident #64. Administrator stated that the facility had resident sign the smoking contract, and they are care planned for smoking. Administrator stated, per facility policy, resident is not due for an updated smoking assessment. Administrator provided surveyor with a copy of a facility policy entitled Resident Smoking Policy which read in part, Procedure: During the admission process, nursing will ask residents if they smoke or have a desire/intent to smoke while in the facility. Anyone answering yes is further assessed for smoking safety awareness and the need for reasonable physical or safety accommodations. The assessment is completed thereafter on readmission, quarterly, and with any significant change in the resident's condition. Surveyor spoke with Resident #64 on 02/22/24 at 9:25 am. Surveyor asked resident how long they have been smoking at the facility, and resident stated they have smoked since admission. Surveyor asked resident if there was ever a time they did not smoke or considered not smoking, and resident stated, No, I'm going to smoke. Surveyor spoke with LPN #5 on 02/22/24 at 12:25 PM regarding Resident #64's care plan for smoking. Surveyor asked LPN #5 if resident should have been care planned for smoking upon admission, and LPN #5 stated, She wasn't smoking when she first came, because they wouldn't let her. When I found out she was smoking, I done a care plan for it. Surveyor spoke with the director of nursing (DON) on 02/02/22/24 at 12:30 PM regarding Resident #64. DON stated that resident was not smoking when they were admitted but started smoking after admission. The concern of not completing a safe smoking assessment for Resident #64 was discussed during a meeting with the administrator, DON, assistant DON, and regional director of clinical services on 02/22/24 at 12:45 PM. Facility staff stated that facility policy indicated that smoking assessments are only required upon admission, quarterly and with significant change. The policy does not address residents who choose to start smoking after being admitted and outside of these assessment times. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide respiratory care consistent with the comprehensive person-centered care plan and the provider orders for 1 of 21 residents in the survey sample, Resident #34. The findings included: For Resident #34, the facility staff failed to administer supplemental oxygen as ordered by the physician. Resident #34's diagnosis list indicated diagnoses, which included, but not limited to Chronic Kidney Disease Stage 5, Rheumatoid Arthritis, Type 2 Diabetes Mellitus, and Essential Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 12/06/23 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. Resident #34 was coded as receiving oxygen therapy. Resident #34's comprehensive person-centered care plan included a focus area stating in part .O 2 (oxygen) therapy as ordered with an intervention stating O2 as ordered. On 2/21/24 at 8:58 AM and 2/21/24 at 3:59 PM, surveyor observed Resident #34 in bed receiving oxygen via nasal cannula at the delivery rate of 4 liters per minute (l/m) per the oxygen concentrator setting. The oxygen concentrator was located on the opposite side of the resident's privacy curtain at each observation. Resident #34's current physician's orders included an order dated 1/02/24 for oxygen at 3 l/m via nasal cannula. Surveyor requested and received the facility policy titled Oxygen Administration (all routes) Policy with a revision date of 12/18/23 which read in part Licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by a provider . On 2/21/24 at 4:38 PM, the survey team met with the Administrator, Director of Nursing, and the Assistant Director of Nursing and discussed the concern of Resident #34 receiving oxygen at the rate of 4 l/m instead of the ordered rate of 3 l/m. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/22/24.

Based on observations, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate of less than 5%. There were two (2) medication errors in 29 opportunities for a medication error rate of 6.9%. These medication errors affected Resident #12 and/or Resident #57. The findings included: For Resident #12, the facility staff failed to administer Calcium-Vit D-Min Oral Tablet 600-400 mg-unit; this was documented on Resident #12 medication administration record (MAR) to be provided one time a day. On 2/21/24 at 8:18 a.m., Licensed Practical Nurse (LPN) #4 was observed to provide Calcium 500 mg-Vitamin D 5 mcg. On 2/21/24 at 9:58 a.m., LPN #4 confirmed they had provided Resident #12 the Calcium 500 mg tablet. On 2/21/24 at 10:22 a.m., LPN #4 stated they did not have the Calcium 600/Vit D 400 tablet in the medication cart during Resident #12's aforementioned medication administration observation. For Resident #57, the facility staff failed to administer Senna S (sennosides 8.6 mg and docusate 50 mg) as ordered by the medical provider. Resident #57's medication administration record (MAR) indicated Senna S was to be provided, one (1) tablet, twice a day. On 2/21/24 at 8:58 a.m., LPN #3 was observed to provide Resident #57 a medication that only contained sennosides 8.6 mg; the docusate component of the order was not administered. On 2/21/24 at 9:35 a.m., the surveyor shared this observation with the facility's Director of Nursing (DON). The following information was found in a facility pharmacy services policy titled 6.0 General Dose Preparation and Medication Administration (with the most recent revision date of 1/1/22): Prior to administration of medication, Facility [sic] staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: . Facility staff should: - Verify each time a medication is administered that it is the correct medication, at the correct dose . - Confirm the MAR reflects the most recent medication order . The survey team met with the facility's Administrator, DON, and Assistant DON on 2/21/24 at 4:43 p.m. During this meeting, the surveyor discussed the aforementioned medication administration observations which had resulted in a medication error rate of 6.9%.

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to maintain complete and/or accurate clinical record for three (3) of 21 sampled residents (Resident #66, Resident #101, and Resident #154). The findings included: 1. Resident #101's clinical record failed to include documentation of the change in the resident's condition which resulted in an increase in the resident's pain medication dosage. Resident #101's clinical record failed to include documentation of the medical provider notification which had resulted in the medical provider increasing the resident's pain medication dosage. Resident #101's medication orders indicated: - On 11/24/23 at 7:53 p.m., the resident's pain medication Morphine was increased from 0.5 ml every four (4) hours as needed to 1.0 ml scheduled to be provided every four (4) hours. No documentation in Resident #101's clinical record provided information as to the change in the resident's condition which resulted in this change in the medication order. - On 11/25/23 at 10:46 a.m., the resident's pain medication Morphine was increased from 1.0 ml scheduled to be provided every four (4) hours to 1.0 ml scheduled to be provided every (2) two hours. No documentation in Resident #101's clinical record provided information as to the change in the resident's condition which resulted in this change in the medication order. On 2/22/24 at 8:40 AM, the surveyor asked the facility's Director of Nursing (DON) for Resident #101's documentation related to the resident's condition change which resulted in the aforementioned changes in the resident's pain medication orders. On 2/22/24 at 9:29 a.m., the facility's Director of Nursing (DON) provided the surveyor with a note that had been obtained from Resident #101's hospice provider. This note was dated 11/24/23 but did not include a time. This note was documented as being printed on 2/22/24 at 8:53 a.m. This note indicated facility staff members communicated, that the resident was requesting an increase in their pain medication, to the hospice provider staff. This note did not detail the resident's assessment/condition related to the request for, and the subsequent decision to, increase Resident #101's pain medication. On 2/22/24 at 11:54 a.m., the Nurse Practitioner (NP), who increased Resident #101's morphine from 1.0 ml every four (4) hours to 1.0 ml every two (2), stated they could have entered the order from home. The NP reported they did not see Resident #101. The following information was found in a facility document titled Resident Change in Condition Policy (with a last revised date of 2/9/24): - The Resident/Physician or Provider/Family/Responsible Party [sic] will be notified when there has been: . A need to alter the resident's medical treatment, including a change in provider orders . - The nurse will record the information related to the change in condition and subsequent events and notifications in the resident's health record. On 2/22/24 at 9:43 a.m., the surveyor met with the facility's Administrator, DON, and Regional Vice-President of Clinical Services (RVCS). The lack of facility documentation related to Resident #101's condition/assessment which resulted in the need to increase the pain medication was discussed. The lack of documentation of the medical provider communication which resulted in the aforementioned changes in Resident #101's medications was discussed. On 2/22/24 at 12:49 p.m., the survey team met with the facility's Administrator, DON, Assistant DON, and RVCS. The surveyor discussed the absence of documentation related to Resident #101's condition/assessment when pain medications were increased. The surveyor discussed the absence of documentation detailing the facility staff contacting Resident #101's medical providers to obtain the orders to address Resident #101's pain medication needs. 2. The facility staff failed to ensure that Resident #154's Durable Do Not Resuscitate Order (DDNR) form was complete and/or accurate. The DDNR form has a section where the individual completing the form certifies that the resident is either capable or incapable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment. This section was not answered by the individual completing Resident #154's DDNR Order form. The DDNR form has a section that is to be completed when the resident is determined to be incapable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment . This section identifies by whom and/or under what authority the DDNR was issued for a resident who had been determined incapable in the aforementioned section. This section was answered for Resident #154 even though the previous section has been left unanswered. This DDNR was not signed by Resident #154; it was signed by a family member. On 2/21/24 at 8:14 a.m., the facility's Administrator provided the survey team with a copy of a document titled Authorized Durable Do Not Resuscitate Order Form & Instructions. This form was not dated. This form did not identify its source. The Administrator reported that this document does not specifically address requiring the aforementioned sections of the form to be marked. On 2/21/24 at 4:43 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), and Assistant DON. During this meeting, Resident #154's DDNR order form not being complete was discussed. 3. The facility staff failed to ensure that Resident #66's Durable Do Not Resuscitate Order (DDNR) form was complete and/or accurate. The DDNR form has a section where the individual completing the form certifies that the resident is either capable or incapable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment. This section was not answered by the individual completing Resident #66's DDNR Order form. The DDNR form has a section that is to be completed when the resident is determined to be incapable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment . This section identifies by whom and/or under what authority the DDNR was issued for a resident who had been determined incapable in the aforementioned section. This section was not answered for Resident #66. Resident #66 did not sign the DDNR form; the DDNR form was signed by Resident #66's offspring. On 2/12/24 at 8:14 a.m., the facility's Administrator provided the survey team with a copy of a document titled Authorized Durable Do Not Resuscitate Order Form & Instructions. This form was not dated. This form did not identify its source. The Administrator reported that this document does not specifically address requiring the aforementioned sections of the form to be marked. On 2/21/24 at 4:43 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), and Assistant DON. During this meeting, Resident #66's DDNR order form not being complete was discussed.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow established infection control guidelines to decrease the potential of and/or risk for infection transmission for 1 of 21 current residents, Resident #96. The findings included: During a surgical wound care observation, the facility staff failed to complete hand hygiene and was observed to touch dressing supplies used to clean the wound with their bare hands. Resident #96's diagnoses included, but were not limited to, fractures, attention deficit hyperactivity disorder, anxiety disorder, and bipolar disorder. Section C (cognitive patterns) of Resident #96's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/04/24 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Resident #96's comprehensive care plan included the focus areas, traumatic subluxation of peroneal tendon of left foot. Resident 96's clinical record included a provider order to change dressing to left lower extremity everyday, cleanse with betadine, apply xeroform, cover with ABD pad, and wrap gently with kerlix. 02/20/24 at 3:20 p.m., the surveyor observed Licensed Practical Nurse (LPN) #1 and LPN #2 complete Resident #96's surgical wound treatment. LPN #2 prepared the supplies that included xeroform, ABD pads, kerlix, 4X4 dressings (gauze), dermal wound wash, and betadine. LPN #2 was observed to touch the 4X4's with their bare hands and placed the 4X4's in two clear cups. LPN #2 was observed to add betadine to one cup and dermal wound wash to the other. LPN #2 took the items to the bedside. The surveyor requested LPN #2 to step outside the room and asked LPN #2 if they had touched the 4X4 gauze with their bare hand. LPN #2 verbalized they had, discarded the items, put gloves on and obtained new 4X4 gauze, put part of the 4X4 gauze in one cup and part in a second cup, applied dermal wound cleanser to one cup of the gauze and betadine to the other. LPN #1 was observed by the surveyor to clean the surgical wound on left foot with dermal cleaner, apply betadine, xeroform, ABD pads, and kerlix. LPN #1 was not observed to change their gloves or perform any hand hygiene after cleansing the wound, applying betadine, or before applying any dressing(s). 02/21/24 at 9:20 a.m., LPN #1 was asked if they completed any hand hygiene after touching the wound. LPN #1 stated they had washed their hands prior to beginning the wound care, had dabbed at the surgical wound with the wound cleanser but did not complete any hand hygiene after starting the treatment. 02/21/24 at 8:50 a.m., during an interview with the infection control nurse, this nurse stated the nurse should have completed hand hygiene during wound care. When asked about touching the 4X4's with their bare hands this staff stated it would depend on if the 4X4's came out of a sterile packet. On 02/21/24 at 9:25 a.m., the Director of Nursing (DON) was made aware of the issue with wound care and the policy regarding wound care was requested. On 02/21/24 at 12:50 p.m., the Administrator provided the survey team with a copy of a policy titled, Hand Hygiene/Handwashing Policy. This policy read in part, .Perform hand hygiene .before and after having direct contact with residents, after removing gloves .After contact with body fluids or excretions .non-intact skin and/or wound dressings, If moving from a contaminated body site to a clean body site during resident care . 02/21/24 at 4:38 p.m., during an end of the day meeting with the Administrator, DON, and Assistant Director of Nursing (ADON) the issues with the wound care observation were reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation and staff interview the facility staff failed to ensure the daily staff posting contained the required information. The findings included: On 02/21/24 surveyor observed the daily staff posting located in the lobby of the facility. The daily staff posting for dates prior to 02/21/24 did not contain the actual hours worked for any licensed staff for either shift. Surveyor spoke with the director of nursing and administrator on 02/21/24 regarding the missing information on the staff posting, and administrator stated they would fix it, but did not offer an explanation as to the reason it was not included on the forms. The concern of not including actual staff hours worked on the daily staff posting was discussed with the administrator, director of nursing, assistant director of nursing and regional director of clinical services on 02/22/24 at 12:45 PM. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide written bed hold policy information to the resident or resident representative prior to transfer for 1 of 4 closed record reviews, Resident #86. For Resident #86, the facility failed to provide the resident written bed hold policy information prior to transfer to an acute care hospital. The findings included: Resident #86's clinical record included the medical diagnoses, diabetes, dependence on respirator, neuromuscular dysfunction of bladder, chronic [CONDITION(S)] with [CONDITION(S)], and [CONDITION(S)]. Section C (cognitive patterns) of Resident #86's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 06/24/22 was coded 1/1/3 to indicate the resident had problems with long and short term memory and was severely impaired in cognitive skills for daily decision making. The residents clinical record included an interact form dated 06/29/22 indicating the resident was transferred to a local hospital. On 07/11/22 the Social Worker, documented Resident #86 had been admitted to the hospital. During the record review, the surveyor was unable to find any documentation that referenced a bed hold. 09/29/22 11:25 a.m., the Administrator stated they were unable to find a bed hold for this resident and provided the surveyor with a copy of their policy titled, Bed Hold Letter Policy. This policy read in part, It is the policy of the facility to track Medicaid bed hold days and notify appropriate parties via Medicaid Bed Hold Letter. The Administrator stated they were aware of the issue regarding offering bed holds and were currently completing audits. Resident #86's primary payer was documented as Medicaid VA CCC Plus Vent. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and facility document review it was determined the facility staff failed to prevent an accident hazard by ensuring that a bag of medications had been properly secured on 1 of 3 units in the facility. The scope and severity was originally cited at Immediate Jeopardy, Level IV Isolated and was reduced to a Level II Isolated after the facility was cleared of Immediate Jeopardy. The administrator and regional vice president of operations were notified on 7/16/19 that the extended survey process had begun at 9:02 am, as the survey team had identified Immediate Jeopardy & Substandard Quality of Care in the area of Quality of Care. The findings included: The facility staff failed to ensure that a bag of medications had been properly secured on a dementia unit within the facility. The opened bag of medications was left on the floor in the nurse's station that was open and accessible to the wandering residents on the Carter's Fold secured dementia unit, which created an accident hazard with the potential for a serious adverse outcome. On 7/16/19 at 8:30 am, the surveyor entered the nurse's station on the Carter's Fold secured dementia unit. The surveyor observed that the nurse's station on the unit is open and accessible to anyone on the unit. The surveyor observed Resident # 86 wheel into the nurse's station with her wheelchair and then wheeled back out near the dining room table. The surveyor looked down onto the floor and observed a large plastic bag that was full of medications on the floor of the open and accessible nurse's station. The surveyor observed a total of five residents in the area of the nurse's station at that time. The surveyor did not observe any staff supervision. The surveyor summoned another team member to report observations. On 7/16/19 at 8:38 am, three surveyors observed the large plastic bag full of medications on the floor of the open and accessible nurse's station on Carter's Fold secured dementia unit. The surveyor looked into the bag and observed that the following medications were in the bag: potassium, [MEDICATION NAME], [MEDICATION NAME], gas-x, [MEDICATION NAME], myrbetriq, [MEDICATION NAME], [MEDICATION NAME], anoro inhaler, insulin, and [MEDICATION NAME] eye drops. While the surveyors were observing the medications in the bag, one CNA entered the nurse's station to review the bath list that was posted on the wall at the nurse's station. The CNA looked at the list and exited the area without acknowledging the bag of medications. At that time, the surveyors observed five residents in the area of the open and accessible nurse's station without staff supervision. On 7/16/19 at 8:45 am, one surveyor remained on the unit with the medications to ensure that no resident handled the bag of medications, and the remaining surveyors conducted a team meeting to discuss the findings as stated above. While the team meeting was in progress a surveyor observed one resident in a wheelchair enter the open and accessible nurse's station where the bag of drugs were located. A surveyor also observed two staff members open the drawer directly above where the bag of medications was located to get the bathroom key and neither of the staff members acknowledged the bag of medications. On 7/16/19 at 9:02 am, the administrator, administrator in training, director of nursing, and regional director of clinical services were made aware of the findings as stated above and that a Level IV Immediate Jeopardy deficiency had been cited. On 7/16/19 at 9:13 am, the administrator, administrator in training, director of nursing, and regional director of clinical services went onto the Carter's Fold secured dementia unit along with the surveyor and observed the bag of medications on the floor of the open and accessible nurse's station. The regional director of clinical services removed the bag of medications and searched the nurse's station to ensure that there were no other medications or hazards that had been left unsecured. On 7/16/19 at 1:30 pm, the facility staff presented the survey team with the facility Immediate Jeopardy Removal Plan. The immediate jeopardy removal plan was documented as follows, Identify those recipients who have suffered or likely to suffer as a result of the noncompliance: Residents on the Carter's Fold (secured unit) could be affected by this noncompliance practice of securing medications. There were not any residents identified to be affected. On 7/16/19, the unsecured medications were immediately removed from the Carter's Fold nurse's station. A door was installed at the nurse's station with a slide lock to prevent wandering residents from entering the nurse's station. The nurse's station was immediately assessed for potential hazards for wandering residents. Residents likely to suffer a serious adverse outcome as a result of the noncompliance. All residents have the potential to be affected by this noncompliance practice. On 7/16/19, the facility staff immediately conducted observation rounds in all resident rooms and nurse's stations to ensure all medications are appropriately stored and secured so that residents remained free of accidents. No additional medications were found or identified to be unsecured in any areas. The action the entity will take to alter the process/system failure to prevent an adverse outcome from occurring or reoccurring: To prevent this from reoccurring, the facility Director of Nursing and designee immediately began to provide education for all staff regarding securing medications, and potential hazards for wandering residents. All staff will be educated prior to starting their next assignment when they return. These staff members will not be permitted to work until education is received. This education will be included in all new hire training and on boarding. On 7/16/19, the Regional Director of Clinical Services provided education to the Director of Nursing and Nursing Home Administrator on securing medication, medication storage, as well as potential accidents and hazards for secured unit. DON (director of nursing) or designee will complete observation rounds daily to ensure medications remain secure for four weeks. Results of rounds will be brought to monthly Quality Assurance and Performance Improvement (QAPI) meetings for review and revision as necessary. Person responsible: NHA (nursing home administrator) (Administrator's name withheld) Action Complete Date July 16, 2019 On 7/16/19 at 6:34 pm, the surveyor interviewed LPN # 2 (licensed practical nurse). The surveyor asked LPN # 2 if she had worked the night shift on Carter's Fold on 7/15/19. LPN # 2 stated, Yes. The surveyor asked LPN # 2 if she had seen the bag of medications that had been left unsecured in the nurse's station on Carter's Fold. LPN # 2 stated, Me and another nurse bagged them up to send them back to the pharmacy. The surveyor asked LPN # 2 if she locked the bag of medications up before she left the facility. LPN # 2 stated, No. The surveyor asked LPN # 2 if there was somewhere to lock the medications up until they are picked up from the pharmacy. LPN # 2 stated, Yes there's an area to lock them up. The facility policy on Storage and Expiration of Medications, Biologicals, Syringes, and Needles contained documentation that included but was not limited to, .Procedure 3.3 Facility staff should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 17. Facility staff should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis. On 7/16/19 at 7:00 pm, the administrator in training presented the survey team with evidence that the corrective action as listed in the plan of correction had been completed. On 7/16/19 at 7:02 pm, the regional vice president of operations, the administrator, the administrator in training, the director of nursing, and the regional director of clinical services were made aware that the Level IV Isolated Immediate Jeopardy citation had been reduced to a Level II Isolated deficiency. On 7/17/19 at 6:00 pm, the director of nursing provided the surveyor with 2 statements that had been signed by the director of nursing. The first statement was documented as, Statement for LPN # 3. LPN # 3 states that medications were bagged to be sent back to pharmacy. She states she intended to take medications and was called away, and failed to remove them. The second statement was documented as, Statement obtained from LPN # 2. LPN # 2 states that medications had been secured in med room until she removed the bag with the intention of putting them in Clinch Hall med room to be picked up by pharmacy. LPN # 3 states she sat the medication down, and accidentally walked away, leaving the medication at the desk. No further information regarding this issue was presented to the survey team prior to the exit conference on 7/18/19.medications.

Based on observation, clinical record review, staff interview, and facility document review, the facility staff failed to appropriately store medications on 1 of 3 units and failed to label a medication for 1 of 34 residents, Resident # 20. The findings included: 1. The facility staff failed to ensure that a bag of medications had been properly stored on a dementia unit within the facility. The opened bag of medications was left on the floor in the nurse's station that was open and accessible to the wandering residents on the Carter's Fold secured dementia unit, which created the potential for a serious adverse outcome. The scope and severity was originally cited at Immediate Jeopardy, Level IV Isolated and was reduced to a Level II Isolated after the facility was cleared of Immediate Jeopardy. The administrator and regional vice president of operations were notified on 7/16/19 that the extended survey process had begun at 9:02 am, as the survey team had identified Immediate Jeopardy & Substandard Quality of Care in the area of Quality of Care. On 7/16/19 at 8:30 am, the surveyor entered the nurse's station on the Carter's Fold secured dementia unit. The surveyor observed that the nurse's station on the unit is open and accessible to anyone on the unit. The surveyor observed Resident # 86 wheel into the nurse's station with her wheelchair and then wheeled back out near the dining room table. The surveyor looked down onto the floor and observed a large plastic bag that was full of medications on the floor of the open and accessible nurse's station. The surveyor observed a total of five residents in the area of the nurse's station at that time. The surveyor did not observe any staff supervision. The surveyor summoned another team member to report observations. On 7/16/19 at 8:38 am, three surveyors observed the large plastic bag full of medications on the floor of the open and accessible nurse's station on Carter's Fold secured dementia unit. A total of five residents were observed in the area of the open and accessible nurse's station with no staff supervision. The surveyor looked into the bag and observed that the following medications were in the bag: potassium, [MEDICATION NAME], [MEDICATION NAME], gas-x, [MEDICATION NAME], myrbetriq, [MEDICATION NAME], [MEDICATION NAME], anoro inhaler, insulin, and [MEDICATION NAME] eye drops. While the surveyors were observing the medications in the bag, one CNA entered the nurse's station to review the bath list that was posted on the wall at the nurse's station. The CNA looked at the list and exited the area without acknowledging the bag of medications. At that time, the surveyors observed five residents in the area of the open and accessible nurse's station without staff supervision. On 7/16/19 at 8:45 am, three surveyors observed two CNA staff members leave the unit. The surveyors observed five residents in the area of the open and accessible nurse's station without staff supervision. One surveyor remained on the unit with the medications to ensure that no resident handled the bag of medications, and the remaining surveyors conducted a team meeting to discuss the findings as stated above. While the team meeting was in progress a surveyor observed one resident in a wheelchair enter the open and accessible nurse's station where the bag of drugs were located. A surveyor also observed two staff members open the drawer directly above where the bag of medications was located to get the bathroom key and neither of the staff members acknowledged the bag of medications. On 7/16/19 at 9:02 am, the administrator, administrator in training, director of nursing, and regional director of clinical services were made aware of the findings as stated above and that a Level IV Immediate Jeopardy deficiency had been cited. On 7/16/19 at 9:13 am, the administrator, administrator in training, director of nursing, and regional director of clinical services went onto the Carter's Fold secured dementia unit along with the surveyor and observed the bag of medications on the floor of the open and accessible nurse's station. The regional director of clinical services removed the bag of medications and searched the nurse's station to ensure that there were no other medications or hazards that had been left unsecured. On 7/16/19 at, the facility staff presented the survey team with the facility Immediate Jeopardy Removal Plan. The immediate jeopardy removal plan was documented as follows, Identify those recipients who have suffered or likely to suffer as a result of the noncompliance: Residents on the Carter's Fold (secured unit) could be affected by this noncompliance practice of securing medications. There were not any residents identified to be affected. On 7/16/19, the unsecured medications were immediately removed from the Carter's Fold nurse's station. A door was installed at the nurse's station with a slide lock to prevent wandering residents from entering the nurse's station. The nurse's station was immediately assessed for potential hazards for wandering residents. Residents likely to suffer a serious adverse outcome as a result of the noncompliance All residents have the potential to be affected by this noncompliance practice. On 7/16/19, the facility staff immediately conducted observation rounds in all resident rooms and nurse's stations to ensure all medications are appropriately stored and secured so that residents remained free of accidents. No additional medications were found or identified to be unsecured in any areas. The action the entity will take to alter the process/system failure to prevent an adverse outcome from occurring or reoccurring: To prevent this from reoccurring, the facility Director of Nursing and designee immediately began to provide education for all staff regarding securing medications, and potential hazards for wandering residents. All staff will be educated prior to starting their next assignment when they return. These staff members will not be permitted to work until education is received. This education will be included in all new hire training and on boarding. On 7/16/19 at 1:30 pm, the Regional Director of Clinical Services provided education to the Director of Nursing and Nursing Home Administrator on securing medication, medication storage, as well as potential accidents and hazards for secured unit. DON (director of nursing) or designee will complete observation rounds daily to ensure medications remain secure for four weeks. Results of rounds will be brought to monthly Quality Assurance and Performance Improvement (QAPI) meetings for review and revision as necessary. Person responsible: NHA (nursing home administrator) (Administrator's name withheld) Action Complete Date July 16, 2019 On 7/16/19 at 6:34 am, the surveyor interviewed LPN # 2 (licensed practical nurse). The surveyor asked LPN # 2 if she had worked the night shift on Carter's Fold on 7/15/19. LPN # 2 stated, Yes. The surveyor asked LPN # 2 if she had seen the bag of medications that had been left unsecured in the nurse's station on Carter's Fold. LPN # 2 stated, Me and another nurse bagged them up to send them back to the pharmacy. The surveyor asked LPN # 2 if she locked the bag of medications up before she left the facility. LPN # 2 stated, No. The surveyor asked LPN # 2 if there was somewhere to lock the medications up until they are picked up from the pharmacy. LPN # 2 stated, Yes there's an area to lock them up. The facility policy on Storage and Expiration of Medications, Biologicals, Syringes, and Needles contained documentation that included but was not limited to, .Procedure 3.3 Facility staff should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 17. Facility staff should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis. On 7/16/19 at 7:00 pm, the administrator in training presented the survey team with evidence that the corrective action as listed in the plan of correction had been completed. On 7/16/19 at 7:02 pm, the regional vice president of operations, the administrator, the administrator in training, the director of nursing, and the regional director of clinical services were made aware that the Level IV Isolated Immediate Jeopardy citation had been reduced to a Level II Isolated deficiency. On 7/17/19 at 6:00 pm, the director of nursing provided the surveyor with 2 statements that had been signed by the director of nursing. The first statement was documented as, Statement for LPN # 3. LPN # 3 states that medications were bagged to be sent back to pharmacy. She states she intended to take medications and was called away, and failed to remove them. The second statement was documented as, Statement obtained from LPN # 2. LPN # 2 states that medications had been secured in med room until she removed the bag with the intention of putting them in Clinch Hall med room to be picked up by pharmacy. LPN # 3 states she sat the medication down, and accidentally walked away, leaving the medication at the desk. No further information regarding this issue was presented to the survey team prior to the exit conference on 7/18/19. 2. The facility staff failed to ensure a medication bottle was labeled in a manner that provided the needed instructions to correctly mix and administer the medication. On 7/12/19 at 8:48 a.m., LPN (licensed practical nurse) #11 was observed administering medications to Resident #20. Resident #20 was admitted to the facility on [DATE]. Resident #20's [DIAGNOSES REDACTED]. Resident #20's 4/22/19 quarterly minimum data set (MDS) assessment indicated the resident had adequate hearing and clear speech; the resident was also assessed as being oriented to year, month, and day. Resident #20's clinical documentation included the following medication order: Sodium [MEDICATION NAME] Suspension 15GM/60ML. Give 60 ml by mouth one time a day for [MEDICAL CONDITION]. ([MEDICAL CONDITION] is when the potassium level in one's blood is elevated.) The facility's pharmacy staff provided administration information about Sodium [MEDICATION NAME]. This information included the following: The average total daily adult dose of sodium [MEDICATION NAME] is 15 g. to 60 g. administered as a 15-g dose (four level teaspoons), one to four times daily. The following information was found in a policy titled 6.0 General Dose Preparation and Medication Administration (with an effective date of 12/1/07 and the most recent revision date of 01/01/13): Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct time, for the correct resident . Facility staff should not administer a medication if the medication or prescription label is missing or illegible. This policy was provided to the survey team by the Regional Director of Clinical Services (RDCS) on 7/18/19 at 12:50 p.m.; the RDCS reported this policy was obtained from the facility's pharmacy. On 7/16/19 at 9:49 a.m., a unit manager (Registered Nurse (RN) #11) was interviewed about the labeling of Resident #20's Sodium [MEDICATION NAME] Suspension bottle; RM #11 acknowledged a label was covering the mixing instructions On 7/17/19 at 10:45 a.m., the mxing instructions on the aforementioned medication label being covered was discussed during a survey team meeting with the facility's Director of Nursing, Administrator, Administrator-In-Training, Regional Director of Clinical Services, and Regional Vice-President of Operations. On 7/18/19 at 12:57 p.m., the RDCS was interviewed about the aforementioned medication administration. The RDCS reported that if the label placed on the bottle was covering the administration directions then the pharmacy should be called for guidance.

Based on observation and staff interview the facility staff failed to prepare, distribute and serve food in a manner that would prevent foodborne illnesses. The facility staff did not complete any hand hygiene prior to obtaining food temperatures. The findings included: The facility staff when obtaining food temperatures allowed the top of the thermometer to touch the food. The top of this thermometer is what the facility staff held while obtaining food temperatures. The facility staff did not have gloves in place, were not observed to wash their hands prior to obtaining the temperatures, and were observed touching the top of the thermometer with their bare hands. On 07/16/19 at 11:41 a.m., the surveyor entered the kitchen to obtain tray line temperatures. Tray aide #1 was working in the kitchen area and stated she would obtain the tray line temperatures. Tray aide #1 did not wash their hands or apply any gloves prior to obtaining these temperatures. Tray aide #1 picked up the thermometer with their bare hands and placed the thermometer into a pan of broccoli. Tray aide #1 did not hold onto the thermometer and allowed the top of the thermometer to lay backwards onto the broccoli which resulted in the top of the thermometer touching the broccoli. On 07/16/19 at 12:00 p.m., the administrator in training who was in the kitchen stated he would discard the broccoli. The administrator, administrator in training, director of nursing, regional director of clinical services, and the regional vice president of operations were notified of the above issue during a meeting with the survey team on 07/17/19 at 11:35 a.m. No further information regarding these issues were provided to the survey team prior to the exit conference.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure an infection control program during a medication pass and pour observation and for 4 of 34 residents (Resident 21, Resident #91, Resident #79, and Resident #20). The findings included: 1. The facility staff failed to perform hand hygiene during a medication pass and pour observation on 7/16/19 with licensed practical nurse #2. The surveyor observed a medication pass and pour observation on 7/16/19 beginning at 8:12 a.m. with licensed practical nurse #2. [MI]P.N. #2 used hand sanitizer before entering the medication cart to begin the medication pass. L.P.N. #2 prepared seven medications for Resident #21 and administered the medications. [MI]P.N. #2 returned to the medication cart. No hand washing was observed upon exiting Resident #21's room or prior to entering the medication cart. L.P.N. #2 left the medication cart, went to the medication room for two medications for Resident #21, poured the two medications, administered the two medications to Resident #21, exited the resident room, and returned to the medication cart. No hand washing or hand hygiene was observed except the initial use of hand sanitizer. L.P.N. #2 entered the medication cart and began to prepare Resident #20's medication. [MI]P.N. #2 prepared three medications for the resident. [MI]P.N. #2 locked the medication cart, entered Resident #20's room and administered the medications. While administering the medications, Resident #20 dropped one of the medications on the floor (Aspirin 81 mg (milligrams)). [MI]P.N. #2 picked the dropped medication from the floor with bare hands, returned to the medication cart, placed the dropped pill in the sharps container and headed to the medication room to retrieve a new Aspirin 81 mg from the floor stock. L.P.N. #2 did not perform hand hygiene after picking the pill up from the floor, going to the medication cart to discard the dropped pill, and entering and exiting the medication room. The surveyor requested the facility policy on handwashing from the director of nursing on 7/16/19 at 4:56 p.m. The facility policy titled Hand Washing Date Revised: (MONTH) (YEAR) read 3. Perform hand hygiene a. before and after having contact with residents. G. Wash hands with either plain or antimicrobial soap and water or rub hands with an alcohol based formulation before handling medication and preparing food. The surveyor informed the administrator, the director of nursing, the regional director of clinical services, and the administrator-in-training of the above observation on 7/18/19 at 11:56 a.m. The surveyor interviewed [MI]P.N. #2 on 7/18/19 12:19 p.m. [MI]P.N. #2 stated an in-service had been held that morning about the location of germicidal sprays and making sure medications were locked appropriately. [MI]P.N. #2 stated the spray wasn't available for use and [MI]P.N. #2 stated I got nervous. No further information was provided prior to the exit conference on 7/18/19. 2. The facility staff failed to follow physician's orders [REDACTED].#91. The clinical record of Resident #91 was reviewed 7/15/19 through 7/18/19. Resident #91 was admitted to the facility 6/13/19 with diagnoses, that included but not limited [MEDICAL CONDITION], metastatic [MEDICAL CONDITION], type 2 diabetes mellitus, [MEDICAL CONDITION], urogenital implants, chronic [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION], obstructive sleep apnea, systemic lupus [DIAGNOSES REDACTED]tous, depression, and [MEDICAL CONDITION]. Resident #91's admission minimum data set (MDS) with an assessment reference date (ARD) of 6/20/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #91's current comprehensive care plan had the focus area that read Resident is at risk of infection due to recent [MEDICAL CONDITION] treatments secondary [MEDICAL CONDITION]. Date initiated 6/18/19. Interventions: Reverse isolation precautions as ordered. The (MONTH) 2019 physician's orders [REDACTED]. The surveyor observed Resident #91 on 7/15/19 at 3:26 p.m. The surveyor observed a treatment cart between the resident's door and the entrance to the bedroom. The treatment cart contained PPE (personal protective equipment). There was no sign on the door describing the type of isolation. Resident #91 stated to the surveyor the type of isolation he/she was currently on. I [MEDICAL CONDITION] and you have to wear gloves and a mask when you come into my room. The surveyor interviewed licensed practical nurse #7 on 7/15/19 at 3:27 p.m. [MI]P.N. #7 stated Resident #91 was on reverse isolation and a sign should be on the door. The surveyor and [MI]P.N. #7 checked the door for signage for isolation. There was none. [MI]P.N. #7 stated she would contact the physician to see if isolation should continue. The surveyor interviewed the director of nursing on 7/15/19 at 4:14 p.m. regarding reverse isolation. The DON stated a sign should be on the door directing staff and visitors what precautions to take. The surveyor requested the facility policy on reverse isolation. The director of nursing provided the surveyor with the Reverse Isolation Precautions Guidelines for Immunocompromised Residents/Patients on 7/16/19 at 11:30 a.m. The guidelines read in part The purpose is to protect the resident/patient from any germs the staff or visitors are carrying. Residents/patients, who have a decreased immune system (neutropenic), usually from [MEDICAL CONDITION], may be placed in reverse isolation. For a resident/patient in reverse isolation, staff should wear gloves, a mask, and a gown. The use of Standard Precautions for all residents/patients and Transmission-Based Precautions for specified patients, as recommended in this guideline, should reduce the acquisition by these residents/patients of institutionally acquired bacteria from other patients and environments. The surveyor reviewed the facility policy titled Infection Control-Transmission Based Precautions Date Revised (MONTH) (YEAR). The policy read in part D. A sign will be placed on the door frame of the resident's room indicating that visitors should stop at Nurses Station before entering. The surveyor informed the administrator, the director of nursing, the regional director of clinical services, the regional vice president of operations, and the administrator-in-training of the above issue on 7/17/19 at 11:35 a.m. No further information was provided prior to the exit conference on 7/18/19. 3. The facility staff failed to follow infection control guidelines for Resident #79 who was on contact isolation. The surveyor was unable to locate the site of the infection for contact precautions. The clinical record of Resident #79 was reviewed 7/15/19 through 7/18/19. Resident #79 was admitted to the facility 5/2/19 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #79's 30-day minimum data set (MDS) assessment with an assessment reference date (ARD) of 7/3/19 assessed the resident to be in a persistent vegetative state in Section B0100. The surveyor observed wound care on 7/17/19 at 8:33 a.m. with licensed practical nurse #3. Resident #79's door had a sign that read Contact Precautions. L.P.N. #3 knocked and entered the room and hands washed. L.P.N. #3 returned to the treatment cart and cleaned the over-the-bed table with a Sani-cloth wipe. L.P.N. #3 left the treatment cart, went into Resident #79's room and washed hands. [MI]P.N. #3 returned to treatment cart and placed a barrier on the table. L.P.N. #3 removed supplies from cart-poured hydrogel into graduated cup and placed on barrier. Cleaned scissors with Sani cloth and placed on barrier. Removed [MEDICATION NAME] Extra AG 2 packages and placed on table. Dated all dressings prior to entering the resident's room. L.P.N. #3 placed a box of gloves, an opened package of [MEDICATION NAME], 4x4's and a bottle of normal saline on the over-the-bed table. L.P.N. #3 donned gown, masks and gloves, entered Resident #79's room with the over-the-bed table, and positioned the table on the left side of the bed. Resident #79 was turned to the left side. Old dressing on left leg (hip region) removed and discarded. Gloves off and hands washed. Gloves applied and dressing on coccyx/sacrum removed. Gloves off and discarded. Hands washed. Gloves applied. Area on left leg cleaned with normal saline and discarded. Gloves removed and hands washed. Gloves applied. [MEDICATION NAME] extra AG applied. Covered with [MEDICATION NAME] (dated prior to applying). Gloves removed and hands washed. L.P.N. #3 then left the resident's room, went to treatment cart for supplies, and then returned. [MI]P.N. #3 did not remove gown or masks when exiting Resident #79's room and re-entering. Upon return to room, [MI]P.N. #3 did wash hands and gloves applied. Area on coccyx cleaned with normal saline. Gloves removed and hands washed. Gloves applied. Area cleaned again with normal saline. Gloves off and hands washed. Gloves applied. [MEDICATION NAME] Extra AG applied then [MEDICATION NAME] Island dressing applied (dated prior to applying). L.P.N. #3 removed gloves and washed hands. Gloves on and cleaned scissors before leaving the room. [MI]P.N. #3 removed gloves and washed hands. Over-the-bed table and the box of gloves removed from the room. [MI]P.N. #3 cleaned the top of the over-the- bed table with Sani-wipe cloth. None of the metal frame of the over-the-bed table was cleaned with any type of disinfectant. The box of gloves was placed back on top of the treatment cart. The surveyor interviewed [MI]P.N. #3 about the wound care observations. The surveyor questioned [MI]P.N. #3 if the gown and masks should have been removed and hands washed when the nurse exited the room to get supplies from the treatment cart. [MI]P.N. #3 stated he/she thought he/she should but then didn't. The surveyor also asked about taking gloves and the over-the-bed-table in and out of Resident #79's room. The surveyor asked if those items should be dedicated items and left in the resident's room. [MI]P.N. #3 stated he/she should have used the resident's over-the-bed table and left the box of gloves in the room when wound care was finished. The surveyor interviewed the director of nursing (DON) on 7/17/19 at 10:00 a.m. and requested the facility policy on isolation, standard precautions, the (MONTH) 2019 physician orders [REDACTED]. The DON was informed of the surveyor's observations during wound care. The DON stated the gloves and table should have been left in the room and gown and masks should have been removed when [MI]P.N. #3 left the room. The surveyor reviewed the facility policy titled Infection Control-Transmission Based Precautions-Date Revised (MONTH) (YEAR) on 7/17/19. The policy read in part Procedure 1. Contact Precautions-d. Resident -Care equipment-use disposable non-critical equipment (thermometers, B/P (blood pressure) cuffs, stethoscope, etc.) or implement resident-dedicated equipment. If common use of equipment is unavoidable, clean and disinfect equipment before use on another resident. The surveyor did not receive the facility policy on Standard Precautions. On 7/18/19 at 8:00 a.m., the director of nursing stated Resident #79's contact isolation had been removed. The director of nursing stated the resident had been on isolation prior to admission and the most recent progress note dated 7/16/19 did not address the reason for the isolation. The surveyor informed the administrator, the director of nursing, the regional director of clinical services, and the administrator-in-training of the above concern on 7/18/19 at 11:56 a.m. No further information was provided prior to the exit conference on 7/18/19. 4. Facility staff members failed to ensure point-of-care equipment (a glucometer) was cleaned prior to returning it to its storage area and facility staff members failed to ensure used laboratory blood draw equipment/supplies were not commingled with clean, unused laboratory blood draw equipment/supplies. On 7/16/19 at 10:45 a.m., LPN (licensed practical nurse) #14 was observed to attempt to collect Resident #20's blood; LPN #14 made two (2) unsuccessful attempts to collect Resident #20's blood. Registered Nurse (RN) #11 was assisting LPN #14 with the attempt to collect the blood. It was noted after each of the two unsuccessful attempts that the protective device was put in place over the used butterfly needle but the used butterfly needle was placed in the laboratory caddy which also held clean blood collection supplies. On 7/16/19 at 11:10 a.m., LPN #11 was observed to use a point-of-care device (a glucometer) to obtain a FSBS (finger stick blood sugar) test on Resident #20. LPN #11 was observed to return the glucometer to its storage area in the medication cart without cleaning and disinfecting the glucometer. The following information, guiding the cleaning of the facility's glucometer, was found in a facility policy titled Blood Glucose Monitoring via Finger Stick and Cleaning of Glucometers (with the most recent revised date of 11/28/2018): Wipe glucometer surface using a germicidal disposable wipe with bleach per manufacturer's directions and recommendation. The Surface must be visibly wet. a. Friction is the key to cleaning and disinfecting environmental surfaces. b. Take care not to get liquid in the test strip and key code ports of the meter. This policy indicated the aforementioned cleaning should occur prior to obtaining blood for testing and after the blood test is completed. The following information was found in the facility's glucometer's User Instruction Manual: Cleaning and Disinfecting: The cleaning procedure is needed to clean dirt as well as blood and other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure. The disinfection procedure is needed to prevent transmission of blood-borne pathogens. -The meter should be cleaned and disinfected after use on each patient. This Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed . Cleaning . 1. Wear appropriate protective gears (sic) such as disposable gloves. 2. Open the cap of the disinfectant container and pull out 1 towelette and close the cap. 3. Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids. 4. Dispose of the used towelette in a trash bin. The meter should be cleaned prior to each disinfection step. Disinfecting . 5. Pull out 1 new towelette and wipe the entire surface of the meter 3 times horizontally and 3 times vertically using a new towelette to remove blood-borne pathogens. 6. Dispose of the used towelette in a trash bin. 7. Allow exteriors to remain wet for the corresponding contact time for each disinfectant. 8. After disinfection, the user's gloves should be removed to be thrown away and hands washed before proceeding to the next patient. The following information was found in the facility policy titled Infection Control (with an effective date of (MONTH) (YEAR)): .Staff and residents shall maintain clean work areas . All waste products shall be placed in appropriate containers . On 7/17/19 at 10:45 a.m., the following infection control concerns were discussed during a survey team meeting with the facility's Director of Nursing, Administrator, Administrator-In-Training, Regional Director of Clinical Services, and Regional Vice-President of Operations: (a) observations of used butterfly needles being placed in the laboratory caddy which contained cleaned blood draw equipment and supplies and (b) the observation of a point-of-care device (glucometer) being returned to its storage area after use without first being cleaned and disinfected.

Based on observation, staff interview, and facility document review, the facility staff failed to provide privacy for 1 of 4 residents observed during a medication pass and pour observation, Resident # S2. The findings included The facility staff failed to pull the privacy curtain to provide privacy while administering medications through a peg tube for Resident # S2. On 9/12/19 at 8:47 am, the surveyor was conducting a medication pass and pour observation with LPN # 1 (licensed practical nurse). The surveyor observed that LPN # 1 did not pull the privacy curtain and Resident # S2 was visible to her roommate as LPN # 1 administered medications to Resident # S2 via peg tube. On 9/12/19 at 10:03 am, the surveyor interviewed LPN # 1. The surveyor asked LPN # 1 why she did not pull the privacy curtain during medication administration for Resident # S2. LPN # 1 stated, I didn't even think about it. Her husband used to be in the room with her, and he used to like to watch her get her medicine. The person that is in there now is usually in therapy when I give her medication, and I didn't think to pull the curtain. The facility policy on Resident Privacy contained documentation that included but was not limited to, . Procedure 2. A closed door, drawn curtain, or both, shields the resident from passerby, as well as their roommate. On 9/12/19 at 2:30 pm, the administrator, the administrator in training, the director of nursing and the regional director of clinical services were made aware of the findings as stated above. The administrative team was provided the opportunity to ask questions and submit more information to dispute the deficient practice as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 9/12/19.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide a reasonable accommodation by maintaining the breath activated call cord/light within the resident's reach for 1 of 34 residents (Resident #260). The findings included: Resident #260's breath activated call cord was out of reach for twenty-five minutes. The clinical record of Resident #260 was reviewed 7/15/19 through 7/18/19. Resident #260 was admitted to the facility 6/24/19 and readmitted [DATE] with [DIAGNOSES REDACTED]. The admission MDS (minimum data set) assessment had not yet been completed but other clinical documentation indicated the resident was not cognitively impaired but did require total assistance with all aspects of care, was a [MEDICAL CONDITION], and was ventilator dependent. Resident #260's current care plan identified the focus area dated 6/25/19 that read the resident is ventilator dependent r/t (related to) [MEDICAL CONDITION]. Interventions: Keep call bell within reach. The surveyor interviewed Resident #260 on 7/15/19 at 5:22 p.m. Resident #260 was in bed, ventilator in use. The surveyor observed the breath activated call cord was approximately 1 ½-2 inches from Resident #260's mouth. The surveyor sat in a chair at bedside and interviewed the resident. Resident #260 spoke in a very soft voice. The surveyor did not understand most of the words spoken by the resident. The surveyor had to have ear to Resident #260's mouth in order to hear the spoken words. During the interview, Resident #260 kept trying to blow into the breath activated call cord but was unable to activate it as indicated by his care plan. The call cord was approximately 1 ½ inches-2 inches from the resident's mouth. During the interview of approximately 25 minutes, the surveyor did not witness any staff attempt to check on Resident #260. Upon completion of the interview at 5:40 p.m., the surveyor informed Resident #260's nurse for the day-registered nurse #1 of the above concern. R.N. #1 followed the surveyor to Resident #260's room, adjusted the breath activated call cord and stated the call cord was within reach when checked earlier in the shift. The surveyor informed the administrator, the director of nursing, the regional director of clinical services, the vice president of regional operations, and the administrator-in-training of the above concern on 7/17/19 at 11:35 a.m. No further information was provided prior to the exit conference on 7/18/19.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to determine that medication self-administration for 2 out of 34 residents was appropriate (Resident #91 and Resident #95). The findings included: 1. The facility staff failed to assess Resident #91 for medication self-administration of eye drops ([MEDICATION NAME] Ultra). The clinical record of Resident #91 was reviewed 7/15/19 through 7/18/19. Resident #91 was admitted to the facility 6/13/19 with diagnoses, that included but not limited [MEDICAL CONDITION], metastatic [MEDICAL CONDITION], type 2 diabetes mellitus, [MEDICAL CONDITION], urogenital implants, chronic [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION], obstructive sleep apnea, systemic lupus [DIAGNOSES REDACTED]tous, depression, and [MEDICAL CONDITION]. Resident #91's admission minimum data set (MDS) with an assessment reference date (ARD) of 6/20/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. The surveyor interviewed Resident #91 on 7/15/19 at 6:31 p.m. During this interview, the surveyor observed a bottle of [MEDICATION NAME] Ultra eye drops on the over the bed table. The bottle of eye drops did not have a label with directions for use. Resident #91 stated the eye drops were used for dry eyes. The surveyor reviewed the clinical record for an order for [REDACTED]. The surveyor was unable to locate any of the above items in the clinical record. The surveyor interviewed the director of nursing (DON) on 7/16/19 at 2:06 p.m. about the medication self-administration process. The DON stated an assessment of that resident would be done prior to the start of medication self-administration. The surveyor asked the DON to see if Resident #91 had a medication self-administration assessment for [MEDICATION NAME] Ultra eye drops. The DON informed the surveyor on 7/16/19 at 2:30 p.m. that a medication self-administration assessment had not been completed on Resident #91. The DON stated someone from the resident's family probably brought the medicine in. The surveyor requested the facility policy on medication self-administration on 7/16/19. The surveyor reviewed the facility policy titled Self Administration of Medication Date Revised (MONTH) (YEAR). The policy read in part 1. Verify physician's orders [REDACTED]. 2. Complete Self-Administration of Medications Assessment form (AL 1008) with the resident. 5. In the event the Interdisciplinary team has determined the resident safe to administer medication (s), administration of medication (s) will be Care Planned for approved self-administered medication. 8. The MAR (medication administration record) must identify medications that are self-administered and the medication nurse will need to follow-up with the resident as to documentation and storage of medication during each medication pass. If medication (s) are kept at bedside, it must be kept in a locked box. The surveyor informed the administrator, the director of nursing, the regional director of clinical services, the administrator-in-training, and the regional vice president of operations of the above concern on 7/17/19 at 11:35 a.m. No further information was provided prior to the exit conference on 7/18/19. 2. The facility staff failed to assess Resident #95 for medication self-administration of nasal spray. The clinical record of Resident #95 was reviewed 7/15/19 through 7/18/19. Resident #95 was admitted to the facility 11/10/15 and readmitted [DATE]. [DIAGNOSES REDACTED]. Resident #95's 5-day minimum data set (MDS) assessment with an assessment reference date (ARD) of 6/24/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. The surveyor interviewed Resident #95 on 7/16/19 at 11:40 a.m. and observed a bottle of Deep Sea moisturizing nasal spray on the over-the-bed table. The label read that resident may keep at bedside. Use in both nostrils. Resident #95 stated the oxygen tends to dry her nose and the spray helps with the dryness. The surveyor reviewed the clinical record for an order for [REDACTED]. The surveyor was unable to locate any of the above items in the clinical record. The surveyor informed the director of nursing on 7/16/19 at 12:31 p.m. and requested if the DON could locate the order for the nasal spray and the medication self-administration assessment. The DON informed the surveyor on 7/16/19 at 2:04 p.m. that a medication self-administration assessment had not been completed for the resident for the use of the nasal spray. The surveyor requested the facility policy on medication self-administration. The surveyor reviewed the facility policy titled Self Administration of Medication Date Revised (MONTH) (YEAR). The policy read in part 1. Verify physician's orders [REDACTED]. 2. Complete Self-Administration of Medications Assessment form (AL 1008) with the resident. 5. In the event the Interdisciplinary team has determined the resident safe to administer medication (s), administration of medication (s) will be Care Planned for approved self-administered medication. 8. The MAR (medication administration record) must identify medications that are self-administered and the medication nurse will need to follow-up with the resident as to documentation and storage of medication during each medication pass. If medication (s) are kept at bedside, it must be kept in a locked box. The surveyor informed the administrator, the director of nursing, the regional director of clinical services, the administrator-in-training, and the regional vice president of operations of the above concern on 7/17/19 at 11:35 a.m. No further information was provided prior to the exit conference on 7/18/19.

Based on observation, staff interview, and facility document review, the facility staff failed to provide privacy for 1 of 4 residents observed during a medication pass and pour observation, Resident # S2. The findings included The facility staff failed to pull the privacy curtain to provide privacy while administering medications through a peg tube for Resident # S2. On 9/12/19 at 8:47 am, the surveyor was conducting a medication pass and pour observation with LPN # 1 (licensed practical nurse). The surveyor observed that LPN # 1 did not pull the privacy curtain and Resident # S2 was visible to her roommate as LPN # 1 administered medications to Resident # S2 via peg tube. On 9/12/19 at 10:03 am, the surveyor interviewed LPN # 1. The surveyor asked LPN # 1 why she did not pull the privacy curtain during medication administration for Resident # S2. LPN # 1 stated, I didn't even think about it. Her husband used to be in the room with her, and he used to like to watch her get her medicine. The person that is in there now is usually in therapy when I give her medication, and I didn't think to pull the curtain. The facility policy on Resident Privacy contained documentation that included but was not limited to, . Procedure 2. A closed door, drawn curtain, or both, shields the resident from passerby, as well as their roommate. On 9/12/19 at 2:30 pm, the administrator, the administrator in training, the director of nursing and the regional director of clinical services were made aware of the findings as stated above. The administrative team was provided the opportunity to ask questions and submit more information to dispute the deficient practice as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 9/12/19.

Based on facility document review, staff interview and clinical record review, the facility staff failed to report an allegation of abuse to the appropriate agencies for 1 of 12 residents in the survey sample (Resident #209). The findings included: The facility staff failed to report an allegation of abuse to the appropriate agencies for Resident #209. Resident #209 was originally admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. This resident was first admitted to a facility in which it was a sister facility but was transferred to present facility due to being able to meet the increased needs of this resident in a secure unit due to wandering tendencies and family request. This transfer of this resident occurred on 8/23/19. During the clinical record review by the surveyor on 9/11/and 9/12/19, the following documentation was noted on the Admission/Readmission Evaluation, which was completed on 8/23/19: o .During the last 90 days resident had No Falls . o The resident's cognitive status changed in the last 90 days was answered as No . o Moderately impaired limited vision, but can identify objects . o Confined to a chair . o Balance not steady, only able to stabilize with physical assistance . o 3 or more medications taken currently or within the last 7 days . o Memory loss . o Resident #209 was also marked as requiring 1 person assist with ambulation, bed mobility, bathing, dressing, eating, toileting, and transfers. The surveyor reviewed the resident's clinical record on 9/11/19 and 9/12/19. During this review, the surveyor noted the following documentation dated and timed for 8/27/19 at 10:57 am which read, While attempting to get resident dressed and cleaned up for the day, resident started yelling before anyone even touched this resident. No, your not going to beat me up and put more bruises on me! Do not touch me, you guys are mean to me! The resident was left alone for now to rest. The surveyor reviewed the nursing notes after this incident and there was no further documentation on the allegation of abuse. On 9/11/19 at approximately 4:45 pm, the surveyor asked the administrative team in the end of the day conference if they had any FRI's (Facility Reported Incidents) on Resident #209 for this date. The director of nursing and the regional nurse consultant both stated they were not aware of any FRI's that had been completed concerning this resident. Both stated they would look into this and provide the surveyor with any information that they find. On 9/12/19 at 9:15 am, the regional nurse consultant, director of nursing (DON) and administrator in training (AIT) were present with the surveyor in the conference room. The regional nurse consultant stated, I was wondering why you asked us for a FRI on this resident yesterday because all that we were aware of was 2 falls that occurred on 8/26 and 8/27/19. Both the DON and I worked late and read the nurses' notes and that was when we found the allegation of abuse that was documented by the nurse of 8/27/19 at 10:57 am. Both the regional nurse consultant and the DON stated they were not aware of this allegation until they were reviewing the notes last night (9/11/19). The regional nurse consultant stated, After finding this out, we immediately faxed in a FRI to your office and notified the appropriate agencies of this allegation. The administrator in training stated that after these measures were taken, the staff was educated on reporting of any allegations of abuse immediately to their supervisor and then follow the chain of command so any allegations that are reported and investigations could be started within 2 hours of being told of an allegation. We have been doing this as staff was clocking into work last night and following through until all staff are in-serviced on this. The surveyor asked if the nurse that wrote this note was working today. The DON stated, No, she is on vacation and not on the schedule. The surveyor asked for a copy of the facility's policy on reporting allegations of abuse or neglect. The surveyor also requested a copy of any in services that staff had received in the past year on abuse and neglect of any resident in the facility. The surveyor was provided with a copy of the facility's policy titled Virginia Resident Abuse Policy which read in part, .Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy . The administrator in training provided the surveyor with a list of courses that the facility staff are required to have on an annual base. Included in these courses, were the courses on abuse and neglect, who and how to report this to if they ever receive a report of any of this. The surveyor reviewed the documentation on this list and noted there was a completion percentage of 99.12% of staff had completed these annual courses. The unit manager for the Memory Care Unit was interviewed on 9/12/19 at approximately 1 pm in the conference room. The surveyor asked if she had received any allegations of abuse in which Resident #209 had reported to a nurse and then that nurse documented the statements in a nurses' note on 8/27/19 at 10:57 am. The unit manager stated, No one reported this incident to me and I was not aware of it until the DON had shown me the nurses' notes this morning. The surveyor notified the Administrator along with the rest of the administrative team of the above documented findings on 9/12/19 at 3:30 pm. The surveyor asked the administrator if he had been aware of the allegation of abuse that had been documented in the nurses' notes of Resident #209 on 8/27/19 at 10:57 am. The administrator replied, No one knew of this allegation until my staff was reading over the notes last night and found it. No further information was provided to the surveyor prior to the exit conference on 9/12/19.

Based on facility document review, staff interview and clinical record review, the facility staff failed to report an allegation of abuse to the appropriate agencies for 1 of 12 residents in the survey sample (Resident #209). The findings included: The facility staff failed to report an allegation of abuse to the appropriate agencies for Resident #209. Resident #209 was originally admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. This resident was first admitted to a facility in which it was a sister facility but was transferred to present facility due to being able to meet the increased needs of this resident in a secure unit due to wandering tendencies and family request. This transfer of this resident occurred on 8/23/19. During the clinical record review by the surveyor on 9/11/and 9/12/19, the following documentation was noted on the Admission/Readmission Evaluation, which was completed on 8/23/19: o .During the last 90 days resident had No Falls . o The resident's cognitive status changed in the last 90 days was answered as No . o Moderately impaired limited vision, but can identify objects . o Confined to a chair . o Balance not steady, only able to stabilize with physical assistance . o 3 or more medications taken currently or within the last 7 days . o Memory loss . o Resident #209 was also marked as requiring 1 person assist with ambulation, bed mobility, bathing, dressing, eating, toileting, and transfers. The surveyor reviewed the resident's clinical record on 9/11/19 and 9/12/19. During this review, the surveyor noted the following documentation dated and timed for 8/27/19 at 10:57 am which read, While attempting to get resident dressed and cleaned up for the day, resident started yelling before anyone even touched this resident. No, your not going to beat me up and put more bruises on me! Do not touch me, you guys are mean to me! The resident was left alone for now to rest. The surveyor reviewed the nursing notes after this incident and there was no further documentation on the allegation of abuse. On 9/11/19 at approximately 4:45 pm, the surveyor asked the administrative team in the end of the day conference if they had any FRI's (Facility Reported Incidents) on Resident #209 for this date. The director of nursing and the regional nurse consultant both stated they were not aware of any FRI's that had been completed concerning this resident. Both stated they would look into this and provide the surveyor with any information that they find. On 9/12/19 at 9:15 am, the regional nurse consultant, director of nursing (DON) and administrator in training (AIT) were present with the surveyor in the conference room. The regional nurse consultant stated, I was wondering why you asked us for a FRI on this resident yesterday because all that we were aware of was 2 falls that occurred on 8/26 and 8/27/19. Both the DON and I worked late and read the nurses' notes and that was when we found the allegation of abuse that was documented by the nurse of 8/27/19 at 10:57 am. Both the regional nurse consultant and the DON stated they were not aware of this allegation until they were reviewing the notes last night (9/11/19). The regional nurse consultant stated, After finding this out, we immediately faxed in a FRI to your office and notified the appropriate agencies of this allegation. The administrator in training stated that after these measures were taken, the staff was educated on reporting of any allegations of abuse immediately to their supervisor and then follow the chain of command so any allegations that are reported and investigations could be started within 2 hours of being told of an allegation. We have been doing this as staff was clocking into work last night and following through until all staff are in-serviced on this. The surveyor asked if the nurse that wrote this note was working today. The DON stated, No, she is on vacation and not on the schedule. The surveyor asked for a copy of the facility's policy on reporting allegations of abuse or neglect. The surveyor also requested a copy of any in services that staff had received in the past year on abuse and neglect of any resident in the facility. The surveyor was provided with a copy of the facility's policy titled Virginia Resident Abuse Policy which read in part, .Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy . The administrator in training provided the surveyor with a list of courses that the facility staff are required to have on an annual base. Included in these courses, were the courses on abuse and neglect, who and how to report this to if they ever receive a report of any of this. The surveyor reviewed the documentation on this list and noted there was a completion percentage of 99.12% of staff had completed these annual courses. The unit manager for the Memory Care Unit was interviewed on 9/12/19 at approximately 1 pm in the conference room. The surveyor asked if she had received any allegations of abuse in which Resident #209 had reported to a nurse and then that nurse documented the statements in a nurses' note on 8/27/19 at 10:57 am. The unit manager stated, No one reported this incident to me and I was not aware of it until the DON had shown me the nurses' notes this morning. The surveyor notified the Administrator along with the rest of the administrative team of the above documented findings on 9/12/19 at 3:30 pm. The surveyor asked the administrator if he had been aware of the allegation of abuse that had been documented in the nurses' notes of Resident #209 on 8/27/19 at 10:57 am. The administrator replied, No one knew of this allegation until my staff was reading over the notes last night and found it. No further information was provided to the surveyor prior to the exit conference on 9/12/19.

Based on staff interview, facility document review and clinical record review, the facility staff failed to immediately start an investigation when 1 of 12 residents in the survey sample alleged abuse by a staff member and failed to report these completed findings within 5 days of the becoming aware of an alleged abuse to a resident in the nursing facility (Resident #209). The findings included: The facility staff failed to immediately investigate an allegation of abuse that was reported to staff by Resident #209 on 8/27/19 at 10:57 am Resident #209 was originally admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. This resident was first admitted to a facility in which it was a sister facility but was transferred to present facility due to being able to meet the increased needs of this resident in a secure unit due to wandering tendencies and family request. This transfer of this resident occurred on 8/23/19. During the clinical record review by the surveyor on 9/11/and 9/12/19, the following documentation was noted on the Admission/Readmission Evaluation, which was completed on 8/23/19: o .During the last 90 days resident had No Falls . o The resident's cognitive status changed in the last 90 days was answered as No . o Moderately impaired limited vision, but can identify objects . o Confined to a chair . o Balance not steady, only able to stabilize with physical assistance . o 3 or more medications taken currently or within the last 7 days . o Memory loss . o Resident #209 was also marked as requiring 1 person assist with ambulation, bed mobility, bathing, dressing, eating, toileting, and transfers. The surveyor reviewed the resident's clinical record on 9/11/19 and 9/12/19. During this review, the surveyor noted the following documentation dated and timed for 8/27/19 at 10:57 am which read, While attempting to get resident dressed and cleaned up for the day, resident started yelling before anyone even touched this resident. No, your not going to beat me up and put more bruises on me! Do not touch me, you guys are mean to me! The resident was left alone for now to rest. The surveyor reviewed the nursing notes after this incident and there was no further documentation on the allegation of abuse. On 9/11/19 at approximately 4:45 pm, the surveyor asked the administrative team in the end of the day conference if they had any FRI's (Facility Reported Incidents) on Resident #209 for this date. The director of nursing and the regional nurse consultant both stated they were not aware of any FRI's that had been completed concerning this resident. Both stated they would look into this and provide the surveyor with any information that they find. On 9/12/19 at 9:15 am, the regional nurse consultant, director of nursing (DON) and administrator in training (AIT) were present with the surveyor in the conference room. The regional nurse consultant stated, I was wondering why you asked us for a FRI on this resident yesterday because all that we were aware of was 2 falls that occurred on 8/26 and 8/27/19. Both the DON and I worked late and read the nurses' notes and that was when we found the allegation of abuse that was documented by the nurse of 8/27/19 at 10:57 am. Both the regional nurse consultant and the DON stated they were not aware of this allegation until they were reviewing the notes last night (9/11/19). The regional nurse consultant stated, After finding this out, we immediately faxed in a FRI to your office and notified the appropriate agencies of this allegation. The administrator in training stated that after these measures were taken, the staff was educated on reporting of any allegations of abuse immediately to their supervisor and then follow the chain of command so any allegations that are reported and investigations could be started within 2 hours of being told of an allegation. We have been doing this as staff was clocking into work last night and following through until all staff are in-serviced on this. The surveyor asked if the nurse that wrote this note was working today. The DON stated, No, she is on vacation and not on the schedule. The surveyor asked for a copy of the facility's policy on reporting allegations of abuse or neglect. The surveyor also requested a copy of any in services that staff had received in the past year on abuse and neglect of any resident in the facility. The surveyor was provided with a copy of the facility's policy titled Virginia Resident Abuse Policy which read in part, .Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy . The administrator in training provided the surveyor with a list of courses that the facility staff are required to have on an annual base. Included in these courses, were the courses on abuse and neglect, who and how to report this to if they ever receive a report of any of this. The surveyor reviewed the documentation on this list and noted there was a completion percentage of 99.12% of staff had completed these annual courses. The unit manager for the Memory Care Unit was interviewed on 9/12/19 at approximately 1 pm in the conference room. The surveyor asked if she had received any allegations of abuse in which Resident #209 had reported to a nurse and then that nurse documented the statements in a nurses' note on 8/27/19 at 10:57 am. The unit manager stated, No one reported this incident to me and I was not aware of it until the DON had shown me the nurses' notes this morning. The surveyor notified the Administrator along with the rest of the administrative team of the above documented findings on 9/12/19 at 3:30 pm. The surveyor asked the administrator if he had been aware of the allegation of abuse that had been documented in the nurses' notes of Resident #209 on 8/27/19 at 10:57 am. The administrator replied, No one knew of this allegation until my staff was reading over the notes last night and found it. No further information was provided to the surveyor prior to the exit conference on 9/12/19.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to ensure a hazard free environment for 3 of 33 residents (Resident #13, Resident #9, and Resident #10), and failed to ensure hazard free environments on 2 of 3 units (dementia unit and B wing) and in the laundry area. The findings include: 1. For Resident #13 who was described in a 1/30/14 physical therapy note as ambulating with "Min (minimal) assist with cuing" and on 1/31/14 as "min (minimal) assist", the facility staff failed to ensure a hazard free environment on the dementia unit. Resident #13 was left unsupervised in the dining room on the dementia unit and was found on the floor. Resident #13 had an un-witnessed fall with injuries that occurred on 2/2/14. He was admitted to the hospital with [REDACTED]. Resident #13 was admitted to the facility 2/11/13 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #13's significant change in assessment minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/27/14 assessed Resident #13 with a BIMS (brief interview for mental status) score of 05 out of 15 in Section C Cognitive Patterns. The resident was assessed to be totally dependent on two people for bed mobility and requiring extensive assistance of one person for transfers. The MDS prior to the fall on 2/2/14 was a quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/3/13. The quarterly MDS assessed the resident to be independent in bed mobility and only required supervision of one person for transfers. The clinical record for Resident #13 was reviewed 5/6/14 and 5/7/14. The progress note dated 2/2/14 10:58 read "Obtained order to send to ------ (name of hospital emergency room ) for eval (evaluation), family notified, report called to hosp (hospital)." The next entry for 2/2/14 14:16 (2:16 p.m.) read "Spoke with daughter re (regarding): residents condition, resident will be admitted with closed skull fx (fracture) and brain bleed. Spoke with wife informed her that resident being admitted , she informed me that she was waiting on son and that she was going over, wanted to know why staff didn't know what happened, informed her that this nurse was passing meds (medications) to other residents and that other staff was assisting other residents down hallway when this resident fell ." The surveyor found no fall risk assessments in the clinical record. The PT (physical therapy) daily treatment note dated 1/26/14 read "Pt (patient) completed AROM (active range of motion) to BLE (bilateral lower extremities) all planes in sitting at EOB (edge of bed) x 3 sets of 15 in order to increase ROM (range of motion), strength, and endurance. Patient worked on ambulating to bathroom as with to increase (I) (independence) and decrease fall risk. Patient presents with crouched posture as well as increased unsteadiness. 1/30/14 PT note read "Bed mobility, transfer activity, verbal cuing needed throughout treatment. Short ambulation activity for toileting using rolling walker, patient teaching verbal cuing. Min (minimal) assist with cuing." 1/31/13 PT note read "Patient ambulated 130 x 2 feet using a rollator with min (minimal) assist. Increased trunk flexion during ambulation." There was no documentation on 2/2/14 regarding the un-witnessed fall. The "trauma consult" from the emergency room dated 2/2/14 read "Chief complaint: Ground level fall on the tile floor of a nursing home. This [AGE] year-old male fell from ground level at a nursing home and was brought to the emergency room , evaluated by the ER physician, and the neurosurgeon, decision was made to ask trauma to evaluate and possibly admit the patient on behalf of neurosurgery and down in the emergency room to see him. He is complaining of 7/10 pain in the head. Has had some twitching, which is normal for him. The fall was allegedly mechanical involving. The patient being recalcitrant to using his walker according to the report. CT of the head and C-spine shows displaced right occipital bone fracture with an anterior subarachnoid hemorrhage and minimal right posterior subarachnoid hemorrhage. The patient was seen, evaluated and examined. We will see the patient and decide if he needs a syncopal work-up for a medicine evaluation. He will be admitted for observation, neuro (neurological) checks, and treatment along with neurosurgery. Family updated at bedside." CT head dated 2/2/14 listed these findings: "There has been interval extension of diffuse bilateral subarachnoid hemorrhage. There is more extensive hemorrhage within the sulci of the frontal lobes bilaterally and there is also intraventricular hemorrhage now evident in the posterior horn of the left lateral ventricle. There is a moderate amount of hemorrhage involving the terminus of the left internal carotid artery and extending into the anterior aspect of the left middle cranial fossa. There are also intracerebral hematomas within the frontal lobes bilaterally, more pronounced on the right. There is also hemorrhage within the anterior left temporal lobe. There is also a left parafalcine subdural hematoma present. A non-displaced fracture of the right occipital bone is again noted. A CT angiogram of the brain might be considered to exclude a ruptured cerebral aneurysm." The comprehensive care plan dated 10/28/13 and updated 3/11/14 was reviewed 5/7/14. The care plan contained information dated 2/2/14 that Resident #13 had a closed skull fracture with brain bleed. The comprehensive care plan also included documentation of falls that occurred 3/9/14, 4/5/14, 4/11/14, 4/25/14, and 5/3/14. One intervention listed was "pad alarm applied to bed/chair to alert staff when resident gets up unassisted." The physician note dated 1/23/14 prior to the 2/2/14 fall read in part "Pt (patient) alert, aware, afebrile, stable, confused." The physician note dated 2/17/14 read "Pt (patient) returning from hospital. Recent fall with subarachnoid hemorrhage and occipital fracture. Arousable but lethargic; follows simple commands. Head trauma s/p (status [REDACTED]. Pt (patient) poor prognosis. Consider comfort care." The director of nursing (DON) was asked on 5/7/14 at 2:50 p.m. for any investigation into the un-witnessed fall on 2/2/14 that resulted in a non-displaced right occipital bone fracture with an anterior subarachnoid hemorrhage and minimal right posterior subarachnoid hemorrhage-extensive intracranial hemorrhage. The DON stated no investigation was done "it was an un-witnessed fall. We don't investigate un-witnessed falls. There was no one in the area. Staff were in the hallway. There was no one to interview. No one saw what happened." The DON did provide the surveyor with the incident report dated 2/2/14 at 09:51 which was completed by the director of nursing and read under nursing description "was called to dining rm (room) by staff, resident found in floor on back." There was no documentation under "Resident Description." "Description of Action Taken" read "_____ (name of) amb (ambulance) svs (services) called, report called to _____ (name of hospital), wife notified. Type of injury read "No injuries observed at this time." Level of pain was marked "No hurt." Level of consciousness was "Alert." Mobility "Ambulatory with assistance." Mental Status: "Oriented to person." The administrator and the director of nursing were informed of the concern related to the un-witnessed fall of Resident #13 on 2/2/14 with injuries, the facility's staff failure to implement the facility policy to investigate and report the incident to the appropriate licensing agencies, and the failure to document the timeline of events of the un-witnessed fall of Resident #13 on 2/2/14 on 5/8/14 at 8:55 a.m. and again on 5/9/14 at 12:10 p.m. The surveyor requested the facility policy on investigating injuries of unknown origin, the facility policy on accidents, and the facility policy on documentation. The administrator stated "We all knew about it. He had a big fall and he did hurt himself. We just didn't document anything about it." The director of nursing stated the nurse who worked that day was no longer an employee of the facility. The director of nursing provided the surveyor a standard of practice for the assessment and documentation of falls on 5/8/14 at 3:45 p.m. The policy titled "Accidents/Incidents Management" was as follows under Procedure: ? 3. Assessment of any injuries present will be completed by licensed nursing and medical attention will be provided pursuant to physician recommendation at the time of MD notification. ? 4. If head injury was noted or is suspected neurological checks will be completed. ? 5. If/when an incident/accident occurs the DNS or licensed designee shall: a. Complete an assessment of the environment and resident (s) b. Render immediate assistance as necessary and summon help if needed c. Assess and exam the resident (s) for possible injury before moving d. If necessary transfer the resident to the emergency room for evaluation and/or treatment e. Notify the physician, responsible party, and the facility administrative staff of the incident/accident f. Document a factual account of the event in the following: i. Interdisciplinary Progress Notes or nurses' notes ii. 24-Hour report g. Facility Incident/accident tracking log h. Initiate measures to prevent a re-occurrence i. Update the care plan and nursing assistant care card as applicable Two Adult Protective Services workers from Scott County met with the survey team on 5/9/14 at approximately 12:30 p.m. APS worker #1 was asked if the local APS had been informed of Resident #13's un-witnessed fall with injures on 2/2/14. She stated this was the first she had heard of the fall with injuries and would have expected the facility staff to inform their office of the incident. No further information was obtained from the facility prior to survey exit on 5/9/14. 2. The facility staff failed to ensure that 1 of 3 units was environment free of accident hazards. The facility staff also failed to ensure that the laundry dryer vents were free from excessive amounts of lint. On May 9, 2014 at 9:20 a.m. the surveyor made a walkthrough of the facility with the Maintenance Director (MD). The surveyor and MD walked into the locked unit/dementia/ Alzheimer's unit. The surveyor observed several residents' walking/wandering in the hallway. The surveyor observed a puddle of liquid in the floor and pointed the liquid substance out to the MD. The MD stated that he would obtain something and get the liquid substance up. The MD stood at the puddle in the floor for a few moments and the surveyor observed several staff members walking in the hallway. The surveyor pointed out the liquid substance in the floor and the staff members stepped in the liquid substance and tracked the liquid substance down the hallway. The MD left the surveyor and stated he could not see a housekeeping staff member or wet floor sign. The MD left the locked unit/dementia/Alzheimer's unit and returned in a few minutes with a mop. During this time a resident was walking down in the hallway and coming directly toward the liquid spill in the floor. The surveyor spoke to the resident and walked beside him to guide him around the liquid substance/spill in the floor. The surveyor and MD continued their tour of the facility. The surveyor requested to see the emergency generator and the facility boilers. The surveyor and MD left the building and the surveyor observed a vent exiting the building. The surveyor noted a large area on the ground and under the vent, approximately 4 feet by 4 feet that was heavily soiled with a whitish substance. The surveyor also noted that the vent exiting the facility had large clumps of the whitish substance hanging from the vent. The surveyor asked the MD what was on the ground and hanging from the vent. The MD stated that the facility had four (4) dryers and that two (2) of the dryers were vented through the vent. The MD indicated that the white substance was lint from the dryers. The MD stated that he cleaned the area every few months and at times he had to clean the dryers to remove the excess lint. The surveyor notified the MD that the area was a potential for a fire hazard. On May 9, 2014 at 12:15 p.m. the survey team met with the Administrator (Adm) and Director of Nurses (DON) and 2 MDS nurses. The surveyor notified the Administrative Team (AT) that during a tour of the facility with the MD the surveyor had identified 2 environmental hazards. The surveyor notified the AT that during the tour a liquid substance had been noted in the hallway by the surveyor. The surveyor notified the AT that she had pointed out the spill to the MD and that two staff members had stepped in the substance and tracked the substance down the hallway. The surveyor also notified the AT that the MD had left the unit and several residents were walking/wandering in the hallway. The surveyor notified the AT that she had had to walk/guide a resident around the spill to prevent him from falling. The surveyor also notified the AT that one of the sets of dryer vents exiting the building had large clumps of lint hanging off of the vent. The surveyor also notified the AT that the ground under the dryer vent was heavily soiled with an accumulation of dryer lint. The surveyor notified the AT that she believed that the heavy accumulation of lint in and on the dryer vents were a fire hazard. No additional information was provided prior to exiting the facility as to why the facility staff failed to ensure an environment free of accidents hazards for the residents of the facility. 3. For Resident #9 the facility staff failed to ensure an environment free of accident hazards. Resident #9's reclining geri-chair (RGC) armrests were ripped and torn exposing jagged and sharp edges. Resident #9 was an [AGE] year old female who was originally admitted on [DATE] and readmitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was a Quarterly MDS assessment with an Assessment Reference Date (ARD) of 3/28/14. The facility staff coded that Resident #9 had a Cognitive Summary Score of 6. The facility staff also coded that Resident #9 required extensive (3/3) to total nursing care (4/2) with Activities of Daily Living (ADL's). On May 6, 2014 at 2:15 p.m. the surveyor made an initial tour of the facility. The surveyor observed Resident #9 sitting in a reclining geri-chair (RGC) at the side of her bed. The surveyor noted that the armrests were ripped and torn, exposing jagged edges. The surveyor noted that Resident #9 had several bruises on both arms. On May 7, 2014 at 12:05 p.m. the surveyor observed Resident #9 sitting in her RGC. The armrests on the RGC were ripped and torn exposing sharp and jagged edges. On May 8, 2014 at 10:35 a.m. the survey team met with the Administrator (Adm) and Director of Nursing (DON). The surveyor notified the Administrative Team (AT) that Resident #9's RGC's had ripped and torn armrests, exposing ripped and jagged edges. The surveyor notified the AT that Resident #9's environment was not free from accident hazards as her RGC was ripped and torn exposing sharp and jagged edges. On May 9, 2014 at 9:20 a.m. the surveyor made a tour of the facility with the Maintenance Director (MD). The surveyor pointed out Resident #9's ripped and torn RGC. The MD stated that the facility was very large and that he did not have enough time or help to fix everything. The MD stated that he had requested to have an assistant. The MD also stated that all of the RGC were old and needed to be replaced and that he exchanged RGC parts as able to maintain them. No additional information was provided prior to exiting the facility as to why the facility staff failed to ensure an environment free of accident hazards for Resident #9. For additional information regarding Resident #9 refer to F Tags 157, 252, 253, 281, 312, 314, 328, 329, 425 and 514. 4. For Resident #10 the facility staff failed to ensure an environment free of accident hazards. Resident #10's reclining geri-chair (RGC) armrests were ripped and torn exposing jagged and sharp edges. Resident #10 was an [AGE] year old female who was originally admitted on [DATE] and readmitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was an Annual MDS assessment with an Assessment Reference Date (ARD) of 3/28/14. The facility staff coded that Resident #10 had a Cognitive Summary Score of 10. The facility staff also coded that Resident #10 required extensive (3/3) to total nursing care (4/3) with Activities of Daily Living (ADL's). On May 7, 2014 at 7:30 a.m. the surveyor observed Resident #10 in the dayroom. Resident #10 was sitting in a Reclining Geri-Chair (RGC) eating her breakfast. The surveyor observed that the armrests of the RGC were ripped and torn, exposing sharp, jagged edges. The surveyor observed that Resident #10 had bruising on the left anticubital and right hand. On May 8, 2014 at 7:45 a.m. the surveyor observed Resident #10 sitting in the dayroom in her RGC. The RGC armrests were ripped and torn exposing sharp and jagged edges. On May 8, 2014 at 10:35 a.m. the survey team met with the Administrator (Adm) and Director of Nursing (DON). The surveyor notified the Administrative Team (AT) that Resident #10's RGC armrests were ripped and torn, exposing jagged and sharp edges. The surveyor notified the AT that Resident #10's environment was not free from accident hazards as her RGC was ripped and torn exposing sharp and jagged edges. On May 9, 2014 at 9:20 a.m. the surveyor made a tour of the facility with the Maintenance Director (MD). The surveyor and the MD observed Resident #10 sitting in her RGC in the Activity/Dayroom. The surveyor pointed out that the armrests were ripped and torn. The MD stated that the facility was very large and that he did not have enough time or help to fix everything. The MD stated that he had requested to have an assistant. The MD also stated that all of the RGC were old and needed to be replaced and that he exchanged RGC parts as able to maintain them. No additional information was provided prior to exiting the facility as to why the facility staff failed to ensure an environment free of accident hazards for Resident #10. 5. The facility staff failed to lock and/or secure a medication cart on the B wing during a medication pass and pour observation. On 05/07/14 beginning at approximately 8:10 a.m., the surveyor observed LPN (licensed practical nurse) #1 during a medication pass and pour observation. During this observation LPN #1 was observed preparing and administering medications to Resident's #25 and #27. Resident #25 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment completed on this Resident was an annual assessment with an ARD (assessment reference date) of 03/07/14. Section C (cognitive patterns) of this assessment scored the Resident 13 out of a possible 15 points. Resident #27 was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS assessment completed on this Resident was a quarterly review assessment with an ARD of 04/25/14. Section C of this assessment scored the Resident 15 out of a possible 15 points. After preparing each individuals medications (Resident #25 and #27) LPN #1 left her medication cart unattended in the hallway. LPN #1 did not lock or secure the medication cart and the medication cart was out of her view upon entering each Resident's room. The surveyor was able to observe various staff and other Resident's in the vicinity of the medication cart. Immediately after the medication observation the surveyor reconciled the Resident's medications and interviewed LPN #1 concerning the unlocked/unsecured medication cart. LPN #1 verbalized to the surveyor that she thought as long as she was giving medications she could leave the cart unlocked. The DON (director of nursing) and administrator were notified of the above on 05/07/14 at approximately 5:00 p.m., during an end of the day meeting. On 05/09/14 the facility staff provided the surveyor with a copy of a policy/procedure titled "Medication Administration General Guidelines" page 5 of this document read in part "During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse...The cart must be clearly visible to the personnel administering medications when unlocked." No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, facility document review, clinical record review, and in the course of a complaint ivestigation, the facility staff failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property are immediately reported to the administrator of the facility and to the other officials in accordance with Federal and State law through established procedures (including to the State survey and certification agency) for 3 of 33 residents (Resident #13, Resident #17, and Resident #10). 1. For Resident #13 who was described in a 1/30/14 physical therapy note as ambulating with "Min (minimal) assist with cuing" and on 1/31/14 as "min (minimal) assist", the facility staff failed to investigate and report an un-witnessed fall on 2/2/14 with injuries to the appropriate agencies. Resident #13 was left unsupervised in the dining room on the dementia unit and found on the floor 2/2/14. Resident #13 was admitted to the hospital with [REDACTED]. 2. For Resident #17, the facility staff failed to investigate and report to the appropriate agencies an injury of unknown origin. Resident #17 was found in the floor in her room "lying in a large pool of blood." 3. For Resident #10, the facility staff failed to investigate and report a bruise of unknown origin to the right hand. The findings include: 1. For Resident #13, the facility staff failed to investigate and report an un-witnessed fall with injuries that occurred on 2/2/14 to the appropriate agencies. Resident #13 was left unsupervised in the dining room on the dementia unit and found on the floor 2/2/14. Resident #13 was admitted to the hospital with [REDACTED]. Resident #13 was admitted to the facility 2/11/13 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #13's significant change in assessment minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/27/14 assessed Resident #13 with a BIMS (brief interview for mental status) score of 05 out of 15 in Section C Cognitive Patterns. The resident was assessed to be totally dependent on two people for bed mobility and requiring extensive assistance of one person for transfers. The MDS prior to the fall on 2/2/14 was a quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/3/13. The quarterly MDS assessed the resident to be independent in bed mobility and only required supervision of one person for transfers. The clinical record for Resident #13 was reviewed 5/6/14 and 5/7/14. The progress note dated 2/2/14 10:58 read "Obtained order to send to ------ (name of hospital emergency room ) for eval (evaluation), family notified, report called to hosp (hospital)." The next entry for 2/2/14 14:16 (2:16 p.m.) read "Spoke with daughter re (regarding): residents condition, resident will be admitted with closed skull fx (fracture) and brain bleed. Spoke with wife informed her that resident being admitted , she informed me that she was waiting on son and that she was going over, wanted to know why staff didn't know what happened, informed her that this nurse was passing meds (medications) to other residents and that other staff was assisting other residents down hallway when this resident fell ." The surveyor found no fall risk assessments in the clinical record. The PT (physical therapy) daily treatment note dated 1/26/14 read "Pt (patient) completed AROM (active range of motion) to BLE (bilateral lower extremities) all planes in sitting at EOB (edge of bed) x 3 sets of 15 in order to increase ROM (range of motion), strength, and endurance. Patient worked on ambulating to bathroom as with to increase (I) (independence) and decrease fall risk. Patient presents with crouched posture as well as increased unsteadiness. 1/30/14 PT note read "Bed mobility, transfer activity, verbal cuing needed throughout treatment. Short ambulation activity for toileting using rolling walker, patient teaching verbal cuing. Min (minimal) assist with cuing." 1/31/13 PT note read "Patient ambulated 130 x 2 feet using a rollator with min (minimal) assist. Increased trunk flexion during ambulation." There was no documentation on 2/2/14 regarding the un-witnessed fall. The "trauma consult" from the emergency room dated 2/2/14 read "Chief complaint: Ground level fall on the tile floor of a nursing home. This [AGE] year-old male fell from ground level at a nursing home and was brought to the emergency room , evaluated by the ER physician, and the neurosurgeon, decision was made to ask trauma to evaluate and possibly admit the patient on behalf of neurosurgery and down in the emergency room to see him. He is complaining of 7/10 pain in the head. Has had some twitching, which is normal for him. The fall was allegedly mechanical involving. The patient being recalcitrant to using his walker according to the report. CT of the head and C-spine shows displaced right occipital bone fracture with an anterior subarachnoid hemorrhage and minimal right posterior subarachnoid hemorrhage. The patient was seen, evaluated and examined. We will see the patient and decide if he needs a syncopal work-up for a medicine evaluation. He will be admitted for observation, neuro (neurological) checks, and treatment along with neurosurgery. Family updated at bedside." CT head dated 2/2/14 listed these findings: "There has been interval extension of diffuse bilateral subarachnoid hemorrhage. There is more extensive hemorrhage within the sulci of the frontal lobes bilaterally and there is also intraventricular hemorrhage now evident in the posterior horn of the left lateral ventricle. There is a moderate amount of hemorrhage involving the terminus of the left internal carotid artery and extending into the anterior aspect of the left middle cranial fossa. There are also [MEDICATION NAME] hematomas within the frontal lobes bilaterally, more pronounced on the right. There is also hemorrhage within the anterior left temporal lobe. There is also a left parafalcine subdural hematoma present. A non-displaced [MEDICAL CONDITION] occipital bone is again noted. A CT angiogram of the brain might be considered to exclude a ruptured cerebral aneurysm." The comprehensive care plan dated 10/28/13 and updated 3/11/14 was reviewed 5/7/14. The care plan contained information dated 2/2/14 that Resident #13 had a closed skull fracture with brain bleed. The comprehensive care plan also included documentation of falls that occurred 3/9/14, 4/5/14, 4/11/14, 4/25/14, and 5/3/14. One intervention listed was "pad alarm applied to bed/chair to alert staff when resident gets up unassisted." The physician note dated 1/23/14 prior to the 2/2/14 fall read in part "Pt (patient) alert, aware, afebrile, stable, confused." The physician note dated 2/17/14 read "Pt (patient) returning from hospital. Recent fall with subarachnoid hemorrhage and occipital fracture. Arousable but lethargic; follows simple commands. Head trauma s/p (status [REDACTED]. Pt (patient) poor prognosis. Consider comfort care." The director of nursing (DON) was asked on 5/7/14 at 2:50 p.m. for any investigation into the un-witnessed fall on 2/2/14 that resulted in a non-displaced right occipital bone fracture with an anterior subarachnoid hemorrhage and minimal right posterior subarachnoid hemorrhage-extensive [MEDICAL CONDITION]. The DON stated no investigation was done "it was an un-witnessed fall. We don't investigate un-witnessed falls. There was no one in the area. Staff were in the hallway. There was no one to interview. No one saw what happened." The DON did provide the surveyor with the incident report dated 2/2/14 at 09:51 which was completed by the director of nursing and read under nursing description "was called to dining rm (room) by staff, resident found in floor on back." There was no documentation under "Resident Description." "Description of Action Taken" read "_____ (name of) amb (ambulance) svs (services) called, report called to _____ (name of hospital), wife notified. Type of injury read "No injuries observed at this time." Level of pain was marked "No hurt." Level of consciousness was "Alert." Mobility "Ambulatory with assistance." Mental Status: "Oriented to person." The administrator and the director of nursing were informed of the concern related to the un-witnessed fall of Resident #13 on 2/2/14 with injuries and the facility's staff failure to investigate and report the incident to the appropriate licensing agencies on 5/8/14 at 8:55 a.m. and again on 5/9/14 at 12:10 p.m. The surveyor requested the facility policy on investigating injuries of unknown origin and the facility policy on accidents. The administrator stated "We all knew about it. He had a big fall and he did hurt himself. We just didn ' t document anything about it. " The director of nursing stated the nurse who worked that day was no longer an employee of the facility. The facility policy titled "Resident Abuse Prevention and Reporting" reviewed 5/9/14 read under procedure "Any alleged violations or injuries of unknown origin shall be reported to the Director of Nursing and/or Administrator (or designee) immediately. The DON, Administrator, or designees will notify Adult Protective of alleged violation and the State Abuse registry. A full and complete investigation will be done. The results of all investigations must be reported to the administrator or his/her designee and to the appropriate state agency, as required by state law, within five (5) working days of the alleged violation. The DNS (director of nursing services) or his/her designee, shall notify the resident's representative that an investigation has been initiated and appropriate action will be taken. This contact shall be documented. All investigations shall be conducted by the Administrator or DNS. In the event an alleged violation occurs when neither of these people is in the facility, the charge nurse is responsible for initiating the investigation procedure. The investigation shall include interviews of associated, visitors, or residents who may have knowledge of the alleged incident. Factual information only should be documented, not assumptions or speculation. Written statements form (sic) involved parties should not be requested. The documentation of the investigation shall be kept in the Administrator's office in an administrative file. Federal Law requires the facility to have evidence of investigations of alleged violations. The attached "Verification of Investigation" form shall be completed after the investigation is complete and provided to survey agencies when requested or required by state or federal law. This form shall be maintained in the Administrator office as an administrative file. It is not part of the medical record. The facility shall make reasonable efforts to determine the cause of the alleged violation and to take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident. In addition to the Verification of Investigation, all alleged violations shall be recorded on a Verification of Investigation form. Documentation in the medical record shall be make (sic) where necessary for continuity of care. Separate incident reports or other written reports, when required by state law, shall be maintained and produced in accordance with state law." The facility policy titled "Accidents/Incidents Management" was also reviewed 5/9/14. The policy read in part: ? 8. The DNS (director of nursing services) or designee conduct a thorough investigation of each incident/accident. ? 9. The DNS or designee implements appropriate interventions to protect the resident and prevent re-occurrence. ? 10. The Administrator or designee directs staff to secure evidence, if any, associated with an incident/accident. ? 11. The Administrator or designee files reports with appropriate departments and/or state agencies according to State and Federal requirements. ? 12. The DNS or designee maintains records related to incident/accidents and reports regularly to the Quality Assurance Committee. Two Adult Protective Services workers from Scott County met with the survey team on 5/9/14 at approximately 12:30 p.m. APS worker #1 was asked if the local APS had been informed of Resident #13's un-witnessed fall with injures on 2/2/14. She stated this was the first she had heard of the fall with injuries and would have expected the facility staff to inform their office of the incident. No further information was obtained from the facility prior to survey exit on 5/9/14. This is a complaint deficiency. 2. For Resident #17, the facility staff failed to investigate and report to the appropriate agencies an injury of unknown origin. Resident #17 was found in the floor in her room "lying in a large pool of blood." Resident #17 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Resident's annual MDS (minimum data set) assessment with an ARD (assessment reference date) of 06/28/13 had a documented BIMS (brief interview for mental status) score of 5. Section G (functional status) was coded to indicate the Resident required extensive assistance of two people for bed mobility, transfer, and for walking in room. Section J (health conditions) was coded to indicate the Resident hadn't had any falls since admission/entry or reentry. The Resident was not interviewable. The clinical record included a nursing note documented by LPN (licensed practical nurse) #2 that read "called to patients room by roommate. pt lying in floor in large pool of blood. pt noted to have large knot with small laceration to right eye. pressure applied to bleeding area and ems contacted. pt being transported to _____ (name omitted) ER for evaluation. pt son ____ (name omitted) aware." This note had been documented on 12/22/13 at 02:13. On 12/22/13 at 07:25 LPN #2 documented "pt returned to facility via stretcher by ______ (name omitted) ambulance service with no new orders noted. pt with large bandaid over right eye." The facility staff provided the surveyor with a transfer order form dated 12/22/13. Under [DIAGNOSES REDACTED]." The Resident's CCP (comprehensive care plan) included the focus area high risk for falls and had been updated to include the incident on 12/22/13. The interventions included. "Bed alarm in use to alert staff when getting up unassisted, check frequently, instruct resident not to try to get up unassisted, anticipate and meet my needs." On 05/09/14 at approximately 10:20 a.m., the surveyor interviewed 2 workers from the local APS (adult protective service) office. APS worker #1 verbalized to the surveyor that they were not made aware of any injury regarding this Resident in December and would have expected to be notified especially since the Resident had to be transported out to a local hospital. On 05/09/14 at approximately 10:35 a.m., the administrator and DON (director of nursing) were interviewed regarding the Residents incident on 12/22/13. The administrative staff verbalized to the surveyor that they had not completed an FRI (facility reported incident) or reported this incident as they had considered it a fall due to the Residents history of falls. The facility staff provided the survey team with a copy of their policy and procedure titled "RESIDENT ABUSE PREVENTION AND REPORTING." Page 2 of this policy/procedure read in part "Any alleged violations or injuries of residents of unknown origin shall be reported to the Director of Nursing and/or Administrator (or designee). The DON, Administrator, or designee will notify Adult Protective of alleged violation and the State Abuse Registry...a full and complete investigation will be done. After completing investigation the alleged will be notified of the results. The findings will be documented within 5 days of the report...Results of the investigation will be sent to the Abuse Registry and to APS." Numerous observations were made of the Resident during the survey process the Resident was noted to have a low bed with fall mats on either side and a bed alarm in place. No investigation of this incident was provided to the surveyor while on site at the facility. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #10 the facility staff failed to investigate and report an injury of unknown origin, bruise to the right hand, to appropriate State Agencies. Resident #10 was an [AGE] year old female who was originally admitted on [DATE] and readmitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was an Annual MDS assessment with an Assessment Reference Date (ARD) of 3/28/14. The facility staff coded that Resident #10 had a Cognitive Summary Score of 10. The facility staff also coded that Resident #10 required extensive (3/3) to total nursing care (4/3) with Activities of Daily Living (ADL's). On May 6, 2014 at 2:15 p.m. during the initial tour of the facility, the Unit Manager (UM) reported that Resident #10 had an injury of unknown origin to her right hand a few weeks ago. The UM stated that the facility had obtained X-Rays and no fractures were found. The surveyor asked the UM what had caused the bruising to the right hand. The UM stated that Resident #10 leaned heavily to the right side and that the facility thought that she might have caught her hand in a reclining geri-chair (RGC). The surveyor observed that Resident #10 had bruising at her left anticubital and on the top of the right hand. On May 7, 2014 at 7:45 a.m. the surveyor reviewed Resident #10's clinical record. Review of the clinical record produced a "Progress Notes." The Progress Notes dated 4/25/14 read ... "15:34 (3:34 p.m.) called to b wing resident complained of pain in rt (right) hand some noted bruising that was greenish yellow in color noted order obtained for xray which was obtained and results on chart m.d (MD) was notified and order was received to splint finger and he would assess it again on Monday stated that we may have to send her to ortho (orthopedic) called and spoke with (name of son withheld) concerning this explained that we would be splinting it and that m.d would follow up on Monday stated he understood. 17:37 (4:37 p.m.) this nurse splinted residents r middle finger as ordered by m.d. resident noted to have taken it off and put on the opposite hand stating "i am right handed, i can't do anything with this on my hand." 18:03 (6:03 p.m.) this nurse attempted to splint residents r finger. Resident kept removing hand and said "stop i can't do anything with my left hand" witnessed by CNA (name withheld)." (sic) Progress Notes dated 4/28/14 at 12:44 (12:44 p.m.) read ... "follow up from noted bruising on rt finger asked this resident what happened she stated that she didnt no what happened to it that she woke up and it was sore was able to move it without difficulty myself and social service (name withheld) spoke with her at this time." (sic) Progress Notes dated 4/28/14 at 12:58 (12:58 p.m.) read ... "This SSD (Social Services Director) and (name of staff member withheld) followed up with resident regarding bruising to finger, SSD asked resident what happened to her finger. She replied, "I don't know. I just woke up with it sore." SSD asked her if she shut her finger in the door. Again she replied, "Honey I just don't remember. I don't know." SSD asked her if it was hurting and she shook her head and said, "A little." Resident was moving hand and arm w/o (without) difficulty." (sic) Progress Notes dated 4/28/14 at 14:51 (2:51 p.m.) read ... "NEW XRAY DONE ON RESIDENT XRAY SHOWED NO FRACTURES IT DID SHOW SOME [MEDICAL CONDITION] IN THE HAND CALLED AND SPOKE WITH RESIDENT SON WHO STATED THAT DAUGHTER WAS NOT AT HOME AND HE STATED HE WOULD TELL HIS SISTER WHAT WE HAD DISCUSSED APOLOGIZED FOR PRIOR RESULTS." (sic) Further review of the clinical record produced a physician telephone order dated 4/25/14 that ordered for an X-ray to be obtained of the right hand. The results of the physician ordered right hand X-ray were contained in the clinical record and documented that there was no evidence of a fracture. On May 7, 2014 at 5 p.m. the survey team met with the Administrator (Adm) and Director of Nursing (DON). The surveyor notified the Administrative Team (AT) that on initial tour the UM had informed her that Resident #10 had an injury of unknown origin, bruising to her right hand, a few weeks ago. The surveyor notified the AT that review of the clinical record failed to produce any investigational details of how the injury/bruising had happened. The surveyor asked if an investigation had been done or if the injury of unknown origin had been reported. The Adm stated that she thought an investigation had been done, but that she didn't believe the occurrence had been reported. The surveyor asked if a Facility Reported Incidence had been faxed to the State Agency and she stated, "No." On May 8, 2014 at 10:35 a.m. the survey team met with the AT. The Adm hand delivered the Progress Note dated 4/28/14 at 12:58 (12:58 p.m.) that read ..."This SSD (Social Services Director) and (name of staff member withheld) followed up with resident regarding bruising to finger, SSD asked resident what happened to her finger. She replied, "I don't know. I just woke up with it sore." SSD asked her if she shut her finger in the door. Again she replied, "Honey I just don't remember. I don't know." SSD asked her if it was hurting and she shook her head and said, "A little." Resident was moving hand and arm w/o (without) difficulty." (sic) The surveyor asked the Adm if anyone else had been questioned/interviewed to determine how the injury of unknown origin/bruise to the right hand had occurred. The Adm stated not that she was aware of. The surveyor notified the AT that a thorough investigation had not been done on the injury of unknown origin/bruising to the right hand and that the injury of unknown origin/bruising to the right hand had not been reported to appropriate State Agencies. No additional information was provided prior to exiting the facility as to why the facility staff failed to investigate and report an injury of unknown origin on Resident #10.

Based on staff interview, facility document review, clinical record review and in the course of a complaint ivestigation, the facility staff failed to implement the facility policy for resident abuse prevention and reporting that all alleged violations involving injuries of unknown origin are immediately reported to the administrator of the facility and to other officials in accordance with Federal and State law through established procedures (including to the State survey and certification agency) for 3 of 33 residents (Resident #13, Resident #17, and Resident #10). 1. For Resident #13 who was described in a 1/30/14 physical therapy note as ambulating with "Min (minimal) assist with cuing" and on 1/31/14 as "min (minimal) assist", the facility staff failed to implement the facility policy to investigate and report an un-witnessed fall on 2/2/14 with injuries to the appropriate agencies. Resident #13 was left unsupervised in the dining room on the dementia unit and found on the floor 2/2/14. Resident #13 was admitted to the hospital with [REDACTED]. 2. For Resident #17, the facility staff failed to implement the facility policy to investigate and report to the appropriate agencies an injury of unknown origin. Resident #17 was found in the floor in her room "lying in a large pool of blood." 3. For Resident #10, the facility staff failed to implement the facility policy to investigate and report a bruise of unknown origin to the right hand. The findings include: 1. For Resident #13, the facility staff failed to implement the facility policy to investigate and report an un-witnessed fall with injuries that occurred on 2/2/14 to the appropriate agencies. Resident #13 was left unsupervised in the dining room on the dementia unit and found on the floor 2/2/14. Resident #13 was admitted to the hospital with [REDACTED]. Resident #13 was admitted to the facility 2/11/13 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #13's significant change in assessment minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/27/14 assessed Resident #13 with a BIMS (brief interview for mental status) score of 05 out of 15 in Section C Cognitive Patterns. The resident was assessed to be totally dependent on two people for bed mobility and requiring extensive assistance of one person for transfers. The MDS prior to the fall on 2/2/14 was a quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/3/13. The quarterly MDS assessed the resident to be independent in bed mobility and only required supervision of one person for transfers. The clinical record for Resident #13 was reviewed 5/6/14 and 5/7/14. The progress note dated 2/2/14 10:58 read "Obtained order to send to ------ (name of hospital emergency room ) for eval (evaluation), family notified, report called to hosp (hospital)." The next entry for 2/2/14 14:16 (2:16 p.m.) read "Spoke with daughter re (regarding): residents condition, resident will be admitted with closed skull fx (fracture) and brain bleed. Spoke with wife informed her that resident being admitted , she informed me that she was waiting on son and that she was going over, wanted to know why staff didn't know what happened, informed her that this nurse was passing meds (medications) to other residents and that other staff was assisting other residents down hallway when this resident fell ." The surveyor found no fall risk assessments in the clinical record. The PT (physical therapy) daily treatment note dated 1/26/14 read "Pt (patient) completed AROM (active range of motion) to BLE (bilateral lower extremities) all planes in sitting at EOB (edge of bed) x 3 sets of 15 in order to increase ROM (range of motion), strength, and endurance. Patient worked on ambulating to bathroom as with to increase (I) (independence) and decrease fall risk. Patient presents with crouched posture as well as increased unsteadiness. 1/30/14 PT note read "Bed mobility, transfer activity, verbal cuing needed throughout treatment. Short ambulation activity for toileting using rolling walker, patient teaching verbal cuing. Min (minimal) assist with cuing." 1/31/13 PT note read "Patient ambulated 130 x 2 feet using a rollator with min (minimal) assist. Increased trunk flexion during ambulation." There was no documentation on 2/2/14 regarding the un-witnessed fall. The "trauma consult" from the emergency room dated 2/2/14 read "Chief complaint: Ground level fall on the tile floor of a nursing home. This [AGE] year-old male fell from ground level at a nursing home and was brought to the emergency room , evaluated by the ER physician, and the neurosurgeon, decision was made to ask trauma to evaluate and possibly admit the patient on behalf of neurosurgery and down in the emergency room to see him. He is complaining of 7/10 pain in the head. Has had some twitching, which is normal for him. The fall was allegedly mechanical involving. The patient being recalcitrant to using his walker according to the report. CT of the head and C-spine shows displaced right occipital bone fracture with an anterior subarachnoid hemorrhage and minimal right posterior subarachnoid hemorrhage. The patient was seen, evaluated and examined. We will see the patient and decide if he needs a syncopal work-up for a medicine evaluation. He will be admitted for observation, neuro (neurological) checks, and treatment along with neurosurgery. Family updated at bedside." CT head dated 2/2/14 listed these findings: "There has been interval extension of diffuse bilateral subarachnoid hemorrhage. There is more extensive hemorrhage within the sulci of the frontal lobes bilaterally and there is also intraventricular hemorrhage now evident in the posterior horn of the left lateral ventricle. There is a moderate amount of hemorrhage involving the terminus of the left internal carotid artery and extending into the anterior aspect of the left middle cranial fossa. There are also [MEDICATION NAME] hematomas within the frontal lobes bilaterally, more pronounced on the right. There is also hemorrhage within the anterior left temporal lobe. There is also a left parafalcine subdural hematoma present. A non-displaced [MEDICAL CONDITION] occipital bone is again noted. A CT angiogram of the brain might be considered to exclude a ruptured cerebral aneurysm." The comprehensive care plan dated 10/28/13 and updated 3/11/14 was reviewed 5/7/14. The care plan contained information dated 2/2/14 that Resident #13 had a closed skull fracture with brain bleed. The comprehensive care plan also included documentation of falls that occurred 3/9/14, 4/5/14, 4/11/14, 4/25/14, and 5/3/14. One intervention listed was "pad alarm applied to bed/chair to alert staff when resident gets up unassisted." The physician note dated 1/23/14 prior to the 2/2/14 fall read in part "Pt (patient) alert, aware, afebrile, stable, confused." The physician note dated 2/17/14 read "Pt (patient) returning from hospital. Recent fall with subarachnoid hemorrhage and occipital fracture. Arousable but lethargic; follows simple commands. Head trauma s/p (status [REDACTED]. Pt (patient) poor prognosis. Consider comfort care." The director of nursing (DON) was asked on 5/7/14 at 2:50 p.m. for any investigation into the un-witnessed fall on 2/2/14 that resulted in a non-displaced right occipital bone fracture with an anterior subarachnoid hemorrhage and minimal right posterior subarachnoid hemorrhage-extensive [MEDICAL CONDITION]. The DON stated no investigation was done "it was an un-witnessed fall. We don't investigate un-witnessed falls. There was no one in the area. Staff were in the hallway. There was no one to interview. No one saw what happened." The DON did provide the surveyor with the incident report dated 2/2/14 at 09:51 which was completed by the director of nursing and read under nursing description "was called to dining rm (room) by staff, resident found in floor on back." There was no documentation under "Resident Description." "Description of Action Taken" read "_____ (name of) amb (ambulance) svs (services) called, report called to _____ (name of hospital), wife notified. Type of injury read "No injuries observed at this time." Level of pain was marked "No hurt." Level of consciousness was "Alert." Mobility "Ambulatory with assistance." Mental Status: "Oriented to person." The administrator and the director of nursing were informed of the concern related to the un-witnessed fall of Resident #13 on 2/2/14 with injuries and the facility's staff failure to implement the facility policy to investigate and report the incident to the appropriate licensing agencies on 5/8/14 at 8:55 a.m. and again on 5/9/14 at 12:10 p.m. The surveyor requested the facility policy on investigating injuries of unknown origin and the facility policy on accidents. The administrator stated "We all knew about it. He had a big fall and he did hurt himself. We just didn ' t document anything about it. " The director of nursing stated the nurse who worked that day was no longer an employee of the facility. The facility policy titled "Resident Abuse Prevention and Reporting" reviewed 5/9/14 read under procedure "Any alleged violations or injuries of unknown origin shall be reported to the Director of Nursing and/or Administrator (or designee) immediately. The DON, Administrator, or designees will notify Adult Protective of alleged violation and the State Abuse registry. A full and complete investigation will be done. The results of all investigations must be reported to the administrator or his/her designee and to the appropriate state agency, as required by state law, within five (5) working days of the alleged violation. The DNS (director of nursing services) or his/her designee, shall notify the resident's representative that an investigation has been initiated and appropriate action will be taken. This contact shall be documented. All investigations shall be conducted by the Administrator or DNS. In the event an alleged violation occurs when neither of these people is in the facility, the charge nurse is responsible for initiating the investigation procedure. The investigation shall include interviews of associated, visitors, or residents who may have knowledge of the alleged incident. Factual information only should be documented, not assumptions or speculation. Written statements form (sic) involved parties should not be requested. The documentation of the investigation shall be kept in the Administrator's office in an administrative file. Federal Law requires the facility to have evidence of investigations of alleged violations. The attached "Verification of Investigation" form shall be completed after the investigation is complete and provided to survey agencies when requested or required by state or federal law. This form shall be maintained in the Administrator office as an administrative file. It is not part of the medical record. The facility shall make reasonable efforts to determine the cause of the alleged violation and to take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident. In addition to the Verification of Investigation, all alleged violations shall be recorded on a Verification of Investigation form. Documentation in the medical record shall be make (sic) where necessary for continuity of care. Separate incident reports or other written reports, when required by state law, shall be maintained and produced in accordance with state law." The facility policy titled "Accidents/Incidents Management" was also reviewed 5/9/14. The policy read in part: ? 8. The DNS (director of nursing services) or designee conduct a thorough investigation of each incident/accident. ? 9. The DNS or designee implements appropriate interventions to protect the resident and prevent re-occurrence. ? 10. The Administrator or designee directs staff to secure evidence, if any, associated with an incident/accident. ? 11. The Administrator or designee files reports with appropriate departments and/or state agencies according to State and Federal requirements. ? 12. The DNS or designee maintains records related to incident/accidents and reports regularly to the Quality Assurance Committee. Two Adult Protective Services workers from Scott County met with the survey team on 5/9/14 at approximately 12:30 p.m. APS worker #1 was asked if the local APS had been informed of Resident #13's un-witnessed fall with injures on 2/2/14. She stated this was the first she had heard of the fall with injuries and would have expected the facility staff to inform their office of the incident. No further information was obtained from the facility prior to survey exit on 5/9/14. This is a complaint deficiency. 2. For Resident #17, the facility staff failed to implement their policy and procedures on reporting an injury of unknown origin. On 12/22/13 Resident #17 was found in the floor in her room "lying in a large pool of blood." This incident was not reported to the appropriate agencies. Resident #17 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Resident's annual MDS (minimum data set) assessment with an ARD (assessment reference date) of 06/28/13 had a documented BIMS (brief interview for mental status) score of 5. Section G (functional status) was coded to indicate the Resident required extensive assistance of two people for bed mobility, transfer, and for walking in room. The Resident was not interviewable. The clinical record included a nursing note documented by LPN (licensed practical nurse) #2 that read "called to patients room by roommate. pt lying in floor in large pool of blood. pt noted to have large knot with small laceration to right eye. pressure applied to bleeding area and ems contacted. pt being transported to _____ (name omitted) ER for evaluation. pt son ____ aware." This note had been documented on 12/22/13 at 02:13. On 12/22/13 at 07:25 LPN #2 documented "pt returned to facility via stretcher by ______ ambulance service with no new orders noted. pt with large bandaid over right eye." The facility staff provided the surveyor with a transfer order form dated 12/22/13. Under [DIAGNOSES REDACTED]." The Resident's CCP (comprehensive care plan) included the focus area high risk for falls and had been updated to include the incident on 12/22/13. The interventions included. "Bed alarm in use to alert staff when getting up unassisted, check frequently, instruct resident not to try to get up unassisted, anticipate and meet my needs." On 05/09/14 at approximately 10:20 a.m., the surveyor interviewed 2 workers from the local APS (adult protective service) office. APS worker #1 verbalized to the surveyor that they were not made aware of any injury regarding this Resident in December and would have expected to be notified especially since the Resident had to be transported out to a local hospital. On 05/09/14 at approximately 10:35 a.m., the administrator and DON (director of nursing) were interviewed regarding the Residents incident on 12/22/13. The administrative staff verbalized to the surveyor that they had not completed an FRI (facility reported incident) or reported this incident as they had considered it a fall due to the Residents history of falls. The facility staff provided the survey team with a copy of their policy and procedure titled "RESIDENT ABUSE PREVENTION AND REPORTING." Page 2 of this policy/procedure read in part "Any alleged violations or injuries of residents of unknown origin shall be reported to the Director of Nursing and/or Administrator (or designee). The DON, Administrator, or designee will notify Adult Protective of alleged violation and the State Abuse Registry...a full and complete investigation will be done. After completing investigation the alleged will be notified of the results. The findings will be documented within 5 days of the report...Results of the investigation will be sent to the Abuse Registry and to APS." Numerous observations were made of the Resident during the survey process the Resident was noted to have a low bed with fall mats on either side and a bed alarm in place. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #10 the facility staff failed to implement policies and procedures to prohibit abuse. Resident #10 had an injury of unknown origin/bruising on the right hand and the facility staff failed to thoroughly investigate and report the injury of unknown origin. Resident #10 was an [AGE] year old female who was originally admitted on [DATE] and readmitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was an Annual MDS assessment with an Assessment Reference Date (ARD) of 3/28/14. The facility staff coded that Resident #10 had a Cognitive Summary Score of 10. The facility staff also coded that Resident #10 required extensive (3/3) to total nursing care (4/3) with Activities of Daily Living (ADL's). On May 6, 2014 at 2:15 p.m. during the initial tour of the facility, the Unit Manager (UM) reported that Resident #10 had an injury of unknown origin to her right hand a few weeks ago. The UM stated that the facility had obtained X-Rays and no fractures were found. The surveyor asked the UM what had caused the bruising to the right hand. The UM stated that Resident #10 leaned heavily to the right side and that the facility thought that she might have caught her hand in a reclining geri-chair (RGC). The surveyor observed that Resident #10 had bruising at her left anticubital and on the top of the right hand. On May 7, 2014 at 7:45 a.m. the surveyor reviewed Resident #10's clinical record. Review of the clinical record produced a "Progress Notes." The Progress Notes dated 4/25/14 read ... "15:34 (3:34 p.m.) called to b wing resident complained of pain in rt (right) hand some noted bruising that was greenish yellow in color noted order obtained for xray which was obtained and results on chart m.d (MD) was notified and order was received to splint finger and he would assess it again on Monday stated that we may have to send her to ortho (orthopedic) called and spoke with (name of son withheld) concerning this explained that we would be splinting it and that m.d would follow up on Monday stated he understood. 17:37 (4:37 p.m.) this nurse splinted residents r middle finger as ordered by m.d. resident noted to have taken it off and put on the opposite hand stating "i am right handed, i can't do anything with this on my hand. " 18:03 (6:03 p.m.) this nurse attempted to splint residents r finger. Resident kept removing hand and said "stop i can't do anything with my left hand" witnessed by CNA (name withheld)." (sic) Progress Notes dated 4/28/14 at 12:44 (12:44 p.m.) read ... "follow up from noted bruising on rt finger asked this resident what happened she stated that she didnt no what happened to it that she woke up and it was sore was able to move it without difficulty myself and social service (name withheld) spoke with her at this time." (sic) Progress Notes dated 4/28/14 at 12:58 (12:58 p.m.) read ... "This SSD (Social Services Director) and (name of staff member withheld) followed up with resident regarding bruising to finger, SSD asked resident what happened to her finger. She replied, "I don't know. I just woke up with it sore." SSD asked her if she shut her finger in the door. Again she replied, "Honey I just don't remember. I don't know." SSD asked her if it was hurting and she shook her head and said, "A little." Resident was moving hand and arm w/o (without) difficulty." (sic) Progress Notes dated 4/28/14 at 14:51 (2:51 p.m.) read ... "NEW XRAY DONE ON RESIDENT XRAY SHOWED NO FRACTURES IT DID SHOW SOME [MEDICAL CONDITION] IN THE HAND CALLED AND SPOKE WITH RESIDENT SON WHO STATED THAT DAUGHTER WAS NOT AT HOME AND HE STATED HE WOULD TELL HIS SISTER WHAT WE HAD DISCUSSED APOLOGIZED FOR PRIOR RESULTS." (sic) Further review of the clinical record produced a physician telephone order dated 4/25/14 that ordered for an X-ray to be obtained of the right hand. The results of the physician ordered right hand X-ray were contained in the clinical record and documented that there was no evidence of a fracture. On May 7, 2014 at 5 p.m. the survey team met with the Administrator (Adm) and Director of Nursing (DON). The surveyor notified the Administrative Team (AT) that on initial tour the UM had informed her that Resident #10 had an injury of unknown origin, bruising to her right hand, a few weeks ago. The surveyor notified the AT that review of the clinical record failed to produce any investigational details of how the injury/bruising had happened. The surveyor asked if an investigation had been done or if the injury of unknown origin had been reported. The Adm stated that she thought an investigation had been done, but that she didn't believe the occurrence had been reported. The surveyor asked if a Facility Reported Incidence had been faxed to the State Agency and she stated, "No." The surveyor requested the facility policy and procedure for prohibiting resident abuse. On May 8, 2014 at 10:35 a.m. the survey team met with the AT. The Adm hand delivered the Progress Note dated 4/28/14 at 12:58 (12:58 p.m.) that read ..."This SSD (Social Services Director) and (name of staff member withheld) followed up with resident regarding bruising to finger, SSD asked resident what happened to her finger. She replied, "I don't know. I just woke up with it sore." SSD asked her if she shut her finger in the door. Again she replied, "Honey I just don't remember. I don't know." SSD asked her if it was hurting and she shook her head and said, "A little." Resident was moving hand and arm w/o (without) difficulty." (sic) The surveyor asked the Adm if anyone else had been questioned/interviewed to determine how the injury of unknown origin/bruise to the right hand had occurred. The Adm stated not that she was aware of. The surveyor notified the AT that a thorough investigation had not been done on the injury of unknown origin/bruising to the right hand and that the injury of unknown origin/bruising to the right hand had not been reported to appropriate State Agencies. On May 8, 2014 at 5:20 p.m. the DON hand delivered the facility policy and procedure titled, "Policies and Procedures Regarding Investigation and Reporting of Alleged Violations of Federal or State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resiednt's Property." The policy and procedure read in part ... "It is the policy of this facility to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source, misappropriation of resident property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown source, and misappropriation resident property ("alleged violations"), are reported immediately to the executive director of the facility. Such violations will also be reported to State Agencies in accordance with existing State law. The facility will investigate each such alleged violation and report the results of all investigations to the executive director or his or her designee, as will as to State Agencies as required by State and Federal law ....Reporting ...B. The results of all investigations must be reported to the Administrator or his/her designee and to the appropriate state agency, as required by state law, within five (5) working days of the alleged violation ....Investigation ...A. All investigations shall be conducted by the Administrator or DNS (Director of Nursing Services). In the event an Alleged violation occurs when neither if these people are in the facility; the charge nurse is responsible for initiating the investigation procedure. B. The investigation shall include interviews of associated, visitors or Or residents who may have knowledge of the alleged incident. Factual Information only should be documented, not assumptions or speculation. Written statements form involved parties should not be requested. The documentation of the investigation shall be kept in the Administrator's office in an administrative file. C. The medical record should be reviewed to determine the resident's past History and condition and its relevance to the alleged violations. D. Federal Law requires the facility to have evidence of investigations of Alleged violations. The attached "Verification of Investigation" form shall be completed after the investigation is complete and provided to survey agencies when requested or required by state and federal laws. This form shall be maintained in the Administrator office as an administrative file. It is not part of the medical record." No additional information was provided prior to exiting the facility as to why the facility staff failed to implement facility policies and procedures for abuse prohibition on Resident #10.

Based on observation, resident interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to prevent, identify, assess and treat the development of pressure ulcers for 5 of 33 residents (Resident #13, Resident #9, Resident #8, Resident #12, and Resident #2). The findings include: 1. For Resident #13, the facility staff failed to prevent, identify, assess, and treat a stage 1 pressure ulcer on the resident's left heel found by the surveyor on 5/7/14 but when assessed again on 5/8/14 it was determined to be a deep tissue injury. Resident #13 was admitted to the facility 2/11/13 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #13's significant change in assessment minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/27/14 assessed Resident #13 with a BIMS (brief interview for mental status) score of 05 out of 15 in Section C Cognitive Patterns. The interview for daily preferences at F0400 was reviewed. Choosing what to wear was coded as a 1. This coding indicated that choosing what to wear was very important to him. Section G Functional Status was assessed to be totally dependent on two people for bed mobility and requiring extensive assistance of one person for transfers. Resident #13 was assessed to be totally dependent on two people for dressing. Resident #13 was assessed to be totally dependent on 1 person for eating. Resident #13 was also assessed to be dependent on one person for personal hygiene-combing hair, brushing teeth, shaving, washing/drying hands and face. Section H Bladder and Bowel revealed Resident #13 was always incontinent of urine and bowel. Section M Skin Conditions assessed that Resident #13 was at risk for developing pressure ulcers but had no coding for pressure ulcers on the MDS. Skin and Ulcer treatments marked were pressure reducing device for bed and application of dressings to feet (with or without topical medication). The nursing process includes collecting data about a patient through assessment which includes the use of observation, measurements, record reviews, collaboration and interviews. Mosby's Textbook for Nursing Assistants, Sheila A. Sorrentino, 5th edition, 2000, pages 596-597 was reviewed. A pressure ulcer is any injury caused by unrelieved pressure. It usually occurs over a bony prominence. Prominence means to stick out. Therefore a bony prominence is an area where the bone sticks out or projects out from the flat surface of the body. The shoulder blades, elbows, hip bones, sacrum, knees, ankle bones, heels, and toes are bony prominences. The current comprehensive care plan dated 3/11/14 read "I am at risk for skin breakdown due to decreased mobility. Follow facility policies/procedures for the prevention of skin breakdown. Monitor nutritional status. Serve diet as ordered. Monitor intake and record. Notify family and MD of any pressure area. Obtain and monitor lab/diagnostic work as ordered. Report to MD and follow-up as indicated. Weekly skin assessment." Resident #13 currently had physician orders [REDACTED]. Resident #13's weight had slowly decreased from a weight of 174 pounds in August 2013 to 156.2 pounds obtained 5/1/14. Interventions had been put in place that included fortified foods, med pass, and mighty shakes. A ST (speech therapy) evaluation was ordered on [DATE]. The surveyor observed Resident #13 on 5/7/14 at 12:30 p.m. He was sitting in a Geri-chair. His children present. One of the children stated to the surveyor that Resident #13 needed some attention to his toenails and then proceeded to remove first his left sock and then the right one. Both great toes were thick and long and curled over the tip of the big toe. She stated they have requested the facility cut them but the facility stated that they would have to send him out. She stated at some time during his stay, the toenails were cut after the staff told the family they couldn't be cut here. The surveyor also observed a dark red/purple area on the left heel approximately the size of a quarter. The surveyor informed the wound care nurse licensed practical nurse #6 that the surveyor would like to observe a skin assessment. The surveyor observed a partial skin assessment on 5/7/14 at 3:10 p.m. with licensed practical nurse #6. Skin assessment that focused on both feet was done while Resident #13 was sitting in the Geri-chair. The door was not closed, the blinds were not closed and the privacy curtain was not pulled during the skin assessment done by L.P.N. #6. Upon completion of the skin assessment, she stated Resident #13's left heel had a Stage I pressure area. She stated "It's a little red and non-blanching. It's a stage 1. Not blistering." L.P.N. #6 described a stage 1 pressure ulcer to the surveyor stating that a stage 1 was an area with redness and was non-blancheable. She stated a deep tissue injury was dark and wouldn't blanche. "This is red." The surveyor requested that the director of nursing assess the left heel. Upon her entrance to the room, the door remained open, the blinds were not closed and the privacy curtain was not pulled. She donned gloves, checked the left heel and stated the area on Resident #13's left heel was also a Stage I pressure area. Both L.P.N. #6 and the DON took off their gloves and washed their hands briefly. L.P.N. #6 stated "Resident #13 had heel protectors but wouldn't keep them on. He is not receiving any treatment for [REDACTED]. During clinical record review on 5/7/14, the surveyor noted a weekly nursing assessment effective date of 5/7/14 at 13:19 (1:19 p.m.). The assessment included an area for "Skin." On Resident #13's assessment, there were no skin issues (skin tear, rash, lesion, laceration, bruising, surgical incision) documented yet the surveyor had observed a healed skin tear and bruising to Resident #13's upper extremities on 5/6/14 at 5:10 p.m. during a wound care observation. The assessment also read "Warm/dry." The surveyor interviewed the writer of the weekly nursing assessment licensed practical nurse #7 on 5/7/14 at 3:10 p.m. She was asked about the assessment and noted that the skin section only revealed that his skin was warm and dry. "I only assess what I can visualize. It's only a partial assessment. The wound care nurses do the skin assessments." The May 2014 physician order [REDACTED]. The clinical record did reveal that L.P.N. #6 had obtained physician orders [REDACTED]. The May 2014 treatment administration record (TAR) did not reveal evidence that the skin prep had been applied on 5/7/14 during the night shift. The treatment order was not placed on the TAR. There was no proof of the heel being assessed or treated on 5/7/14 evening shift. The surveyor interviewed licensed practical nurse #7 on 5/9/14 at 7:20 a.m. She stated bid (twice a day) treatments are done on days and evening. "We only have 2 shifts. I don't see where there was any documentation that the treatment to the heels was done on 5/7/14 at bedtime." A second skin assessment was done 5/8/14 at 9:45 a.m. with wound care licensed practical nurse #5. Resident #13's wound care was observed with the resident in bed. During the first assessment on 5/8/14, wound care nurse L.P.N. #5 had positioned him on his back and stated the area on his left heel was red and a stage 1 pressure area; however, when Resident #13 was turned to the left side, the wound care nurse L.P.N. #5 assessed the area on the left heel and stated "That's a DTI (deep tissue injury). You can see the dark." The area measured 5 centimeters (length) by 3 centimeters (width). She stated she was going to start treatment with "Marathon liquid skin protectant every 3 days." She also stated the area blanched between the darker area and the red area along the ridge where the two areas differed in color. She went on to say that the dementia unit was the last unit to have skin assessments done. She also stated that Resident #13 was tried with heel protectors but wouldn't leave them on. The surveyor requested the Braden scales and skin assessments for February-May 2014 from the director of nursing and the facility policy on the staging of pressure areas and the facility policy on wound care. The surveyor reviewed the Braden scales provided on 5/9/14. The most recent Braden Scale for Predicting Pressure Sore Risks was done 2/14/14. His score was 13. A score of 13 was categorized as "Moderate Risk." The Skin/Wound Note dated 5/2/14 read "Head to toe assessment on this date. Scant hematomas to extremities. Blancheable redness to sacrum and buttocks d/t (due to) incontinence. No other skin concerns seen at this time. Will monitor for any changes." The Skin/Wound Note dated 4/25/14 read "Head to toe assessment on this date. Scant bruising to extremities. Blancheable redness to sacrum and buttocks d/t (due to) incontinence. Dryness noted to facial area, cream applied. No other skin concerns seen at this time. Will monitor for any changes." The Skin/Wound Note dated 4/22/14 read "Head to toe assessment on this date. Scant fading bruising to extremities. Blancheable redness and s/s (signs and symptoms of) shearing to sacrum and buttocks d/t (due to) incontinence. No other skin concerns seen at this time. Will monitor for any changes." The Skin/Wound Note dated 4/10/14 read "Head to toe assessment on this date. Scant bruising to extremities. Blancheable redness to sacrum and buttocks d/t (due to) incontinence. No other skin concerns seen at this time. Will monitor for any changes." The Skin/Wound Note dated 4/4/14 read "Head to toe assessment on this date. Blancheable redness to sacrum and buttocks, and groin area. Cream applied. Scant bruising to extremities. No other skin concerns seen at this time. Will monitor for any changes." The Skin/Wound Note dated 3/30/14 read "Skin assessment: Redness noted buttocks/groin d/t (due to) incontinence. No other skin issues seen at this time." The Skin/Wound Note dated 3/21/14 read "Skin assessment: Head to toe assessment on this date. Scant bruising to extremities. Blancheable redness to sacrum and buttocks d/t (due to) incontinence. No other skin concerns seen at this time. Will monitor for changes." The Skin/Wound Note dated 3/16/14 read "Skin assessment. Resident has no noted skin issues at this time." The Skin/Wound Note dated 2/28/14 read "Skin assessment: Head to toe assessment on this date. Multiple hematomas to upper/lower extremities. Blancheable redness to sacrum and buttocks d/t (due to) incontinence. Skin is pale, warm, dry. No other skin concerns seen at this time. Will monitor for changes." Certified nursing assistant #1 was interviewed 5/8/14 after the skin assessment at 9:45 a.m. She stated residents get baths twice per week. Clothes should be changed every day. She stated she had not dressed Resident #13 but "you should see their feet when you are dressing them." The surveyor interviewed certified nursing assistant #3 on 5/9/14 at 11:30 a.m. She stated Resident #13 received his baths on Wednesdays. She stated she had not bathed him this week or dressed him. The surveyor interviewed certified nursing assistant #9 on 5/9/14 at 11:30 a.m. She stated she had not bathed him this week but had changed him. She stated if the clothes look clean, she doesn't change them every day. The surveyor interviewed licensed practical nurse #11 on 5/8/14 at 9:30 a.m. She provided the bath list for the secure unit that included what resident received their baths on which shift and what days of the week. Resident #13 was to receive baths on day shift on Wednesdays and Saturdays. On Sundays, each resident was to be shaved and nail care done on day shift. She stated shaves and nail care are done with each bath day. The May 2014 ADL (activities of daily living) sheet was reviewed and revealed Resident #13 received a Full Bath on 5/3/14 (Saturday) and 5/7/14 (Wednesday) on the 7a-7p shift. Personal hygiene was coded that Resident #13 required extensive assistance of 1 person for combing hair, brushing teeth, washing and drying face, and perineum. The National Pressure Ulcer Advisory Panel (NPUP) describes a suspected deep tissue injury as "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." The NPUAP describes the following use of support systems for the prevention of heel ulcers: 3.1. Ensure that the heels are free of the surface of the bed. 3.2. Heel-protection devices should elevate the heel completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. The knee should be in slight flexion. Hyperextension of the knee may cause obstruction of the popliteal vein, and this could predispose an individual to [MEDICAL CONDITION]. 3.3. Use a pillow under the calves so that heels are elevated (i.e., "floating"). Using a pillow under the calves elevates the heels from the mattress. 3.4. Inspect the skin of the heels regularly The care plan interventions listed above read to do weekly skin assessments. The surveyor found no evidence of weekly skin assessments from 2/28/14 through 3/16/14. The care plan did not reveal evidence of Resident #13's non-compliance with the use of the heel protectors or the use of a pressure reducing mattress. The surveyor reviewed the facility policy on wound documentation and pressure ulcers on 5/9/14. The policy read in part "2. The nurse will obtain orders for treatment, preventative care and restorative care from the physician. 6. Pressure ulcers will be staged according to the staging codes given on the pressure ulcer sheet and in accordance with current MDS RAI specifications." The failure of the facility to prevent, identify, assess and treat the stage 1 pressure on the left heel found by the surveyor and that was later identified as a deep tissue injury was discussed with the administrator and the director of nursing on 5/9/14 at 12:10 p.m. No further information was made available prior to the exit conference on 5/9/14. This is a complaint deficiency. 2. For Resident #9 the facility staff failed to identify, assess, treat and prevent the development of an unstageable pressure ulcer on the left little toe. Resident #9 was an [AGE] year old female who was originally admitted on [DATE] and readmitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was a Quarterly MDS assessment with an Assessment Reference Date (ARD) of 3/28/14. The facility staff coded that Resident #9 had a Cognitive Summary Score of 6. The facility staff also coded that Resident #9 required extensive (3/3) to total nursing care (4/2) with Activities of Daily Living (ADL's). In Section M. Skin Conditions the facility staff coded that Resident #9 was at risk for the development of pressure ulcers. On May 7, 2014 at 10 a.m. the surveyor reviewed Resident #9's clinical record. Review of the clinical record produced "Progress Notes" dated 5/5/14 at 12:58 (12:58 p.m.). The Progress Notes read ...."SKIN ASSESSMENT: RESIDENT HAS A MAROON DISCOLORATION TO BLE (bilateral lower extremities). BLANCHEABLE REDNESS TO SACRUM/BUTTOCKS, SCANT BRUISING TO EXT (extremity).NO OTHER SKIN ISSUES NOTED AT THIS TIME" (sic) Continued review of the clinical record produced the most current "Braden Scale for Predicting Pressure Sore Risk" dated 12/26/13 at 14:29)2:49 p.m.). The Braden Scale documented that Resident #9 had no impairment in sensory perception, skin was very moist, chairfast and ability to walk was severely impaired or non-existent, mobility was slightly impaired, nutrition was adequate and friction and shear of the skin was a problem-requiring moderate to maximum assistance in moving. Further review of the clinical record produced the Comprehensive Care Plan (CCP). The CCP identified the following "Problem," "Goals" and "Interventions." "Problem-I am at risk for skin breakdown due to decreased mobility and incont. (incontinence). Goal-I will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions-Follow facility policies/protocols for the prevention of skin breakdown. Monitor nutritional status. Serve diet as ordered. Monitor intake and record. Notify family and MD of any pressure area. Obtain and monitor labs/diagnostic work as ordered. Report results to MD and follow up as indicated. Weekly skin assessments." (sic) On May 7, 2014 at 10:15 a.m. the surveyor notified the Unit Manager (UM) and a Certified Nursing Assistant (C.N.A. #6) that the surveyor wanted to see Resident #9's skin. On May 7, 2014 at 12:05 p.m. the surveyor was called to Resident #9's room. The surveyor observed three (3) C.N.A.'s (#4, #5 and #6) preparing to get Resident #9 back into the bed with a hoyer lift. Once Resident #9 was in the bed the surveyor watched incontinence care and looked at Resident #9's buttocks, sacrum, back, shoulders, heels and toes. The surveyor observed that Resident #9's left little toe had a dried brownish/black area on the top of the toe about the size of a pencil eraser. On May 7, 2014 at 12:15 p.m. the Wound Nurse, who was a Licensed Practical Nurse (LPN #6), and UM entered the Resident #9's room. The surveyor pointed out that Resident #9's left little toe had an unstageable pressure ulcer. The surveyor notified the Wound Nurse (LPN #6) that review of the clinical record had produced a skin assessment on 5/5/14. The surveyor notified the Wound Nurse that the skin assessment did not document any skin issue/pressure ulcer on Resident #9's left little toe. The surveyor also notified the Wound Nurse (LPN #6) that a recent Braden Scale was not seen in the clinical record. The Wound Nurse (LPN #6) stated that she didn't think the area on the left little toe was an unstageable pressure ulcer. The surveyor asked the Wound Nurse (LPN #6) what was under the brownish/black area on the left little toe, the Wound Nurse (LPN #6) stated that there was no way to determine what was under the brownish black area. The surveyor said, "Exactly." The surveyor informed the Wound Nurse (LPN #6) that the unstageable area on the left little toe was in an area that was common for the development of a pressure ulcer. The surveyor notified the Wound Nurse (LPN #6) that the blankets/covers and shoes could produce pressure on the top of the toes. The surveyor requested for the Wound Nurse (LPN #6) to obtain any policy/procedure that the used for the staging of pressure ulcers. On May 7, 2014 at 12:45 p.m. the Wound Nurse (LPN #6) returned to the nurses' station and hand delivered a policy and procedure titled, "Pressure Ulcer Prevention and Care." The surveyor reviewed the policy and procedure. The policy and procedure identified the National Pressure Ulcer Advisory Panel (NPUP) guidelines for staging pressure ulcers. The policy and procedure identified that an "Unstageable (pressure ulcer): Full thickness 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. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed." The surveyor pointed out and reviewed the specific information regarding an Unstageable Pressure Ulcer. The surveyor informed the Wound Nurse (LPN #6) that the guidelines for an unstageable pressure ulcer described Resident #9's left little toe precisely. The Wound Nurse (LPN #6) shook her head up and down, indicating that she agreed with the surveyor. On May 7, 2014 at 5 p.m. the survey team met with the Administrator (Adm) and Director of Nursing (DON). The surveyor notified the Administrative Team (AT) that Resident #9 had an unstageable pressure ulcer on the left little toe. The surveyor notified the AT that review of the clinical record produced a skin assessment for 5/5/14 that failed to capture/document the unstageable area on the left little toe. The surveyor also informed the AT that a recent Braden Scale was not noted in the clinical record. The surveyor requested copies of Resident #9's Braden Scales. On May 8, 2014 at 8 a.m. the surveyor reviewed Resident #9's clinical record. The surveyor noted that a Braden Scale had been completed on 5/7/14 that documented that Resident #9 had no impairment in sensory perception, skin moisture occasionally moist, activity bedfast-confined to chair, mobility was very limited, nutrition adequate, and friction/shearing was coded as a potential problem. The surveyor did not observe any additional documentation noted in the clinical record of an assessment of the unstageable pressure ulcer on the left little toe to include staging, a measurement of size, drainage, necrotic tissue or eschar, wound edges, treatment and or further prevention of pressure ulcers. On May 8, 2014 at 10 a.m. a Wound Nurse (LPN #5) called the surveyor into Resident #9's room to observe Resident #9's left little toe. The surveyor and the Wound Nurse (LPN #5) observed Resident #9's left little toe. The Wound Nurse (LPN#5) pointed out that the brownish/black area had come off of the left little toe. The surveyor notified the Wound Nurse (LPN #5) that even after the surveyor had identified the brownish/black area/unstageable pressure ulcer on the left little toe on 5/7/14, the facility staff failed to assess the unstageable pressure ulcer, to stage, measure, document drainage, necrotic or eschar tissue, wound edges, obtain a treatment order and document prevention of further pressure ulcers. On May 8, 2014 at 2 p.m. the surveyor reviewed a copy of the facility policy and procedure titled, " Skin Care. " The policy and procedure read in part ... "Responsible The following individuals may have responsibility for skin care specific to state professional licensing requirements. ? RN ? LPN/LVN ? CNA Purpose The purpose of skin care is to: ? Provide a systemic approach and monitoring process for skin integrity/pressure ulcer care ? Prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcer formation and developing interventions ? Promote healing of pressure ulcers in a cost-efficient and timely manner Policy All residents are assessed for risk of skin breakdown within 24 hours of admission, quarterly and as necessitated by change in resident condition. At-risk residents and those with wounds are reviewed on a routine schedule on a weekly basis. The skin nurse at each facility is responsible for ensuring that the skin integrity program is implemented and monitored for quality. The interdisciplinary plan of care addresses problems, goals and interventions directed toward prevention and/or resolution of pressure ulcers and/or skin integrity concerns identified. Protocols for at risk and Stage I-IV may be instituted by a specific physician order [REDACTED]. The resident and his or her family will be informed upon admission if the resident is assessed at-risk upon admission or if a pressure ulcer develops or is present. Assessment General guidelines for assessment may include, but are not limited to: ? Redness ? Weight loss ? Immobility Documentation guidelines Documentation may appear on any form used in the facility. Frequency of documentation should follow facility policy ..... Identification of risk If the assessment scores at-risk, per the MDS or state-specific tool, and the MDS for bed mobility scores a 1 or 2, then a pressure-relieving device will be used while the resident is in bed and sitting in a chair. The use of this device should be identified in the resident plan of care. If the assessment scores at-risk per the MDS or state-specific tool and the bed mobility score is 3 or 4, a pressure relieving device will be used in bed and while sitting in a chair. A repositioning schedule will be instituted and individualized to the resident, as well as an up/out-of-bed/back-to-bed schedule developed by the interdisciplinary team and the resident. Whenever an MDS triggers a resident at risk for pressure ulcers, implement the immediate plan of care until the comprehensive care plan is complete or updated. All residents must have a pressure- relieving cushion while in a wheelchair." The surveyor also reviewed a policy and procedure titled, "Documentation of Wounds and Pressure Ulcers." The document read in part... "Purpose: To provide continuity in nursing care for the prevention, care and documentation of skin integrity issues. To provide a system to identify and monitor all risk factors for skin integrity issues through appropriate assessment to ensure the residents well being. ... Specific Procedure/Requirements: 1. The initial identification of skin integrity issue must be documented on the nursing progress note in a timely manner. a. Initial Documentaion should include: i.Wound location ii. Size (length, width, and depth) iii. Tunneling/sinus tracts if present iv. Undermining, if present v. Presence of necrotic tissue, slough, or eschar vi. Exudate/drainage, amount, color, odor vii. Granulation if present viii. Description of surrounding tissue ix. Pain x. Immediate action to resolve pressure, short term interventions related to probable cause. 2. The nurse will obtain orders for treatment, preventive care and restorative care from the physician. 3. Document any initial communication with the physician and orders for treatment or care in the nursing progress note. Ongoing treatment changes and notifications may be documented on the wound care record as indicated. 4. The presence of the wound will be communicated to the Wound care/treatment nurse for investigation of cause and ongoing treatment plan. 5. A wound record will be initiated for all acquired and admission pressure ulcers at the time they are noted. Use one sheet for each wound. 6. Pressure ulcers will be staged according to the staging codes given on the pressure ulcer sheet and in accordance with the current MDS RAI specifications. Circulatory wounds will be staged according to current MDS RAI guidelines, if applicable. 7. The Nurse Manager/Charge Nurse will initiate a care plan for all acquired and admission pressure ulcers and all other wounds at the time of onset or discovery. Interventions addressing probable cause will be addressed on the care plan. 8. The wound record will be updated weekly with measurements and progress notes. 9. Ongoing documentation of treatment and status will be completed using the TAR and the Weekly wound record including measurements, descriptions, changes in treatments, and MD and RP notifications. 10. Care plans will be updated when significant changes in the wound occur including decline in status and/or healing. " No additional information was provided as to why the facility staff failed to identify, assess, treat and prevent the development of an unstageable pressure ulcer on Resident #9's left little toe. 3. For Resident #8, the facility staff failed to assess and treat an unstageable pressure ulcer. Resident #8 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A review of Resident #8's clinical record revealed on the most recent minimum data set (MDS) with an assessment reference date of 3/21/14, the facility staff assessed the resident to usually understand and to usually be understood. They also had her coded as a 03 for cognitive pattern. In section M0150, she was coded to be at risk of developing pressure ulcers. In M0900 she was coded to have pressure ulcers on the prior MDS assessment. Resident #8 ' s comprehensive care plan had her care planned to be at risk for skin breakdown due to immobility, and incontinence. Under the goals set for Resident # 8 it read as follows: " I will have intact skin, free of redness, blisters or discoloration by through the review date. " Resident # 8 was also care planned for a significant weight loss over the past 6 months. A Braden scale assessment was done on Resident #8 on 2/12/14. His score was 15. A score of 15 placed the resident at a low risk for developing a pressure ulcer. Resident #8 was observed in her bed at 5/6/14 at 5:00pm. Her roommate was rubbing lotion on her feet. She did not have her physician ordered heel protectors on her feet and none were seen in the bed or near the bed. On 5/7/14 at 7:50am, Resident #8 was again observed with her feet floated but she did not have heel protectors on her feet. On 5/8/14 at 8:05am, the LPN #3 was asked to go with the surveyor to Resident #8 ' s room. Once in the room, the surveyor asked LPN #3 why Resident #8 did not have on her heel protectors. She said, " I will get some heel protectors from the laundry. " On 5/8/14 at 9:10am, the surveyor asked to see a skin assessment on Resident #8. LPN #5, the wound care nurse, performed the assessment. Resident #8 ' s left heel had a small area that was brown and had a loose edge. LPN #5 called the area a scab left from an old pressure ulcer. During the assessment of the heel, LPN #5 touched the brown area and the resident flinched and said, " It hurts. " The surveyor asked LPN #5 if the area was being treated, she said, " No it is healed. " LPN #5 was asked to measure the area and give the surveyor a description of the wound. The following is her description: " 5/8/14 10:43 skin/wound note: this resident continues to have small abraded area 0.2 x 0.2 to left heel. Scab is dry and smooth with no seen drainage or redness. Previous DTI (deep tissue injury) healed 12-26-13. Area is monitored weekly for changes. Resident wears heel protectors and is compliant most of the time, refuses to reposition off her bottom. New order for liquid skin protectant applied daily every 3 days for tenderness and prevention. " Further review of the clinical record review revealed the 5/4/2014 16:14 skin/wound assessment. " Head to toe assessment on this date, no skin concerns seen at this time. Will monitor for any changes. " This nurse ' s note was written four days prior to the surveyors request for a skin assessment indicating there was nothing seen on the heel. For 4/28/14 14:06 skin/wound assessment: Resident has scant bruising to ext. No other skin issues noted at this time. " The wound care nurse had documented the following note that indicated the heel wound had heeled in December. Resident #8 ' s clinical record revealed a nurse ' s note that reads: 12/26/13 16:29 Type: Skin/wound note: " This resident ' s (Resident #8) DTI (deep tissue injury) to left heel has healed. During wound care today dark skin peeled away revealing new pink skin underneath. Skin prep continues for one week for prevention. Resident encouraged elevating heels while in bed and wearing heel protectors. Message left for family. Will monitor this patient for any change. " However in January, another nurse ' s note read as follows: 1/13/14 15:15 Skin/wound note: skin assessment: " Resident has multiple bruising to